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Funding AIDS versus Maternal Health – Does it Really Need to Be Either/Or?

May 16, 2010

Tyler Hicks/The New York Times

Walking skeletons, stacks of bodies in morgues, mountains of newly turned earth in cemeteries.

According to a recent New York Times article, “At Front Lines, AIDS War is Falling Apart,” this will soon be the reality in most of Africa and other countries like Haiti, Guyana and Cambodia.

For those of us in developed nations, AIDS often seems like a thing of the past; a challenge that we’ve overcome. (However, the reality, here too, is that it’s not. Did you know that every 35 minutes an American woman tests positive for HIV? Women and girls of color—especially black women and girls—bear a disproportionately heavy burden of HIV/AIDS in the United States.)

Globally, HIV/AIDS is still an epidemic of unsettling proportions. There are currently 33 million people infected with HIV/AIDS; 14 million are immuno-compromised enough to need drugs yet fewer than four million are on treatment. Globally, 7,400 people are infected every day.

As the global AIDS crisis persists, there is an increasing shift among donors to focus health initiatives on “cost effective interventions.” For example, under its new Global Health Initiative, the Obama administration has announced plans to shift its focus to mother-and-child health—emphasizing investment in “diseases that cost less to fight, including pneumonia, diarrhea, malaria and fatal birth complications” rather than “expensive” AIDS interventions.

I, like other feminists, have been thrilled to witness more and more attention on global maternal and reproductive health in the past year. However, I can’t help but question the motivations. Is a mathematical “bigger bang for our buck” approach valid when we are considering human lives? Furthermore, human beings—and the diseases that impact them—don’t exist in isolation from one another, or from their societal context. Is it effective to confront health initiatives as if they do?

At the onset of the AIDS epidemic, in the early 1990s, Uganda earned renown for pushing its infection rate down from 18 percent to 6 percent. It is now seen as the first and most obvious example of how the war on global AIDS is falling apart. The reason for this is that 500,000 people need treatment, 200,000 are getting it, but each year, an additional 110,000 are infected. Donors and decision-makers are beginning to realize that AIDS treatment will never be widespread enough and that it is not the panacea they hoped it would be. As a result, AIDS interventions in places like Uganda have essentially been deemed a waste of money.

In 2006, I spent several months in Uganda working for a national HIV/AIDS organization called The AIDS Support Organization (TASO). As I traveled throughout the country, I witnessed first-hand that HIV/AIDS is a devastating medical illness which is embedded in and fueled by inter-personal and socio-cultural relationships. Medical treatments alone–even expensive ones–were never going to end the crisis.

In Uganda, as in most countries, heterosexual sex is the primary mode of HIV transmission. Gender inequality is a fundamental factor driving the spread of the disease. It is a relatively well-known fact that social, cultural, and economic factors limit women’s ability to negotiate sexual relations and safeguard themselves against HIV infection. This is as true in Uganda as it is in the rest of the world.

The higher prevalence of HIV in the Ugandan female population and the greater vulnerability of women to infection mean that the epidemic is often described as having a “female face.” However, the reality is that most HIV-positive women contracted the disease through sex with a man. Behind every woman who is HIV-positive or at risk of becoming HIV-positive is a man who is HIV-positive or at risk of becoming HIV-positive. Gender norms both disempower women and obscure men’s vulnerabilities, resulting in an increased risk of death for all.

What public health experts deem “high-risk sex” (defined as sex with multiple, non-marital partners; inconsistent and no condom uses; commercial, transactional, and intergenerational sex; sex without testing or disclosure of HIV status) is the norm in Uganda. It is also precisely the kind of sex that  characterizes ideal masculinity. As one young Ugandan man explained to me, “society rewards aggressive, sexually promiscuous men… this has greatly contributed to the spread of HIV/AIDS.”

Although condom use is one seemingly simple solution to the spread of HIV, the annual supply of condoms in Africa amounts to only four per adult male. Furthermore, men told me that they shun condoms because “they are foreign and unnatural.” Sex with a condom is considered to be “Western sex” whereas African sex is “live, flesh-to-flesh sex.” This way of thinking won’t go away just because we say it should.

I do not say all of this to point the finger at men, or male behavior, as the problem. There is a basis—even if it unacceptable—for risky sex. The fact that Ugandan men are taught from a young age not to ask for help, to “be a man,” not to admit to feeling pain, and that it is shameful to cry has an important role to play in both the spread and prevention of HIV/AIDS. In order to combat the epidemic it is necessary to take seriously both men and women’s gender and cultural identities. As sexual and reproductive health experts have pointed out:

“Traditional men’s gender roles limits men’s options regarding how they can behave, put stress and strain on men, encourage more sexual partners and sexual activity, promote beliefs that sexual relationships are adversarial and lead to more negative condom attitudes and less condom use.”

