A WORLD VISION JOURNAL OF HUMAN DEVELOPMENT · Second Quarter,2004 A WORLD VISION JOURNAL OF HUMAN DEVELOPMENT Alexandre Grangeiro National STD/AIDS Programme,Brazil Milly Katana

Second Quarter, 2004

A W O R L D V I S I O N J O U R N A L O F H U M A N D E V E L O P M E N T

Alexandre GrangeiroNational STD/AIDS Programme, Brazil

Milly KatanaHealth Rights Action Group, Uganda

Jim Yong KimWorld Health Organisation

Lieve FransenEuropean Community

Alexandre GrangeiroNational STD/AIDS Programme, Brazil

Milly KatanaHealth Rights Action Group, Uganda

Jim Yong KimWorld Health Organisation

Lieve FransenEuropean Community

http://www.globalfutureonline.org/

HIV/AIDS – where is hope?

The children’s suffering is neglected Ken Casey . . . . . . . . . . . . . . . . . . 1

“If everyone does a little, much will be achieved” Alexandre Grangeiro. . 4

The ‘3 by 5’ Initiative – to save life and change history Jim Yong Kim . . 6

Towards a future and some hope Lieve Fransen . . . . . . . . . . . . . . . . . . . . 8

A sleeping church awakes Christo Greyling . . . . . . . . . . . . . . . . . . . . . . . . 9

Is enough being done to give hope? Milly Katana. . . . . . . . . . . . . . . . . . . 10

Adolescents, gender and HIV Nafsiah Mboi . . . . . . . . . . . . . . . . . . . . . . . 12

Voices from the village Nigel Marsh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Disrupted lives Mark Connolly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Boys and men – key to reducing girls’ HIV vulnerability Sara Austin . . 17

Mobilising the community Claudina Valdez and Ramón J Soto . . . . . . . . . . . . 18

Helping tumbleweeds grow roots Stuart Flavell . . . . . . . . . . . . . . . . . 20

Women and AIDS in Mumbai – a programme evolves Reena Samuel. . 22

How Chilean children see AIDS Patricio Cuevas . . . . . . . . . . . . . . . . . . . . 24

ONE in the Spirit – against global poverty and AIDS Jenny Eaton . . . . 25

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Global Future is published quarterly by WorldVision to encourage debate and discussion ondevelopment issues.

Publisher Dean R. HirschEditor Heather Elliott

Contributing correspondents: Kelly Currah,Melanie Gow, Brett Parris, Matt Scott, Don Brandt,Joe Muwonge, Siobhan Calthrop, Ruth Kahurananga,Haidy Ear-Dupuy, Alan Whaites, Martin Thomas.

All opinions expressed in Global Future arethose of the authors and do not represent theopinions of the World Vision organisation.Articles may be freely reproduced, withacknowledgement, except where other copyrightis indicated.

Global Future is distributed to many NGOs andnon-profit organisations in developing countries.Donations to support our production and mailingcosts are very welcome (US$20 suggested).

COVER DESIGN BY : FRIEND CREATIVE (Melbourne, Australia) / Cover Image by Jon Warren/World Vision: A seven year-old girl in Malawi,with her caregiver grandmother. This girl watched her mother die of AIDS in 2001. Her elderly grandparents wonder if they can stay stronglong enough to give their beloved granddaughter a chance in life.

Second Quarter, 2004

Late to the partyThis edition of Global Future hasbeen prepared to coincide with theXV International AIDS Conference.

It took far too many deaths for theworld to begin taking HIV/AIDSseriously.To see that it is more thana “health” issue (as critical as that is)and also an economic, political,human rights, security anddevelopment issue.

How could this have happened? Forthe same reason that, still, there ispoliticking and economising of theissue – to the utter exasperation ofthose closer to the suffering.

Denying the problem and stigmatisingpeople living with HIV/AIDS havenot helped.Thankfully, there are nowserious efforts to cease medieval-style “plague or punishment”attitudes and respond proactively,with level-headedness andcompassion. Faith-basedorganisations, including churches,have been waking up to their owncomplicity in this stigma problem,and transforming themselves into vital,values-driven players in the solution.

Meanwhile, millions of childrenorphaned or otherwise madevulnerable by HIV/AIDS are on afrightening obstacle course – undersiege on all sides. If they have madeit through pregnancy and birthwithout becoming infectedthemselves, endured lives of AIDS-related poverty and then lost theirmothers (often both parents), there’sa risk they will end up ostracised,exploited or abused.

Anyone can foresee the diresituation not too far down the track.This is why it is critical not only toshake off any remaining slumbernow, but to empower and equipyounger generations to lead the wayin reducing the epidemic in what is,ultimately, their own future.

Is there hope? There is. But whetherwe follow that path remains to be seen.

_ Heather Elliott

http://www.globalfutureonline.org/

http://www.globalfutureonline.org

mailto:[email protected]

HELEN1 IS 14 YEARS OLD ANDwants to be a secretary for ahumanitarian organisation like theone that has helped people in hervillage in Malawi.

