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Ancestors and Antiretrovirals: The Biopolitics of HIV/AIDS in Post-Apartheid South Africa

 USAID is observing World AIDS Day this year by celebrating ten years of our HIV and AIDS work under PEPFAR.

Book Review: “Ancestors and Antiretrovirals: The Biopolitics of HIV/AIDS in Post-Apartheid South Africa” by Claire Laurier DeCoteau



In her most recent book, Dr. Laurier Decoteau eloquently traces the politics of HIV and AIDS from 1994 through 2010 in Post-Apartheid South Africa. She describes important shifts in health policy and nestles them in real-life stories of people living with HIV and dying from AIDS. Her ethnographic data, collected over ten years, highlights several key issues including the changing relationship between indigenous and biomedical health care and the complex and often contradictory way that the South African government failed to balance a neoliberal existence (i.e., political movement beginning in the 1960s that blends traditional liberal concerns for social justice with an emphasis on economic growth.) with the health needs of its citizens. A major theme throughout the book is that AIDS continues to be terrain upon which many post-colonial paradoxes are played out in South Africa.

South Africa is heralded for adopting one of the most progressive constitutions in the world. It is one of the wealthiest countries on the African continent. And yet, South Africa still maintains the ….distinction of having the highest rates of HIV prevalence in the world, and ranks among the most unequal countries in the world in ….wealth and income distribution (Page 7)


The book has five chapters, each with its own major theme. Chapter one describes the ethnographic setting for the book and introduces the reader to the challenges of living in townships and squatter camps and dealing with the effects that HIV and AIDS can have on a person, family and community.  We are introduced to the author’s method of presenting her arguments and raising important issues though the use of interviewee quotes.  One quote captures the essence of this chapter. “Many people think that HIV might kill them in ten years, but poverty or violence will kill them first, so why worry about it?” (Page 49)

Chapter two describes President Thabo Mbeki’s reign as President and his “AIDS Denialism”. We learn how this denialism affects people living with and affected by HIV and AIDS. President Mbeki’s main premise was that that biomedical science was couched in an imperialist paradigm and ignored the cultural and racial identity of Africans. The chapter outlines how his infusion of AIDS denialism promoted indigenous healing as an alternative to biomedical approaches, going as far as delaying the rollout of antiretroviral therapy and life-saving medication to thousands of people.  The author makes the case that his neoliberal economic policies required the state to cut social services, in essence, undermining ARV rollout. We also are shown ethnographic evidence that national discourses of self-responsibility became particularly prevalent during his tenure as well as a national environment that supported the individualization of blame for the spread of HIV. Ancestors and Antiretrovirals

Chapter three describes the efforts of the Treatment Action Campaign (TAC), a community-based advocacy group that took on the international pharmaceutical industry and ultimately brought free ARVs to South Africa. It also reinforces how structural obstacles often impede impoverished South Africans to participate in biomedical technologies.  The term “Biomedical Citizenship” is introduced and explained as we see examples of people who only have citizen rights if they have disciplined behavior to adhere to ARV medication.

Chapter four, titled “The Politicization of Sexuality” describes President Jacob Zuma’s reign and his ability to speak to poor South Africans.  Because he has been described as symbolizing many traditional aspects of an African Man, this identity is used to highlight several key issues.  The author argues that during this time period, deindustrialization and AIDS challenged idealized and traditional notions of masculinity and increased informalized sex.  This chapter illustrates how shifts in the political economy impacted gender ideologies and sexual practices in post-apartheid South Africa.

Chapter five analyzes the relationship between indigenous and biomedical healing in South Africa. We are provided an in depth analysis of indigenous forms of healing and how they have waxed and waned during the national discourse of AIDS over time.  We learn that “indigenous healing helps situate illnesses and recognizes them as composites of cultural, social, environmental, historical, economic and biological factors.” (Page 225) The book closes with a short critique by the author of “the ways in which biomedical solutions have failed to address some of the underlying, fundamental causes of the epidemic” (Page 23).  She argues that her research shows how an individualized, commodified approach to treating people, without regard for safety, sanitation and sustainability, might do more harm than good.


Having lived in South Africa between 2003 until 2007, this book was a trip down memory lane.  Many of the author’s arguments and many of the ethnographic anecdotes spoke to me personally.  At times I felt like a professor reviewing a doctoral dissertation and wanted to pull out the dictionary for words that I had never seen.  At other times, I found myself nodding in agreement of the points she made.  I regularly appreciated how she challenged core assumptions of Western social science. For example, she regularly offers evidence that the international epidemiological approach and a focus on individualized biomedical interventions decontextualize behavior and ignore the structural factors that create conditions of vulnerability to disease.

