[procaare] "How to Fight HIV/AIDS in the New Millennium"

["David Patient" <david@empow.co.za>]

"How to Fight HIV/AIDS in the New Millennium"

A commentary by David Patient- Person living with AIDS since his diagnosis
with GRIDS back in March, 1983. 
******************
 
The range of social, economic and political issues concerning HIV and AIDS
is vast and complex. The impact of this pandemic will only be known in  future generations. It is an established fact that HIV/AIDS has  significantly reduced life expectancy, educational gains have been reversed,
poverty increased, and it has eroded economic growth.

Other longer-term effects concern urban-rural disparities in terms of all
aspects of service and development. Conversely, the concerted efforts to
deal with all these issues has increased awareness and efforts concerning
gender equity, primary health and capacity, and mobilised diverse
organisations in the pursuit of common objectives. If anything else,
profound change - both negative and positive - has, and is, occurring as a
direct result of HIV/AIDS.

1.    In my view, there are a number of options available to not only
accelerate the attainment of the various MDG objectives, but also to improve
the effectiveness of diverse efforts. Probably the most important is a
re-evaluation of the fundamental value bias of primarily Western-based
agencies: In Africa specifically, the foundation of social norms is a
group-mindedness, whereas Western-based social norms are focused primarily
upon attainment of individual actualisation. This may not appear
significant, but this bias has impacted upon delivered programs and methods
in profound ways: The ethics of confidentiality in individual testing and
counseling, versus relationship or group-based procedures, is such an
example. Without the structures of individual confidentiality - both in
counseling and medical treatment - the scope of efforts could be
significantly broadened, and the relational basis of the pandemic could be
more effectively - and rapidly - addressed. Recent research concerning
concurrent relationships clearly indicates that it is not sexual frequency
that is driving the pandemic, but rather the nature of sexual relationship
networks. I believe it is time we deal directly with those relationships,
versus its' individual parts, in both testing, prevention, and treatment.

How do you apply group-mindedness in practice? Setting aside the implied
legal changes required, what I would like to see is: Couples counseled and
tested for HIV, together, not separately; Family units treated medically,
such as with ART. Quite literally, a family - such as the husband and wife -
going through the medical testing for CD4s and viral load together, knowing
each other's results, and then being treated with the full knowledge (and
counseling) of both persons. This should address many of the non-adherence
problems, including the rise of drug-resistant strains of HIV. More
controversially, the Zero Grazing (Uganda) model should be revived, where
family, friends and neighbours are encouraged to name-and-shame community
members who are being unfaithful to their primary relationship, thus
reducing the ease of engaging in concurrent relationships.  Essentially I am
proposing behavior-change methodology that focuses upon group and
relationship dynamics, versus individual decision-making.

Recommendations:

(a)   VCT: Redesign/expand protocols to include couple/family HIV testing
and pre/post-test counseling. I.e., all stages of the process conducted in
the presence of both persons (or family members);

(b)   ART: Medical examinations, diagnosis, explanations conducted in the
presence of a family member/spouse. 

(c)    Prevention: Revive/adapt the Zero Grazing model to focus upon
reducing multiple concurrent relationships. 

(d)   Create processes that enhance relationships including but not limited
to increasing levels of intimacy, communication, trust and combined future
dreams/plans that both partners desire.

(e)   Adopt mandatory counseling sessions within the workplace with opt-out
testing.


2.      Secondly, with exceptions, leadership at the macro-political
leadership level is weak or absent in terms of setting the social normative
tone for the changes that are required. Instead, leadership tends to be
overly concerned with being seen to be cut from the same cloth as their
constituents, versus leading those constituents through difficult changes.
The need for popularity supersedes the desire for effectiveness. This is
partly associated with the post-colonial desire to build identity and esteem
through adherence to cultural values, some of which directly impede the
attainment of the MDG objectives. This is particularly the case with
gender-related social norms, and the role of women in positions of
authority. Although great strides - legally and constitutionally - have been
made in this regard, it is simply not enough, and certainly not implemented
with great vigour.  

It is a fact that one of the primary drivers of the spread of HIV is
concurrent relationships, which has many roots, some cultural (polygamy),
and some economic. However, this form of open-ended polygamy results in a
radical increase in transmission of HIV during the acute infection stage,
the Window Period. Regardless of our desire to be value-neutral in this
regard, we have few options in eliminating this wide-spread practice. We
have almost no chance of changing this practice when our leaders openly have
multiple partners, some long-term, and some casual. Until they - the leaders
- change, the populace will resist monogamy. The alternative is to legalise
and normalize multiple partnerships in such a way that the responsibility to
economically support and care for a second or third partner is legally
enforceable, similar to closed polygamy, but with the emphasis upon full
economic responsibility. This approach should resonate with many people who
refer to 'traditional values' - which included polygamy - with penalties for
breaking the rules. This should, if done carefully, reduce the casual sex,
and also the Sugar-Daddy (or Sugar-Mommy) and similar situations, which is
based upon attaining economic support.  A simple avenue to implement this
would be to reduce the period of time required for a relationship to be
recognized as Common Law marriage, increase the amount of spouses permitted
per person, and then implement an advocacy campaign educating people about
their rights under this system. The bottom-line with this proposal is: If
you want more than one partner, then you'd better be ready for the economic
and legal consequences. 

Recommendations:

(a)   Implement a scorecard for politicians and community leaders which
includes knowledge level of HIV/AIDS, and also the number of public
statements/projects delivered - personally - regarding HIV/AIDS, poverty,
and other MDG goals. 

(b)   Evaluate traditions and customs that enhance and reduce the attainment
of MDG goals. Facilitate public discourse on these beliefs, customs and
traditions.