She walks 15 kilometres to get tosecondary school each morning,carrying books and wearing clothesprovided by well-wishers. Eachevening she makes the same walkhome and then must help her elderly,infirm Gogo (grandmother) to cookfor her and a seven year-old cousin,John.1 She has little time left forhomework or play.

Helen’s parents died of AIDS in thelate 1990s. Then the uncle and auntwho took her in passed away. Recentlyher only surviving aunt, John’swidowed mum, also died painfully of

AIDS. Her Gogo is the only adult left inthe family, and she needs as much careas she gives.

Helen’s grim determination tosucceed, and a little bit of help fromvolunteers organised and trained byWorld Vision, may make her dreampossible. For millions more childrenin Africa and increasingly aroundthe world, the picture is muchmore troubling.

Before long, one in eight of Africa’schildren will be an orphan: theprojection is 42 million orphans inAfrica by 2010. At least half of thesechildren will have lost a parent toAIDS-related opportunistic infections.And tens of millions more children’slives have been made extremelyvulnerable by HIV/AIDS.

It’s going to be a decade before westart to see the same scale oforphaning in the rest of the world, butas infection rates continue to rise in Asia,Latin America and Eastern Europe, it isinevitable that the misery will spreadfurther among the world’s children.

Tragic lesson

Our most important lesson in Africais that we started far too late to tacklethis overwhelming consequence ofAIDS. If we aren’t to make the samemistake again, what we begin nowmust have a global application.

Those orphans have to go somewhereto live and eat. Like Helen, they areoften taken in by uncles and aunts, thenby grandparents. As that generationdies, they find themselves in the care

The children’s suffering is neglectedKen Casey

Global Future — Second Quarter, 2004 1

Some 130 children aged under five, up to 100 of them orphans, being fed donated maize by volunteers in a World Vision project inChanjoka, Malawi

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of older children and strangers.

Children in families that take inorphans, and those where parents aresick but not yet dead, suffer the samekinds of stress and multiplied povertyas the orphans themselves, creating acategory of “vulnerable children” thatis probably more numerous than thatof the orphans.The burden of care isfalling on families who are already thepoorest in the world. Only one familyin 20 that is caring for these childrenreceives help from any external source.

To avoid the same mistake, we must apply globally the lessons from Africa

Since World Vision launched its firstspecifically AIDS-related projects in1990, the organisation has studied theimpact of HIV in the countries wherewe work, seeking the best ways thatwe and others can take on thischallenge. There’s a long way to go,especially in scaling up the bestpractices that we’ve seen, but we’restarting to produce and use sometools that seem to have an impact.

World Vision is primarily a child-focused organisation, so it was naturalto begin there.

We see deepened poverty,deteriorating nutrition and health,curtailed education and emotionaltrauma for a quarter of Africa’schildren.The pattern is repeating itselfwherever in the world HIV incidenceincreases. The social and economicramifications of so many childrengrowing up without adequatenurturing and support are severe.

Yet the impact of the pandemic onthis vast and voiceless part of thehuman family is rarely talked about.Indeed, if you didn’t travel to Africa,you might wonder if it really is an issue.

A line in the sand

It’s not active ill will toward thesechildren. It’s simply that they aremarginal, powerless, and easy to ignore.Care for orphans and vulnerablechildren is consistently at the bottom

of the list of responses to HIV/AIDS,and often left off the list entirely.

We need to draw a line in the sand,and say that this neglect of one of theleast-regarded segments of humanityis an offence against human dignity. Itmust stop.

It’s not only wrong, but alsoextraordinarily short-sighted. Providingcare and support for orphans andvulnerable children is an essentialinvestment in the security and stabilityof their communities and countries, aswell as their capacity to cope withHIV/AIDS in the coming years.

The plight of African children doesn’tfit within the political messaging ofmany of the activist groups who areloudest when HIV is on the agenda.Drug companies can’t make moneyfrom orphans. Under such pressurefrom powerful constituencies, donorgovernments have focused most oftheir resources on prevention andtreatment.

It’s right to invest in prevention,treatment and care for the sick.Often the lives saved or prolonged arethose of parents – thereby delaying orpreventing orphaning. It’s possiblethat, by effectively using enoughresources, Africa can be saved fromthe primary assault of HIV.

What are we saving Africa for? Thenext generation? We are starvingthat very generation of the resourcesit needs now to be able to take on itsrole in years to come. We must bal-ance these worthy aims, not promoteone or two and ignore others.

Perhaps we are just too daunted bythe scale of the challenge, unsure howto face the reality of 42 millionorphans in five years’ time.The double-edged lesson from sub-Saharan Africais that it will certainly not be easy,because of the pre-existing decay ofmany social and governmentinstitutions due to poverty; but norwill it be as intractable or as expensiveas we might fear.

Unsung heroes

We don’t have to start from zero,because an army of unsung voluntary

heroes – actually, mostly heroines – isalready providing an enormousamount of care to Africa’s orphansand vulnerable children. Distantrelatives, aged village elders, informalwomen’s associations, faith-basedgroups, farmers’ co-operatives; all areplaying a part in rearing the children ofthe HIV generation.