The book nicely captures the nuances of government policy choices and how these policy choices affect people’s lives.  I lived in South Africa during AIDS denialism; a period where drugs were available yet hindered from entering the country.  I fostered an HIV positive infant and worked through the systemic obstacles to get her on treatment.  It was a horrible and life-changing event.  I witnessed TAC marching at the international AIDS conference in 2000 advocating for ARVs on the continent.  I appreciated the author’s detailed account of TAC and although controversial, a critical organization in the fight to get services to people.  I saw an entire industry develop around the production of death and was maddened that people were denied ARVs.  I lived through the government fiascos that labeled the President and Minister of Health as unreasonable.  I remember the reshuffling of the Department of Health in 2006 after then Minister of Health Manta Tshabalala-Msimang displayed beetroot and lemon as a replacement for ARVs at the International HIV/AIDS Conference in Toronto.

Importantly, this book serves as a reminder that ethnographic methods are an essential tool for exploring the ways in which health and disease are experienced and understood by those most affected.  My friends and colleagues shared their stories of the stigma and shame that surrounds this disease.  In my opinion, donors and national governments have not paid enough attention to the power of stigma and discrimination. “With all of the obvious attention paid to the genocidal level of deaths the epidemic has produced, the words of HIV and AIDS are never mentioned at funerals. The bodies are piling up, but their significance is cloaked in silence.” (Page 76).  I appreciated that the author used interviewee quotes to bring important issues to the surface; no amount of epidemiologic data can capture the nuanced social and cultural issues that have an impact on HIV and AIDS.

I found myself wondering if I would appreciate the book as much as I did had I not lived the experience of working in the AIDS field in South Africa at the time.  I do, however, think that this book is artfully presented and an unusual read for those working in the public health arena.  It consistently connects the macro and micro levels and highlights the often complex and contradictory relationships between global processes, national policies and local practices. The emphasis on the broader system, relevant to health and disease, is critical when dealing with complex health issues such as HIV and AIDS.  Professionals and decision makers working on HIV and AIDS issues could learn lessons from disciplines such as sociology and anthropology, and would greatly benefit from a broader perspective than the strictly biomedical view of the world.


Follow @USAIDGH on Twitter through World AIDS Day, observed on December 2, for key facts, resources, and photos from our programs and partners and join the conversation using the hashtag #WAD2013.


Birth in the Age of AIDS: Women, Reproduction and HIV/AIDS in India

USAID is observing World AIDS Day this year by celebrating ten years of our HIV and AIDS work under PEPFAR.

Book Review: “Birth in the Age of AIDS: Women, Reproduction and HIV/AIDS in India” by Cecilia Van Hollen


Birth in the Age of AIDS takes the reader on a very personal journey of the experiences  HIV- positive women in Southern India have during pregnancy, delivery and postpartum.  Through the lens of an anthropologist, the author explores the socio-cultural dynamics of HIV and AIDS, providing emic (an insider’s) insights into such issues as stigma and discrimination, informed consent for HIV testing, confidentiality, partner disclosure, access to HIV and AIDS services, and reproductive decision-making.  Ethnographic methods are used to elicit underlying factors that come into play when HIV-positive women are faced with life altering decisions regarding pregnancy, childbirth and breastfeeding. These factors include blame and shame, gender, authority, religion, poverty, class and caste, sexual norms, kinship and marriage, property inheritance, widowhood and social structure.  The book depicts the interconnectedness between cultural norms and beliefs, HIV status, and motherhood and how they play out in many aspects of a HIV-positive woman’s life. Case after case, Van Hollen documents the consequences of being HIV-positive and the effects of being involved in social networks for people living with HIV.  Birth in the Age of AIDS


Van Hollen in her book, Birth in the Age of AIDS vividly brings out the stark realities that women living with HIV face during their reproductive years. During the early years of the epidemic, women had little access to information and services related to HIV and AIDS. They often learned of their status upon the death of their husbands and faced pregnancy as a HIV-positive widow, which in Indian society, results in double stigma and blame from her in-laws.  These women had to maneuver through complex social environments, carefully considering the impact of every decision on their family, children, and unborn fetus and on their ability to provide for their children.  Each decision was more difficult than the next – whether to get tested, whether to continue or terminate the pregnancy, whether to disclose their status, whose advice to trust, whether to take medicine during the pregnancy, where to deliver the baby to avoid discrimination, and whether to breastfeed. The thoughtfulness and selflessness portrayed by the women who shared their stories is inspiring, and rather than feeling pity (which they despise), the reader feels absolute admiration for their tenacity. Though deeply impoverished, the author demonstrates how women used every resource available to them to survive so that they can be good mothers, including religious conversion and remarriage.  This book brings to life the positive empowering results of being engaged in a network of people living with HIV and AIDS, taking women from the shadows of shame to the brightness of dignity.  Though the book focuses on case studies from a decade back, the stories of stigma, discrimination, avoidance, and rejection are timeless. Today, many HIV-positive women – as well as men, still face the same types of challenges in their families, within the health care system and in broader society as they traverse the worlds of HIV and maternity care.