(c)    Evaluate the existing legal framework regarding multiple
partnerships. Consider legal changes to strengthen the economic and legal
rights of concurrent partners, to bolster the level of responsibility of the
common partner, in order to close what is currently an open polygamous
system. 

(d)   Conduct a public advocacy campaign to make concurrent partners aware
of their legal and economic rights, with respect to the common partner. 

(e)   Revisit current legislation on the paternal laws that hold men
accountable for their off-spring to lessen the burden on State systems.

 

3. The third major factor concerns the urbanisation of our populations, and
the economic power of these urban areas: Rural areas are simply neglected or
given token attention. The reality is that many governments and businesses
are applying an utilitarian approach to the rural areas: It is - per person
- more expensive to develop rural areas, compared to the more densely
populated and economically active urban areas. The current focus is
primarily upon job creation - which mainly focuses upon urban areas - and
the needs of urban populations, while the food production, education,
medical care in rural areas are given second place, consistently. The
general situation - at least in terms of HIV and AIDS - is that if you are
employed in an urban area and have HIV, you will be okay. However, if you
live in a rural area, the outcome is dire. This does not only apply to HIV
and AIDS - it is a generalised scenario in terms of education, medical care,
and service delivery of basic services. As a result, the migration from
rural to urban areas continues relentlessly, with a resulting decrease in
food production, for example. We sorely need greater attention for the
development of rural areas to counter this increasing marginalisation and
impoverishment of large sections of our populations. Young people in
particular would prefer to be unemployed and living in fringe suburbs, than
work on land inherited from their family. This is a direct result of social
marketing, which depicts farming and food production as the domain of the
poor and uneducated. We need the social status of rural areas to be
increased and enhanced, making activities such as farming a desired career
and future, particularly with younger people. 

Africa - with South Africa as an example - is hell-bent on economic
development, as this generates the revenues for the various services the
government is obliged to provide. However, in this process, the ability of
the population to support and feed itself through homestead farming is
neglected in favour of commercial farming. Tremendous dependency is being
created upon industry and government services, with little attention given
to increasing the capacity of individuals and families to take steps to
improve their own food security (e.g., home gardens), and entrepreneurship
(self-employment). These two areas need a great deal of attention, if we are
to uplift both rural and urban areas from unemployment and poverty: The
current mind-set is that if you are not employed or on a government grant,
your prospects are dim. Although programmes exist for developing
entrepreneurship, these are weak, half-hearted, and limited.
Entrepreneurship should be a key subject of education in the education
system. 

The rural areas in particular require far more development in terms of
quality education for children, skills development (e.g., improved farming
methods, homesteading), and adult literacy programmes. Primary health
services are in dire need of improvement and expansion. If we could double -
even treble - the number of primary health nurses in these areas, and also
capacitate them to assume the responsibilities of diagnosing and prescribing
medications such as ART, we may start to address the severe shortages of
doctors in these areas, thus stopping the worsening poverty cycle caused by
removing children from school take care of sick family members, and also
adults who would be otherwise engaged in food production. We bemoan the
poverty and dire circumstances of many communities, and ask how we can 'save
them'. However, we fail to recognize that those communities have the
inherent ability to 'save' themselves, given the necessary information,
education, and start-up resources. We need to end the hand-out era, and
start the hand-up process: When dependency decreases, so does poverty. When
self-reliance increases, so does pride and productivity.  

Recommendations:

(a)   'Create your own job': Raise awareness and knowledge regarding
entrepeneurship at all levels of society, including at secondary schools.
Local, regional and national competitions which promote and reward such
activities - including in the rural areas - would facilitate such awareness,
status, and skills. 

(b)   Significantly increase the budgets and efforts focusing upon self- and
family-sufficiency regarding food security. This would include practical
support regarding seed and fertilizer supplies, skills transfer regarding
issues such as soil quality, water-wise methods, crop rotation and/or
intercropping. Such efforts could be implemented at all primary and
secondary schools, not only to provide food to the children, but also to
provide the venue for such skills development. Include such activities in
annual performance assessments of such schools and personnel.

(c)    Expand the role of Dept Agriculture extension workers to support and
capacitate homesteads in food security, versus focusing primarily upon
commercial farming. Development and research into non-hybrid seed varieties
to encourage seed banking, and thus sustainability of such food security
methods. Dry-land and permaculture methods (e.g., mulching, recycling used
water) to be refined and promoted. I.e., reduce the dependency upon
purchasing processed foods of low nutritional value, and increase
self-produced home produce.

(d)   Raise the awareness of homestead food security methods through the
media (television, radio, newspapers), with regular awards to raise the
status of homestead food production. 

(e)   Revise the policy and education structures to expand the capacity of
nursing personnel to diagnose and dispense medications such as ART and
prophylaxis.

(f)     Elevate the status of the nursing and teaching profession to attract
more applicants from schools. Make such recruitment a national strategic
priority.

(g)   Attach conditions to receipt of social grants for the unemployed. For
example, attendance of skills training (including entrepreneur-related and
food security methods), and demonstrations of application. 

(h)   Introduce micro-lending systems to stimulate economic activity in
rural settings, giving people basic business education to ensure
sustainability.

(i)     Utilize Post-Test clubs in rural settings to support healthier
living through health empowerment programs and education. 

It is high time we started having some very challenging, courageous and
difficult conversations if we hope to be truly effective. We need to have
the courage to challenge so-called 'norms' that are sustaining this pandemic
once and for all.


David R. Patient (MHT)
Empowerment Concepts
Email:  david.patient@empow.co.za |