These volunteer carers represent anenormous network of goodwill that, ifprovided with good organisation,training, and minimal resources, couldquickly multiply the level of qualitycare available.

After 15 years of practical experience,listening and learning,World Vision hasdeveloped a broad strategy onHIV/AIDS, called the Hope Initiative.Foundational to that is the promotionof Community Care Coalitions.

This concords with our philosophy ofdevelopment: we shouldn’t try to dofor communities what they can do forthemselves. Even now, and perhapsespecially now.Where local leadershipand volunteers are willing to act onbehalf of their weakest neighbours, itmakes most sense to help them to dojust that.

In areas with little organised help buta lot of motivation, volunteercaregivers are encouraged to formCommunity Care Coalitions.They areprovided with training and someresources to help them improve thewell-being of the orphans and othervulnerable children in theircommunity.

Care for orphansand vulnerable children is at the bottom of the list

In areas where volunteers are alreadytending to the needs of thesechildren, a local forum is set up inwhich all the parties engaged incombating HIV/AIDS and caring fororphans and vulnerable children canmeet and focus their efforts.This canhelp avoid duplication of effort, ensureno part of the community isoverlooked, give a seamless link to

2 Second Quarter, 2004 — Global Future


government efforts and provide acommon voice to the population in itsappeals for more help.

Within this strategy, the faithcommunity is often an importantsource of motivated and caringvolunteers, and it is one that WorldVision is making particular efforts totry to strengthen. Around the world,faith-based institutions alreadyprovide much of the health care andwelfare support. I have met with manyof these volunteers and havemarvelled at the impact they arehaving in the lives of these children.

Uphold the carers

The potential of community volunteersis enormous. And yet, it’s unfair forthe rest of the world to simply regardthem as a resource to be tapped.Although there is potential leadershipand volunteerism aplenty, there arefew seeds and tools, fewer books, andrarely any spare food or medicinesthat can be useful to the children.

To draw more from the humanresources in Africa, for instance, moremust be put in. From our experienceacross more than 20 Africancountries, I am convinced this will notbe a wasted effort anywhere in theworld. On the contrary, a little moretraining and thoughtful input into thecommunity groups caring for orphansand vulnerable children will result in agreatly expanded and sustained care.

Using this strategy and with adequatecommitment from the internationalcommunity, millions more childrenleft behind by AIDS can be ensuredthe protection, care, and supportthey deserve.

On the day Helen’s aunt died, leavingher and her young cousin in theirGogo’s care, the 63-year-old womanremained stoic. “The children willcome to live with me,” she said.“There really is no-one else left in thefamily who can help.”

“The volunteer visitors who come tohelp us have done commendablework,” she added. “Two have beencoming every day, and that means Ican go and work on my gardens and

bring some food for the children, ordo a day’s labour for someone else toearn half a kwacha (five US cents).Thatmakes all the difference.”

The motivation within localcommunities to provide for the needsof vulnerable children is astonishing,but when an issue of just a few cents isso important to a carer, the resourcesare clearly still woefully insufficient.

The commitment and investment of theinternational community are vital to

take the best of local intentions and turnthem into a response that will give hopeto millions of children like Helen. ■

Ken Casey co-ordinates World Vision’s HIV/AIDSHope Initiative and is an adviser to theInternational President of World Vision on HIV/AIDSissues. See www.wvi.org/wvi/aids/global_aids.htm

1 “Helen” and “John” are pseudonyms.

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Olipa Chimangeni of Malawi is living with HIV and is an active advocate andcaregiver for orphaned children. Her own daughter, aged 2, has the virus.

http://www.wvi.org/wvi/aids/global_aids.htm

GLOBAL FUTURE INTERVIEWSAlexandre Grangeiro, Director ofBrazil’s National STD/AIDSProgramme.

Global Future: What is theimpact of the HIV/AIDS pan-demic on Brazil and its people?

Alexandre Grangeiro: The AIDSepidemic has been under control inBrazil since the introduction ofantiretroviral therapy in 1996.However, we have not yet managed tomove beyond stabilisation at 20,000new AIDS cases per year. Our goal isto effectively reduce new infections,and to this end we have conducted,since the beginning of 2003, apermanent campaign for HIV testingamong the sexually active population.

Around 150,000 people diagnosed asHIV-positive are in treatment.Antiretroviral therapy has reduced by50% mortality from AIDS in Brazil; ithas had an impact of only 1% on socialsecurity (for pensions andsuperannuation) while increasing sixtimes the survival of patients. Peopleliving with HIV in Brazil have a normallife; they work, they study, and mostimportantly, they are very active. Themajority are involved in a non-

governmental organisation that workson an AIDS-related issue – such asintegrating marginalised people intothe health care system, orpsychological support.

GF: How are children and youngpeople affected?

AG: “Vertical” (mother-to-child)transmissions have fallen by around80% through good attention topregnant women.They undergo a pre-natal HIV test, or if this is not possible,are tested during birth. If they showpositive, they are treated with AZTinjection.The babies also receive AZTand a special milk up until the age ofsix months (since breastfeeding issuspended to avoid HIV transmissionvia breast milk). Around 60% ofpregnant women are being reachedwith these processes, and verticaltransmissions now account for only2% of AIDS cases.