Birth in the Age of AIDS provides a new perspective on the history of the international and domestic response to the AIDS epidemic in India from its inception in Tamil Nadu.  By meticulously dissecting each case from a variety of perspectives, Van Hollen uncovers layer after layer the patterns that create stigma, exacerbate gender inequalities, undermine women’s decision-making about their own health and treatment, and lead to family discord.  The book unfolds for policy-makers, program managers and service providers a profound understand of the complexities that underlie seemingly irrational decisions about what experts know as global best practices and evidence-based interventions.  It is not just a matter of taking a pill; we wish it were that simple.

Discussion Questions:

  1. The book calls into question which is a better practice for the HIV-positive woman – HIV testing using informed consent or the “opt out” approach as a routine part of prenatal care. On the one hand, using an informed consent approach offers the opportunity to provide detailed information on HIV prevention, care and treatment. On the other hand, it takes time and resources of health staff.  The U.S. has shifted to the “opt out” approach, which puts the decision about testing in the hands of the medical profession. Should developing countries follow our lead?

  2. Some of the health care providers in the stories demonstrate that their medical decisions were at times guided by misinformation, personal opinion, and discrimination.   Yet, taking health workers away from their health facilities for training and refresher training is both expensive and disruptive of services. What are other ways we can ensure health personnel are up to date on the latest medical information and practice and learn how to treat clients with respect?

  3. Couple counseling and testing during pregnancy is one approach thought to reduce the blame often put on the woman.  What were the experiences of the women who experienced couple counseling and testing? How can we improve the way couple counseling and testing is implemented in societies like those in South India where women are often blamed?

Follow @USAIDGH on Twitter through World AIDS Day, observed on December 2, for key facts, resources, and photos from our programs and partners and join the conversation using the hashtag #WAD2013.

New Evidence on Child Marriage Prevention in Ethiopia

From November 25th (International End Violence Against Women Day) through December 10th (International Human Rights Day), USAID joins the international community for 16 Days of Activism Against Gender Violence. During this time IMPACT will highlight USAID’s work to combat gender-based violence.

Defined as a formal marriage or informal union before the age of 18 years, child marriage is a practice that increases a girl’s risk of school dropout, maternal mortality, short birth intervals, vulnerability to gender-based violence, and poor mental health, among other adverse outcomes. Estimates suggest that 1 in 3 girls in the developing world are married before the age of 18. In areas such as the Amhara Region of Ethiopia, the prevalence of child marriage (CM) is among the highest in the world, with 2009 estimates showing that 50% of girls were married before the age of 18.

To help address the needs of 50 million adolescents who are already married, USAID invested in programs through PEPFAR to reach more than 220,000 married adolescent girls in Amhara, Ethiopia with access to family planning, STI services, HIV services, financial literacy, and menstruation management.

To help combat child marriage before it happens, USAID invests in research to prevent CM in “hot spot” areas with high CM prevalence. In Amhara, Ethiopia, as well as hot spot regions of Tanzania and Burkina Faso, USAID is supporting an innovative five-arm study on the effectiveness and cost of community education, economic incentives, and educational support on delaying marriage among adolescent girls, compared to control communities not receiving interventions.

Join the conversation with @USAID on Twitter using #16days.

Join the conversation with @USAID on Twitter using #16days.

USAID promotes dissemination and use of new evidence on effective strategies for child marriage prevention. A 2013 study (PDF) published by Anastasia Gage, supported under the USAID-funded MEASURE Evaluation project, sheds new light on how exposure to behavior change communication (BCC) affects knowledge and attitudes on CM among parents and guardians in Amhara Region. Although parents and guardians often decide when and who a girl marries, little data exists on effective strategies to change CM attitudes and knowledge among these gatekeepers.

Results from Gage’s study show that almost all parents were exposed to CM prevention messages from 1-2 communication channels.  Social influence was important to parents. Parents who believed their communities disapproved of CM were more likely to believe that marriage before age 18 was too early and that their daughters had the right to choose their own partner. By addressing parental attitudes and perceptions, programs can change social norms around child marriage. Future BCC campaigns on CM prevention should address the role of social influence on parental behaviors and attitudes and reinforce the health, economic, and educational benefits of delayed marriage. Evaluations of BCC programs should include a comparison group, monitor interventions for coverage, and measure changes in behaviors and practices.

USAID continues to support data collection on CM. Since 1984, the Agency has funded more than 260 Demographic and Health (DHS) surveys, which allow for identification of areas with the highest prevalence of CM. USAID supports rigorous evaluations of conditional cash transfer programs to delay CM among girls in India and Bangladesh, countries that account for the largest number of child brides in the world.