Listening to men reveals that they too feel vulnerable. They fear dying alone. And they feel ashamed. Several Ugandan men told me, “men often turn the blame on women yet it is the man who brought the disease to the house. He knows this but fears saying that he was the one.” With tears in his eyes, one man told me: “All those problems I brought [to my wife] because I was misbehaving… when I think about my story and what I brought [to her] I feel pain.” Ignoring these emotions, or dismissing them to instead focus on men’s power in relation to women, will not solve the problem.

It is much easier to treat a disease’s symptoms than to confront the human—and at times controversial—issues that underlie those symptoms. However, as the AIDS crisis shows, that doesn’t work. AIDS is a disease that, in the majority of cases, has everything to do with gender, sex, and sexuality (as in, the state or quality of being sexual) and as Alanna Shaikh wrote last week in the UN Dispatch,

“We ignored AIDS prevention because it was political. It involved a whole lot of things that are hard it talk about in public – homosexuality, casual sex, marriage, abstinence – almost every hot button issue in human politicos. It was a whole lot easier to keep spending money on anti-retroviral treatment than to talk about sex like reasonable adults.”

Focusing on cost-effective—albeit vital and long-overlooked—maternal and child health programs at the expense of holistic strategies (that include AIDS treatment and prevention) may be easier but it isn’t strategic. Rather than talking about money, let’s focus on people–women and men, as equals.

  1. Jessica Mack permalink*
    May 17, 2010 9:46 pm

    Nice post, and I’m glad you picked up on this article in the NYT. It was pretty impressive and a wake up call that I think a lot of people didn’t want to hear. But I don’t think funding has to be either for HIV/AIDS or for maternal health. In the most recent round of stats for maternal mortality — about 13% of those deaths are accounted for by deaths from AIDS. Women comprise the majority of new infections, and are disproportionately vulnerable. So it’s certainly a “both.” I think the maternal health community can learn a lot from the AIDS community, which was able to galvanize a rallying cry for funding and for action — and make the issue both a global north AND global south issue — pretty much like no other issue in history. In the maternal health field, we’re “lucky” that it’s just now becoming clear it’s a “bang for your buck” aid option, and we should capitalize on this momentum by convening in the same, unified way with a clear ask. For the AIDS community, it was largely about getting treatment out, and it was successful in many ways. Yet what is the “silver bullet” in the maternal health issue? I think that’s what makes it so hard…though certainly not impossible.

  2. alicia permalink
    May 18, 2010 10:20 pm

    Thanks Jessica. I absolutely agree that it should be a both – particularly because, as you said, maternal mortality and AIDS affect many of the same women. You make a great point about the AIDS community being able to make the issue both a global south and global north issue. There is certainly alot to be learned from that. What do you think was done in particular that resulted in this?

    In terms of a “silver bullet,” I actually think part of the problem – and why the AIDS crisis is still a crisis – is because people presumed that treatment was the “silver bullet.” Treatment hasn’t failed. It is the fact that in too many situations it was looked to as the exclusive solution. Holistic (“whole-of-body”) approaches are needed – both for AIDS and maternal health issues. AIDS, reproductive health, water-borne diseases, malnutrition, economic rights, etc., don’t exist in isolation. Nor do women. Let’s deal with whole people (rather than individual health issues) and whole communities (rather than select members of communities). Maybe that’s the closest we can get to a “silver bullet?”

    • Jessica Mack permalink
      May 21, 2010 3:39 pm

      While I don’t work in the HIV/AIDS field and wouldn’t claim to be an expert by any stretch, I would argue that treatment really has been the silver bullet in many ways. Is everyone who needs treatment on it? No, but scads more are thanks to really effective advocacy work and pricing strategies over the years. Also, ARVs are increasingly seen to hold the promise for prevention tools like microbicides. By using treatment methods preemptively, new studies suggest a really high level of protection against infection. I think this holds special promise for women, who can control and administer methods like ARV-based microbicides, without their partners’ involvement, and keep themselves much better protected.

  3. May 21, 2010 2:41 pm

    Maternal health, family planning and prevention and treatment of sexually transmitted infections (STIs) including HIV and AIDS should be part of a package of health services required to protect and promote the sexual and reproductive health of women.

    Women need to be equipped with the information, skills and services to make informed decisions about family size.

    They must have access to safe, affordable voluntary contraceptives, including emergency contraception, and male and female condoms. And they need prevention and treatment of the STIs that harm not only their own health and lives, but those of the children they choose to bear.

    This package will ensure that women will live healthy lives.

    This comprehensive package will help to respond to all women’s sexual and reproductive health needs not just one need at the moment of a pregnancy but throughout their life span. Additionally, young people should receive appropriate sexual and reproductive health information in schools and out of them.

    Laura Laski
    UNFPA (the United Nations Population Fund)
    Sexual and Reproductive Health Branch
    Technical Division

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