Children who have lost their parentsand families – and they are not many– are cared for by institutions thathave financial support from theNational AIDS Programme. TheProgramme also supports more than600 households that include peopleliving with AIDS.

For adolescents, Brazil began this year(2004) a broad programme of sexeducation and distribution ofcondoms in schools, to contain anincrease of cases among young peopleaged 13_19 years, primarily girls andyoung women. In this age group, thereare now twice as many new AIDScases among females than amongmales. This age group also has a highbirth rate.While the number of casesis not actually increasing, the profile ofthis age group is changing.

GF: What do you consider to beBrazil’s biggest challenges interms of preventing HIV/AIDS

and caring for those affected?

AG: The major challenge is reachingpeople who are far from the urbancentres. The epidemic is movingoutwards to the peripheries of thecities and to the countryside, wherehealth services and civil societyorganisations are not yet well-established. Our task is to developthis structure as we have done in thelarge urban centres. At present, forexample, we are meeting withneighbouring Latin Americancountries (Argentina, Paraguay,Uruguay, Bolivia and Chile) to draw upa common policy for responding toAIDS in the border areas.

In some municipalities, while thenumbers are still small, we have seen asix-fold growth in AIDS cases over thepast four years. This shows us clearlythat the epidemic is not yet beaten –it only changes shape every four years;and that the fight needs to beconstant if we are not to have arelapse in the advances obtained uptill now.

GF: Brazil has taken consid-erable steps towards producinggeneric antiretroviral drugs.Could you tell us what led to this,and what have been the results ofBrazil’s actions?

AG: When Brazil began tomanufacture generic AIDS drugs, in1998, the Brazilian law of patents hadnot yet been passed. The sevenmedicines that Brazil made were notpatented here and could be copied. Inthe process of manufacturing thesegeneric drugs, Brazil acquired theknow-how to manufacture any newone. Whenever a new medicine isreleased, the state laboratories beginto work on the formula and use thisresource to negotiate a pricereduction with the manufacturers ofthe other medicines Brazil imports.

When the law of patents wasapproved/passed, in 1999, one articleguaranteed that – in case of publichealth risk or abuse of prices, or theformation of a cartel – our countrycan demand the compulsory licence


“If everyone does a little,much will be achieved”Alexandre Grangeiro (interview)

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to a product, or in other words,breach patent. It is also based on thislaw that Brazil is in a position tomanufacture generic forms of anydrug, if we cannot manage to importthem at just and fair prices. Up untilnow, we have not needed to do this.Brazil obtained a reduction in price ofup to 80% on certain AIDSmedications because it is quicker andcheaper to buy them than to producethem. But, if needed, we can producethem in a short period of time.

GF: How will Brazil ensure thatpoor Brazilian people who livewith HIV/AIDS have access tolow-cost antiretroviral drugs?

AG: Brazil’s strategy is to negotiatelow prices and learn to manufacturethe drugs. This has enabled us tomaintain the same budget for thesemedicines for three years (around 520million reais or less than US$250million per year) even with a rise inthe number of people receivingtreatment. Each year we have anaverage increase of 10,000 people in

treatment, as well as including at leastone new drug in the therapy.

And all of the 150,000 Brazilians livingwith AIDS are getting access to themedicines. Brazil’s constitution, and alaw specifically on AIDS, guaranteetreatment, so Brazil will always needto allocate resources in its budget toensure this therapy. This is why suchefforts are made to ensure that theprice increases do not compromisethe budget.

GF: Can you tell us something ofthe support that Brazil is givingto other countries to combatHIV/AIDS?

AG: Brazil offers treatment to 100people a year (a quota reviewedannually) for 14 countries in LatinAmerica, the Caribbean and Africa.The African countries are mostlythose with which we have co-operation agreements (9 in all). Theaim is to demonstrate to the worldthat, if everyone does a little, muchwill be achieved in combating AIDS.

Without solidarity between nations, itwill not be possible to offer treatmentto an extra three million people whoare sick with AIDS by 2005, as theWorld Health Organisation seeks.

Apart from offering this treatment,with antiretrovirals manufactured inBrazil, the AIDS Programme offerstechnical training for healthprofessionals in countries with whichwe have the accord, and technical co-operation only with other countriesthat are not receiving the medicines.In Mozambique, Brazil is offeringtechnical assistance for theconstruction of three statelaboratories for the manufacture ofantiretrovirals, with technology fromthe Oswaldo Cruz Foundation, ourlargest public laboratory. ■

Alexandre Grangeiro is Director of the NationalSTD/AIDS Programme for Brazil’s Ministry ofHealth.This interview was translated from thePortuguese by Global Future.

A nurse examines a newborn baby in Brazil’s Amazon region.The national Ministry of Health is committed to preventing HIV/AIDS andensuring access to antiretrovirals where needed, though it is a huge challenge to reach remote areas of Brazil with public health services.