Learn more about USAID’s policies to address CM in Ending Child Marriage and Meeting the Needs of Married Children: The USAID Vision for Action. This vision is part of a suite of interlinked gender policies including the U.S. Strategy to Prevent and Respond to GBV Globally, the Gender Equality and Female Empowerment Policy, National Action Plan on Children in Adversity, Youth in Development Policy and National Action Plan on Women, Peace & Security.

The Power of a Grandmother’s Love

USAID is observing World AIDS Day this year by celebrating ten years of our HIV and AIDS work under PEPFAR.

As we approach World AIDS Day 2013, children affected by and living with HIV/AIDS must remain central to the global response.  As the largest funder of programs that mitigate the impact of HIV/AIDS in the lives of children worldwide, PEPFAR would like to celebrate the courage and compassion of all the caregivers, the grandmothers, the mothers and fathers, the aunts and uncles and older siblings, who have stepped forward to care for children affected by the epidemic.

GoGo means Grandmother in most South African languages. Photo credit: Tash McCarroll/USAID

“GoGo” means Grandmother in most South African languages. Photo credit: Tash McCarroll/USAID

GoGo is an old woman with a young girl’s bright smile. She lives in a small, tin-roofed, two room house in Soweto, with eight of her grandchildren. When her first daughter died of HIV, she took in her three young children, the oldest of whom was named Precious. At the time, Precious was 14. She was a clever girl who always did well in school and loved learning. When her mother became sick, Precious was forced to drop out of school to take care of her younger siblings and mother. And when her mother died, Precious moved in with her GoGo, who had no income and no means to support Precious to continue her education. Just as Precious began to lose hope, Grace walked into their lives. Grace is a Child and Youth Care Worker (CYCW) with the PEPFAR- supported Isibindi project.

CYCWs are para-social workers that support orphaned and vulnerable children whose lives have been turned upside down by HIV/AIDS. Grace helped Precious return to school and supported all of GoGo’s grandchildren to be tested for HIV. When GoGo’s younger daughter died and she took in her three children as well, Grace helped ensure they were also tested as well. And when tests indicated that none of the children were HIV-positive, GoGo and Grace were relieved, but they knew that they would have to continue to protect themselves and support these children in order to maintain healthy lives. Thanks to help from Grace, GoGo was able to complete an application and gain access to a government grant to cover basic expenses.

Grace still supports the family and visits with them twice a week. She makes sure the children are attending school and doing well psychologically, and helps GoGo to meet their other needs. GoGo still has eight children in her care, but she does not seem burdened or discouraged. She looks to the future with hope. When complimented on the care that she provides to her grandchildren, GoGo responds, “Of course I do this work. They are my children. No one can hold them like I can.”

Learn more about USAID’s role as a leading implementer of PEPFAR programs for orphans and vulnerable children.

This story is part of an ongoing series of blogs from the Office of the Global AIDS Coordinator in recognition of the 10th anniversary of PEPFAR. Previous blogs in the series can be found on the PEPFAR blog site. 

Follow @USAIDGH on Twitter through World AIDS Day, observed on December 2, for key facts, resources, and photos from our programs and partners and join the conversation using the hashtag #WAD2013.

R.E.S.P.E.C.T Find Out What It Means To Us

From November 25th (International End Violence Against Women Day) throughDecember 10th (International Human Rights Day), USAID joins the international community for 16 Days of Activism Against Gender Violence. During this time IMPACT will highlight USAID’s work to combat gender-based violence.

It is no accident that Aretha Franklin’s rendering of “Respect” rapidly became an anthem for marginalized and disenfranchised individuals and groups. The denial of human rights, particularly the most basic rights, such as respect, touches on a universal chord.

In recent years, global attention has been growing surrounding the horrifying issue of disrespect and abuse of women during childbirth.

Indonesia Maternal Health

USAID’s presence in Indonesia has been vital to the success of various health initiatives. The Blue Circle campaign of the 1980s and the Bidan Delima program in 2005 are just two examples of these initiatives that made it possible for women, like those pictured waiting in line, to receive maternal and child health and family planning services at community health centers. Photo credit: USAID/Indonesia

Think about the treatment you, or your wife, sister or daughter, expect from your maternity care provider. He or she is responsible for helping you (or your partner) give birth safely. Can you imagine a doctor scolding you for not using family planning to control your fertility? Or being separated from your newborn because you don’t have enough money to pay the discharge bill? Or giving birth unclothed while visitors walk by?

In both developing and developed countries around the world, pregnant women experience disrespect that ranges from subtle denial of their autonomy to blatant abuse. Numerous studies (PDF) document physical abuse in childbirth, including slapping, restraining, suturing without pain medication, or forcibly pushing on a woman’s abdomen. For women carrying or at high risk for HIV, the fear of stigma and discrimination from providers is often compounded by stigma from partners and families, especially regarding HIV testing or positive status disclosure.

This lack of respectful care also deters many women from seeking hospital care; instead they choose to give birth at home without the care of a skilled health attendant. This increases the change of complications from childbirth, possibly causing death.

While some may blame healthcare providers, many of these providers are working under suboptimal conditions, with many being overworked, underpaid, and burdened with unmanageable caseloads. The lack of empowerment, dignity, and security for midwives and nurses is driven by deep-rooted attitudes derived from gender, class, caste, race and cultural norms towards women. These problems undermine the resilience of midwives and nurses and negatively impact their capacity to provide quality care.

What does respect for women giving birth mean? The Universal Rights of Childbearing Women Charter (PDF) clearly outlines what respect means; certainly it includes the physical safety of pregnant women, but it also includes the respect for women’s basic human rights, including respect for women’s choices, preferences, feelings, and autonomy. It also means addressing the conditions of healthcare providers.

To eliminate the humiliation and abuse of women in childbirth, USAID supports the White Ribbon Alliance to lead global and country level advocacy and the University Research Corporation TRAction Project (PDF) to carry out implementation research to assess the prevalence of disrespect and abuse and test approaches to decrease these behaviors. With USAID funding, the Jhpiego/MCHIP Project has developed a comprehensive Respectful Maternity Toolkit available throughout the world. Furthermore, USAID is partnering with the World Health Organization to review the evidence on the status and working conditions of midwives and address the disrespect and abuse of women in childbirth.

We see the need for increased awareness and support for civil society engagement and advocacy, and the need to work with all involved in the direction, management and provision of care to women giving birth. Global initiatives, such as the Third Global Forum on Human Resources for Health, are key opportunities to realize these basic human rights.

Until recently, this was a problem hidden behind a veil of silence. Now we hear the silence being broken across the globe, but it is just a start.  Women’s voices need to be heard. And all of us need to respond to promote social justice and improve quality of care. Women’s lives depend on it.

Meeting the Needs of Children and Adolescents Who Have Experienced Sexual Violence

From November 25th (International End Violence Against Women Day) through December 10th (International Human Rights Day), USAID joins the international community for 16 Days of Activism Against Gender Violence. The blog below highlights USAID’s work to combat gender-based violence and celebrates ten years of our HIV and AIDS work under PEPFAR in advance of World AIDS Day (December 1).

Ruth was doing “okay,” with the help of her HIV medication and the friends she had made in a local support group for people living with HIV. With a shy smile, Ruth told me that she was getting by, but she missed her two young daughters. Her nine-year-old, Sarah, had been raped a year before and was now at a recovery center with her sister, who stayed with her for company. “She still hasn’t spoken, but she is getting better,” Ruth said with a sad smile.

In Swaziland, just before sunset, a young girl tests out a new seesaw on a playground built by the Elizabeth Glaser Pediatric AIDS Foundation at the Mkhulamini Clinic. Photo credit: Jon Hrusa, Elizabeth Glaser Pediatric AIDS Foundation

In Swaziland, just before sunset, a young girl tests out a new seesaw on a playground built by the Elizabeth Glaser Pediatric AIDS Foundation at the Mkhulamini Clinic. Photo credit: Jon Hrusa, Elizabeth Glaser Pediatric AIDS Foundation

Like many single mothers, Ruth worked during the day doing laundry and chores for other families. A male neighbor took advantage of her daughter when she was home alone. The attack had been so brutal that her daughter had been in the hospital for over a month. With the help of friends, Ruth made sure the man was arrested and prosecuted. It had been hard. The time spent on the case had left little time to earn income. Ruth’s family was struggling, but people were helping. She had hope that things would get better, and that her daughter would recover.

Ruth’s story and her courage epitomize the struggle to achieve an AIDS-free generation. Treatment is a miracle, but the true test of our resolve to end AIDS lies in our commitment to end the inequities of gender, of rich and poor, of powerful and vulnerable.

Girls, often marginalized by age and social status, are at a particularly high risk. Globally, young women aged 15-24 are the most vulnerable to HIV and account for 22 percent (PDF) of all new HIV infections (twice as high as young men). Furthermore, an estimated 150 million girls have experienced some form of gender-based violence before age 18. But this is not just limited to girls. According to the World Report on Violence Against Children (PDF), an estimated 73 million boys globally have also experienced sexual violence before age 18. Such violence has severe consequences for their immediate and long-term health and well-being, including increased risk for sexually transmitted infections such as HIV, reproductive and sexual health complications, alcohol and drug abuse, and psychosocial health issues. In addition, results from the PEPFAR Sexual Gender Based Violence Initiative showed that when sexual assault services were introduced to primary health centers, a large percentage of patients presenting for care were under 18, but services were not tailored to meet their unique needs.