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HIV/AIDS IS DEVASTATINGmany parts of our world. Globally, anestimated 40 million people areinfected with HIV/AIDS. Every singleday AIDS kills 8,000 people andorphans thousands of children. Entirecountries face social and economiccollapse in a few generations ifdecisive steps are not taken.

Treatment in the form ofantiretroviral therapy (ART) exists,and can transform HIV/AIDS from adeath sentence to a manageablechronic disease. However, until now,treatment has been the mostneglected area of HIV/AIDSprogramming. Six million people needART and three million died in 2003because they could not get thenecessary drugs. Worldwide, only440,000 people have access totreatment; in Africa, where some 70%of people with HIV live, ART is avail-able to less than 4% of those in need.

Ambitious target

The failure to deliver life-prolongingdrugs to millions of people in need hasbeen declared a global healthemergency. On World AIDS Day 2003,the World Health Organization(WHO) and the Joint United NationsProgramme on HIV/AIDS (UNAIDS)launched the 3 by 5 Initiative – anambitious global target to get threemillion people living with AIDS onantiretroviral treatment by the end of2005. This target is a vital steptowards the ultimate goal of providinguniversal access to AIDS treatment toall those who need it.

‘3 by 5’ builds on the ground-breakingwork of human rights and treatmentactivists around the world as well ason the political and financialcommitments made by the UnitedStates under President Bush’sHIV/AIDS Initiative ($15 billion dollarsfor an enhanced AIDS response);

Canada, France, the United Kingdomand many other donors who havecontributed to the Global Fund toFight AIDS,TB and Malaria; the WorldBank; and the William J. ClintonFoundation. Never before has therebeen a more opportune moment forcombined, collaborative and comp-rehensive action to combat HIV/AIDS.

We know that HIV/AIDS treatmentcan be scaled up – successfulexamples in Brazil and pilot projectsin other countries have shown that itis both affordable and effective. Wealso know that focusing efforts ontreating HIVAIDS can strengthen andlead to long-term recovery of healthsystems. In Brazil and other countriesthat have increased access totreatment, the costs of providing ARThave been more than offset by savingsdue to reduced demand for inpatientservices by people who are dyingfrom AIDS, as well as by regainedeconomic productivity.

The WHO and UNAIDS ‘3 by 5’strategy is focused on providingsupport to developing countries in theform of simplified norms and

guidelines and other forms of directtechnical assistance for scaling upantiretroviral therapy. Becauseprocurement and supply chainmanagement of pharmaceuticals anddiagnostics is such a problem for mostpoor countries,WHO has establishedthe AIDS Medicines and DiagnosticsService to help countries with allaspects of selecting, procuring anddelivering both HIV medicines anddiagnostic tools to the point ofservice delivery.

We have anunprecedentedopportunity to alterHIV/AIDS’ course

To ensure a comprehensive responseto HIV/AIDS, treatment andprevention, programmes mustenhance and accelerate each other.When people have hope that they canbe treated and lead productive lives,their incentive to know their statusand to protect themselves and theirpartners is much greater. Evidence andexperience shows that rapidly

The ‘3 by 5’ Initiative – to save life and change historyJim Yong Kim

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Living proof that antiretroviral treatment works: this young man is shown inMarch 2003 and August 2003 – before and after receiving therapy for TB andAIDS at a clinic in Haiti.

increasing the availability of ARTincreases community awareness aboutHIV/AIDS, promotes uptake of HIVtesting and can lead to moreopenness about AIDS. Individuals oneffective treatment are also likely tobe less infectious and less able tospread the virus.

People who havehope of being treated have more incentive to know their status

Old and new partnerships

‘3 by 5’ is one of the most ambitiousundertakings in the history of publichealth and it will be essential to learnby doing. Organisations like WorldVision, faith-based and non-governmental organisations, groups ofpeople living with HIV/AIDS,treatment activists, pharmaceuticalcompanies, trade unions and theprivate sector all have an absolutelyvital role to play and can providevaluable lessons about treatmentscale-up in poor settings.We at WHOknow that we must work withpartners old and new, and we believethat if we do so with a commonvision, it will be possible to eventuallyprovide treatment for all who need it.

Involvement of communities andcommunity workers is also essentialto the success of ‘3 by 5’. There issignificant evidence that with strongcommunity support, people find iteasier to adhere to their medicalregimens. Motivating communities toknow their HIV status in a context ofaccess to ART is altering communityresponses to HIV/AIDS, encouraginggreater openness, and helping toreduce the stigma and denial that hasenabled the virus to spread sodisastrously.

Since the launch of ‘3 by 5’ inDecember 2003, 52 countries aroundthe world have appealed to WHO forassistance with efforts to increaseaccess to ART. WHO-led missionshave already travelled to nearly 30countries in all regions (the majorityin Africa) to identify key needs within

countries and to assist with writingnational treatment scale-up plans andfunding proposals. Currently,WHO isrecruiting 40 country co-ordinatorsto provide full-time ‘3 by 5’ assistanceto WHO country offices.