USAID, as a key implementing agency of PEPFAR, has a strong commitment to addressing the unique needs and vulnerabilities of children and adolescents experiencing sexual violence, including addressing the gender-related factors that underlie such violence. The recently launched guide, Clinical Management of Children and Adolescents Who Have Experienced Sexual Violence: Technical Considerations for PEPFAR Programs, offers step-by-step technical advice for clinicians, social workers, pediatricians, child protection workers, HIV specialists and others on appropriate clinical care and management. These technical considerations are meant to serve as a starting point for national level adaptation and development of comprehensive, integrated services for children.

As we travel down the road to an AIDS-free generation, we hope that stories like that of Ruth’s daughter dwindle into extinction. In the meantime, for those children that are afflicted by such unspeakable sexual violence, we pledge to continue serving their unique needs and vulnerabilities.

Fostering Leadership to Eliminate Mother-to-Child Transmission of HIV in Nigeria

USAID is observing World AIDS Day this year by celebrating ten years of ourHIV and AIDS work under PEPFAR.

More than 85,000 infants in Nigeria are at risk of HIV transmission from their mothers every year. While the number of HIV-positive pregnant women who receive antiretroviral treatment (ART) is increasing, robust efforts to improve coverage are needed if national targets (PDF) for prevention of mother-to-child transmission of HIV (PMTCT) are to be met in 2015.

Keziah Samaila, coordinator of PMTCT in Township Clinic, Nigeria, training women on Family Planning and HIV. Photo: Lourdes de la Peza

Keziah Samaila, coordinator of PMTCT in Township Clinic, Nigeria, training women on Family Planning and HIV. Photo: Lourdes de la Peza

Over the past year, the Leadership, Management and Governance (LMG) Project helped support the PLAN-Health Nigeria project, funded by PEPFAR through USAID and managed by Management Sciences for Health (MSH), to pilot Leadership Development Program Plus (LDP+), which focuses on empowering teams to improve PMTCT results. The program also emphasizes new approaches tied in to country ownership, national health priorities, and specific health indicators.

LDP+ was piloted in the town of Gwagwalada, Nigeria. The Gwagwalada Council is one of the five Local Government Area Councils of the Federal Capital Territory (FCT) of Nigeria. LMG and PLAN-Health worked with the Gwagwalada Council, which selected 20 participants—two from each of the 10 facilities providing PMTCT services in the area—to form 10 teams to participate in the LDP+. Together, the teams decided to address PMTCT and focused on improving some standard indicators such as number of new antenatal care (ANC) clients; number of pregnant women tested for HIV, counseled and received their results; and the number of HIV-positive women. The program ran from October 2012 to May 2013. During this time, the teams worked within their facilities to create a vision of improved results around PMTCT, align stakeholders around this vision, implement their action plans, and share learning with other teams to identify the most useful local interventions and activities. The teams also received coaching in the areas of monitoring, evaluation, and reporting.

Keziah Samaila from Township Clinic, left, and Joy Otuokere, right, from Zuba Health Center, singing during the LDP+ training in Gwagwalada, Nigeria. Photo: Lourdes de la Peza

Keziah Samaila from Township Clinic, left, and Joy Otuokere, right, from Zuba Health Center, singing during the LDP+ training in Gwagwalada, Nigeria. Photo: Lourdes de la Peza

Most of the facilities reported encouraging results for their key indicators after participating in LDP+. For example, the Old Kutunku Health Center reported an increase from 17 to 61 new ANC clients per month. At the Gwako health center, the percentage of ANC clients who delivered in a health facility increased from 18 to 42 percent. Prior to LDP+, the Township clinic counseled and tested the partners of only three percent of pregnant women, compared with 20 percent after the program.

Alfa Ndatsu from Gwako Health Center, presenting his team work on the challenge model during LDP+ training. Photo: Lourdes de la Peza

Alfa Ndatsu from Gwako Health Center, presenting his team work on the challenge model during LDP+ training. Photo: Lourdes de la Peza

The Gwagwalada Council’s oversight committee plans to continue the program with its own resources, expanding it to another eight facilities in the area. Through these efforts, this local government agency is furthering Nigeria’s national efforts to ultimately eliminate mother-to-child transmission of HIV.

Follow @USAIDGH on Twitter through World AIDS Day, observed on December 2, for key facts, resources, and photos from our programs and partners and join the conversation using the hashtag #WAD2013.

10 Years in the Making: Celebrating USAID’s Achievements Under PEPFAR

USAID is observing World AIDS Day this year by celebrating ten years of our HIV and AIDS work under PEPFAR.