Reaching the ‘3 by 5’ target will meanmaking the most of the substantialexisting resources in a co-ordinatedway, and ensuring that patients gettreatment for life.This will mean long-term financial commitments from allsources – poor countries themselves,donor governments and multilateralfunding agencies.WHO estimates thatthe funding required by countries toscale up treatment is around US$5.5billion over the next two years.WHOwill need $218 million to provide thenecessary technical assistance to helpcountries with scale-up of preventionand treatment. Thanks to generouscontributions from donors, especiallyfrom Canada, Sweden and the UnitedKingdom,WHO is moving ever closerto reaching its funding target.

There has never been a more urgentcall for action to save lives than now.This is a crucial moment in the historyof HIV/AIDS and an unprecedentedopportunity to alter its course. Wehave the moral imperative to respondto the global pandemic and to savelives. Every one of us has the chanceto make a difference.The time to actis now. ■

Dr Jim Yong Kim (MD, PhD) is Director of theHIV/AIDS Department of the World HealthOrganization. For more information about the 3 by5 Initiative, see www.who.int/3by5/en/


At a Cambodian Red Cross health care centre, Ministry of Health staff who work part-time with World Vision conduct free, confidential, voluntary blood tests and counselling forpeople at risk of HIV/AIDS.

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http://www.who.int/3by5/en/

THE HIV/AIDS PANDEMIC ANDits ramifications for children are issuesof international concern. By workingin co-operation with governments,NGOs, international agencies, theprivate sector and people living withHIV/AIDS, the European Commissionhas been at the forefront of efforts toeffectively address the plight ofchildren infected, affected or leftorphaned by HIV/AIDS.

Children born to HIV-infectedmothers are at risk of infection duringthe pregnancy, birth or breastfeeding.Every year half a million babies, over90% of them in Africa,1 acquire HIVfrom their infected mothers. Morethan 90% of HIV infections in childrenare acquired through mother-to-childtransmission; the remainder occurthrough blood transfusions orunhygienic conditions in hospitals.2

European Community initiatives

The European Commission has been akey player in addressing the issue ofmother-to-child transmission. It hasinitiated and supported some of thefirst research into this issue in Africa,and continues to support projectsthat limit this mode of infection. TheEuropean Commission also developedthe first comprehensive approach toblood safety in developing countries,and in some cases financially supp-orted these projects for over 10 years.

The 30% of children born to HIV-infected mothers who are notthemselves infected suffer anuncertain future, as one or bothparents become ill and eventually die.AIDS has orphaned 3 at least 10.4million children currently under theage of 15,4 and every day more than6,000 children are left orphaned byAIDS, a third of them under five yearsold.5 These vulnerable children areforced into precarious circumstanceswhere they are at high risk ofexploitation, abuse, and becoming

infected with HIV.6 Girls are usuallythe first to be pulled out of school tocare for sick relatives or look afteryounger siblings. In high HIV/AIDS-prevalence countries, girls’ enrolmentin school has decreased over the pastdecade, negatively affecting gains madetowards the goal of universal primaryeducation.7

Children of HIV-infected mothers facea precarious future

The European Commission thereforesupports programmes that targetchildren’s rights and their access toeducation, in an effort to help childrenavoid the most dangerous situationsand provide them with a future andsome hope. The Commission alsofunds programmes that provide careand treatment for children, mothersand families.

HIV/AIDS and poverty

The link between poverty andHIV/AIDS is the cornerstone ofEuropean Commission policy, asHIV/AIDS affects the poorest andvulnerable populations the most –undermining global health anddevelopment. For example, mother-to-child transmission is many timesmore prevalent in developing countries.Currently, only 5% of pregnantwomen have access to programmesfor the prevention of mother-to-childtransmission (only 1% of the 27 millionannual births in Africa are covered),and even fewer to treatment.

The Programme for Action, AcceleratedAction on HIV/AIDS, malaria and TB inthe context of poverty reduction(2001–2006)8 is the EuropeanCommunity’s response to the need fora broad, coherent and comprehensiveapproach to HIV/AIDS, TB andmalaria, in line with the MillenniumDevelopment Goals.The Programme’s

primary goals are:

● to increase the impact of existinginterventions

● to increase the affordability of keypharmaceuticals, and

● to encourage research in anddevelopment of public goods totackle HIV/AIDS,TB and malaria at thenational, regional and global levels.

It has a framework of comprehensiveprevention, treatment and carestrategies directed at the poorest andmost vulnerable groups. In this context,it supports initiatives that aim toprevent mother-to-child transmission.Within the framework of theProgramme for Action, the EuropeanCommunity also focuses on the rightsof children, and in particular, orphans.

Increased funding

In addition to the regular countryprogramme support, the Commissionwill spend EUR 1.1 billion in theperiod 2003–2006 to support theProgramme for Action’s strategies onHIV/AIDS, malaria and TB. Thisrepresents a fourfold increase in ECfunding for these deadly illnesses.

The European Commission also worksthrough the Global Fund to FightAIDS, Tuberculosis and Malaria. TheCommission is a major donor to theGlobal Fund, having pledged EUR 460million from 2001–2006 and havingdisbursed EUR 374 million to date. By2008, Global Fund programmes willhave supported over one millionorphans through medical services,education and community care. ■

Dr Lieve Fransen is head of the Human and SocialDevelopment Unit in the European Commission’sDirectorate-General for Development, and Co-ordinator of the European Union’s Programme forAction on HIV, Malaria and Tuberculosis. She alsorepresents the EC as a voting member on theBoard of the Global Fund.