In less than two short weeks, the global health community will unite to commemorate the fight against AIDS. The United States, foreign governments, civil society, local communities and many others dedicated to reaching an AIDS-free generation will mobilize around the world to celebrate the incredible achievements that have been made since the epidemic was first identified over 30 years ago.

We’ve come a long way in the last three decades: unexplained immune system failure and a race to identify the cause in the early 1980s; life-sustaining therapy introduced in the mid-1990s; a landmark foreign assistance initiative in 2003 that brought treatment to millions of people who had no access before; and a groundbreaking study in 2011 showing that healthy people living with HIV on antiretrovirals can limit transmission by 96 percent. The worldview of the HIV pandemic has changed dramatically in our lifetime.

The Building Local Capacity Project has reached 57,223 orphans and vulnerable children (OCV) and caregivers with child health services in southern Africa. Photo credit: Management Sciences for Health

The Building Local Capacity Project has reached 57,223 orphans and vulnerable children (OCV) and caregivers with child health services in southern Africa. Photo credit: Management Sciences for Health

Our work is not over. As Secretary of State John Kerry said during a speech earlier this year, “As progress continues, we will gradually evolve as our fight against this disease evolves, and that is going to happen both by necessity and by design. Achieving an AIDS-free generation is a shared responsibility and it is going to be a shared accomplishment.”

Some of the most monumental achievements in combating HIV and AIDS have occurred in the past 10 years with the creation of two unprecedented global health programs – the Global Fund Against AIDS, Tuberculosis and Malaria and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). PEPFAR was, and continues to be, ambitious, visionary, and far-reaching. Through access to antiretroviral treatment, it has literally brought people living with HIV back from the brink of death and enabled them to live long and healthy lives.

It’s been ten years since the United States Leadership Against HIV/AIDS Tuberculosis, and Malaria Act of 2003 was passed into law, creating PEPFAR. And today, we can confidently say that the program has saved millions of lives and delivered hope to communities where it was so desperately needed.

As a key implementing agency, USAID has contributed significantly to these remarkable achievements. Through programs that prevent mother-to-child transmission, offer voluntary medical male circumcision and improve condom use, to those that reduce gender-based violence and risky behaviors for select populations; through our commitment to deliver effective treatments and care for the most vulnerable – especially orphans and other affected children – to our support for the development of an HIV vaccine, USAID has played a significant role in changing the face of the pandemic around the world.

In the 10 days leading up to World AIDS Day  – through a digital campaign called 10 for 10 (PDF) – USAID will share stories from the last decade that touch on the various ways the agency has contributed to one of the most successful foreign assistance programs ever created. This campaign will culminate in the launch of “Gift’s Last Ten Years” – an animated video that tells the story of our work through the eyes of a fictional 10-year old southern African girl.

AIDS used to be a disease that everyone feared and discussed only in private. Today, there is a global sense of optimism that did not seem possible at the beginning of this century. What a difference a decade makes – we’re proud to have played our part.

Follow @USAIDGH on Twitter through World AIDS Day, observed on December 2, for key facts, resources, and photos from our programs and partners and join the conversation using the hashtag #WAD2013.

Achieving Equity Through Women in Leadership

I’ve just returned from the International Conference on Family Planning in Addis Ababa, Ethiopia, where thousands of leaders and experts came together to discuss how to improve access and choice in family planning services across the globe. One of the highlights of the conference for me was speaking on a panel about the role women leaders can play in this arena.

I don’t think you have to be a woman to be committed to achieving equity in access to family planning services.  There are countless men in leadership roles that are deeply committed to expanding equity across the board, including in access to family planning.  That said, I think having women in leadership positions is incredibly important.

Mother and child at a health clinic in Ethiopia. Photo credit: USAID

Mother and child at a health clinic in Ethiopia. Photo credit: USAID

We often talk about women leaders as role models for girls.  Certainly having women in leadership roles lets girls see someone who looks like them doing things they might dream of doing and helps validate those dreams.  But women in leadership positions are role models for boys too—that women belong in leadership positions, that having women in these roles is normative. Having women in leadership roles in government is an especially public acknowledgement of legitimacy.

Governments have a responsibility to treat their citizens equitably, which means they have a special role to play in addressing disparities, whether that is as a direct provider of health services or by making it attractive for the private sector to serve the underserved or both. When governments prioritize making it possible for poor women, rural families, adolescents, and racial or ethnic minorities to exercise their right to choose the number, timing, and spacing of their children by expanding access to high quality, voluntary family planning information, services, and methods, they send a message about their commitment to equity and rights.