1 Tapper, A, Mothers and children confronting HIV:Challenges, choices, lessons learnt, 2000, page 11 2 Ibid.,page 16 3 That is, the epidemic has killed their motheror both parents 4 UNAIDS, via www.unaids.org 5 Ibid.6 Almost three million children under age 15 are livingwith HIV today. 7 Millennium Development Goal Twois for all children everywhere to be able to complete afull course of primary education.8http://europa.eu.int/comm/development/body/theme/human_social/pol_health3_en.htm

Towards a future and some hopeLieve Fransen


http://europa.eu.int/comm/development/body/theme/h

www.unaids.org


“ONLY YOU KNOW HOW YOUare going to do it Lord, but let yourkingdom come and your will bedone…” was the prayer that flowedlike a mantra from my lips as I drovefrom the hospital. The rain falling insheets reflected the tears welling upwithin me. I had just heard that I wasHIV-infected.

It was September 1987 in Cape Town.The next year, I would finish sevenyears of theological studies. I knewGod had called me. And now this!What church would ever want areverend with AIDS?

The years that followed have been noeasy road. But what stands out is notthe pain of judgmental attitudes andphysical suffering. It is an expandinghope, nourished by the love of Christthat I received through the amazingsupport of others – especially Liesel,who married me knowing the risk shewas taking.

“I did not want to wait untilI was too ill to be of use”

Sadly, my experience of support andlove has not been shared by millionsof people in Africa living with HIV or

AIDS. Working closely with faithleaders has shown me that many faith-based organisations had (and stillhave) a lack of scientifically accurateknowledge; inappropriate attitudestowards HIV-infected people; andcultural and religious taboos. Theseperpetuate stigma, discrimination,denial, silence and inaction by theorganisations, and fear and self-stigmain people infected or affected by HIVor AIDS.

Breaking the silence

As the first opportunistic infectionsstarted to manifest, God’s call on mylife and the conviction to go publicgrew stronger: I did not want to waituntil I was too ill to be of any use. Iwanted, from first-hand experience, toshow that people living with HIV arelike anyone else, and to share my hopein the resurrected Christ.

Unfortunately, my own church wasnot ready for this in 1992. “AIDS isreally not a problem within theChurch; perhaps you should talk tosome social workers,” was theresponse to my request to start anAIDS ministry. I did not know that atthe exact same time, others – such asRev Gideon Byamugisha in Uganda –had the same vision and were facingsimilar struggles.

I learned that the largest insurancecompany in Africa had a slide series onAIDS, and shared my vision with theirNamibia manager. His eyes floodedwith tears as a new vision started inhim. Six months later Liesel and I wereappointed to develop theircommunity AIDS programme, whichtargeted schools, communityleaders… and faith communities.

Yet our vision grew that God wantedthe Church and faith-basedorganisations (FBOs) to be instru-mental in addressing AIDS. It becameincreasingly obvious to us that denialand stigma not only hurt those

suffering the HIV/AIDS burden, butcaused more people to becomeinfected.

As the impact of HIV/AIDS in Africabecame impossible to ignore,churches and FBOs began to movebeyond judgmentalism, towardscompassionate, effective programmes.At an inter-faith conference onHIV/AIDS in July 1999 inJohannesburg, faith leaders sharedwith each other the realities theywere facing, and some recognised theneed for a resource and trainingcentre.

Someone encouraged us: “God willnot call you, prepare you, then say:‘Sorry, I was joking!’” In 2001, anNGO representative was moved byour vision of a Christian AIDS bureau,and asked me for my CV. Eightmonths later, I was appointed to trainWorld Vision staff in 25 Africancountries to mobilise and equip localchurches and FBOs to respond toAIDS.

Transformed hearts

Faith leaders can be effective changeagents, if they themselves undergochange: confront their own judg-mental attitudes or lack ofinformation, and grow inunderstanding of their role.

These days, at HIV/AIDS workshops, Isee faith leaders on their knees,crying: “Lord, forgive me for judgingothers when I am a broken personmyself!” I stand in awe as 38 Maasaichurch leaders openly repent for theway they treated HIV-infected people.I see people leave transformed, witha new vocabulary. They preach, prayand minister differently as they realiseHIV is no longer “them” versus “us” –only “us”.

My mind goes back to my prayer onthe rainy day in 1987, and I see graceat work. ■

The Reverend Christo Greyling is World Vision’sAfrica Regional HIV/AIDS and Church RelationsAdviser. He has been living with HIV for 17 years.

A sleeping church awakesChristo Greyling

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HI V / A I D S IS NOT ONLY Ahealth problem but also a threat tosustainable development. It isundermining the attainment of all ofthe Millennium Development Goals,including reducing poverty, childmortality and gender disparities. It isreducing social and economiccapacity, with the deaths of peoplewho have many years of training andexpertise behind them. It is resultingin the loss of social values, traditionsand practices that have held societiestogether through history. It iscontributing to regional and globalinsecurity.