Having women employed in visible roles in government programs, whether they are in formalized leadership positions or not, also sends that message.   And there are great examples all around us:

  • Managing the largest portfolio that USAID has in Asia, female Foreign Service Nationals at USAID’s Bangladesh mission have strengthened the family planning portfolio. Dr. Umme Meena in the mission there—and other men and women like her employed as Foreign Service Nationals by the U.S. government worldwide—demonstrate America’s commitment to equity in family planning every day.
  • In Amhara, Ethiopia, USAID supports activities to prevent child marriage by identifying young female community mentors who can advocate against marriage before the age of 18. These youth leaders are powerful agents of change and gender equity in their communities.
  • Community health workers are some of the most passionate and committed champions for equity in access to family planning and health services. Esther Nyokabi in Kenya is an illiterate woman who overcame significant personal obstacles to become a champion for post-abortion care. She mobilized her community to demand better health infrastructure from the government. She is now a passionate community health worker and part of a government –sponsored training team for post-abortion care. Her efforts have brought life-saving antenatal care, skilled attendance at delivery, and family planning services to a community that did not have health services previously.

It is the commitment, passion, and actions of leaders like these that will achieve full choice in family planning.

Watch a video clip of Ellen Starbird at the International Conference on Family Planning and read news and announcements made by USAID at the conference. 

A Lesson in Holistic Care: What I Learned from Working with Transgender Women and Health Providers in the LAC Region

November 20 is Transgender Day of Remembrance.

I have collaborated closely with transgender women and health providers in Latin America and the Caribbean to learn more about the needs of transgender populations and to train health workers to provide quality services. Working alongside transgender women on needs assessments, trainings for health providers, and in the development of a blueprint (PDF) for comprehensive transgender services, opened my eyes to their experiences, gaps in existing programs that limit access to critical services, and the opportunities we need to pursue. To help you understand my recommendations, I would like to share a story I heard repeatedly from transgender women:

I was 13 years old when my family threw me out of the house because of who I am. I tried to continue my studies, but I dropped out of school because my classmates insulted me every day and sometimes hit me, and I was afraid to use the boys’ bathroom (the only one I was allowed to use) because I was afraid of being assaulted by male students. The teachers looked the other way or called me names. I have developed a thick skin because when I step out of my home, people stare, make comments and give menacing gestures. Going to a clinic is also unpleasant. I get sick like everybody else, but the nurses always assume that I am a sex worker and that I have HIV. Frequently, they give me condoms and an HIV test and send me home. One time I was jumped by four guys in the street, and I ended up in the emergency room. When one of the nurses opened my robe and saw that I am a transgender woman, she gave me a look of disgust and called me a homosexual. She must have told others about me because several nurses came, opened my robe and walked away laughing. I waited for a long time before a doctor saw me. He told me that real men do not dress like women, and that I should cut my hair and stop wearing make-up so I could get a job. I had a cut in my head that needed stitches and the doctor did not even clean the blood in my hair.

REDTRANS and Miluska staff conducting a workshop on HIV and human rights. Photo credit: Manuel Contreras

REDTRANS and Miluska staff conducting a workshop on HIV and human rights. Photo credit: Manuel Contreras

This story, and the others that I heard through this work, underscored the need for a new approach to transgender health:

  1. Prevention efforts must engage families and schools to foster supportive environments.  Transgender teens frequently experience rejection from their families and bullying in school. Homelessness, low literacy, and lack of family protection not only increase the likelihood that these teens will experience exploitation, but also severely limit their opportunities to find jobs.
  2. Many people, including health providers, do not clearly understand the spectrum of sexualities, genders, and identities. Their confusion often leads to stigmatizing attitudes and discriminating practices in health care settings, which in turn discourages transgender women from seeking care.
  3. Increasing access to counseling and testing and other HIV services should not be an end in itself. Securing the human rights of transgender communities and creating a safer environment where they can access appropriate services without fear of violence or discrimination should be the focus.
  4. Increasing access to condoms and HIV information are cornerstones of HIV prevention, but national prevention programs need to go beyond these two strategies. Policies and programs should also support employment and education opportunities for transgender persons. The pressure to put food on the table and a roof over their families’ heads can lead to poor decision making, resulting in risk-taking behaviors.
  5. Engaging transgender persons in program activities as facilitators or data collectors strengthens their technical capacities and allows them to engage with health providers and communities as professionals and peers. This can effectively dispel myths and negative beliefs about transgender women, their capacity, and their behavior.

By sharing my observations and the stories I heard, I hope to raise awareness of the issues that come into play and to encourage all of us to reconsider how our programs can better contribute to the well-being of transgender persons and their communities. We can make that commitment today on Transgender Day of Remembrance, an internationally recognized day to memorialize those who suffered or died as a result of anti-transgender hatred or prejudice.

Aysa Saleh-Ramirez, MPH is AIDSTAR-One Senior Technical Advisor at John Snow, Inc. AIDSTAR-One is funded by PEPFAR through USAID.

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