Children are losing parents to AIDS.Many of them are growing updestitute, without social values.Desperate adolescents with little orno value for life do not bode well forsecure, healthy future communities.The ever-increasing numbers ofdeaths and new infections, particularlyof women, does not inspire hopeand motivation.

We can predict the future with a verysmall margin of error. We are losingthe battle to AIDS. There is noindication that the world – developedor developing countries – is geared upfor the huge volume of work thatneeds to be done. Instead, the worldhas been rendered helpless in theface of AIDS.

The needs-driven Global Fund isbeing forced toexclude countries

Even in some rich countries, we areseeing a fresh epidemic. We do nothave women-controlled preventiontechnologies; there is no hope for avaccine, and no cure in the pipeline. Itseems we cannot even equitably usethe technologies that we know work,

including condoms and antiretrovirals.Some international efforts are makingit very difficult for developingcountries to access cheap genericdrugs on a sustainable basis.

Need to gear up

What we need now is new inspirationand motivation to get back on course,to create a future that is desirable forus a global community. The past isgone; it can only serve as a lesson forwhat we commit to do now. Yet thebig question is: what future do wewant to create?

The current response to HIV/AIDS istoo narrow and inadequatelyresourced. The world’s major sourceof funding for the three majordiseases, the Global Fund for AIDS,Tuberculosis and Malaria (GFATM),was able to attract US$5 billion in2001–4. But the target was $10b perannum when the UN SecretaryGeneral announced the Fund in 2001.Today, the GFATM needs $5b for2004–5 to be able to renew oldprogrammes and finance new ones.Budget limitations have forced theGFATM – a fund that was conceivedas need-driven – to develop exclusioncriteria for countries. And we areliving in the 21st century. Shame!

Yet despite this serious under-funding,the GFATM has managed to generatehope in the lives of many peopleacross the world. In Uganda – the only“success story” against AIDS in thedeveloping world so far – the GFATMhas promised to provide ARVs in thepublic sector. This means freetreatment. It is the first time such abold step has been taken by the publicsector in Uganda or indeed, in muchof Africa.

Politicking AIDS

Subjecting HIV/AIDS to routinepower and political struggles is not

inspiring for those committed todelivering peoples of the world out ofthe bondage of AIDS. In South Africa,as AIDS became a political debate,more and more people got infected,sowing enough “seed” to give thatcountry – which has better socialservices than almost all other Africancountries – the tragic distinction ofhaving the biggest number of peopleliving with HIV/AIDS in the world.

Meanwhile, statistics in somecountries in Asia are produced in sucha way that that annually the numbersdo not go beyond certain thresholds.The purpose of epidemiological datais lost and appropriate action againstthe epidemic is not taken.

In some developing countries, as moreresources are being made available,government officials are seizing theopportunity to flex muscles over whoshould control the resources –further marginalising frontline actors.

Where does responsibility lie?Squarely with both developing anddeveloped countries. The developingcountries need to step up their effortsin responding to the disease;developed nations need to take thebold (and, for most, extraordinary)step of supporting these efforts.Commitments made in the past havenot been operationalised. Politicalcommitments made in connectionwith HIV/AIDS are lagging far behind.

Inconsistencies

In April 2001, African heads of statemade the Abuja Declaration andFramework for Action for the fight againstHIV/AIDS, tuberculosis and other relateddiseases. One of the outstandingtargets of their Declaration was toallocate at least 15% of their annualnational budgets to improve thehealth sector to help address theHIV/AIDS epidemic. However, onlytwo countries attained this target by2003. Health care systems are nowstruggling, even crumbling, under theburden of AIDS. The good news isthat with international help, a fewcountries are stepping up theirinvestment in health care. Yet thisinvestment is not enough to turn thetide of HIV/AIDS.


Is enough being done to give hope?Milly Katana


Globally, we have conflictingdevelopment policies. On the onehand, countries commit to increasespending on health care; on the other,they put recruitment ceilings in thepublic sector as well as budget ceilingsto attain macro-economic stability.All this has resulted in a vicious cyclewhere health care systems are notable to deliver services to the people.Decades ago, the Organisation ofEconomic Co-operation andDevelopment (OECD) countriescommitted to providing developmentassistance of at least 0.7% of theirgross domestic product. By 2000,only five countries had attained thistarget.This has major implications forthe level of financing for the globalhealth crisis.1

Countries pledge toincrease health funds, but restrictthe public sector

Some countries have come close tomaking a remarkable dent in theepidemic of HIV/AIDS, but not other

diseases. In Uganda, new HIVinfections have been reduced from ashigh as 30% of pregnant women in thelate 1980s and early 1990s, to as lowas 5% now. This is a breakthrough.However, the country is struggling tocare for those living with HIV/AIDS.And meanwhile, malaria is getting outof hand – killing the young, old andmiddle-aged, and further exacerbatingthe impact of HIV/AIDS. South Africahas done very well in managingmalaria, but it is struggling with theheaviest burden of AIDS in the world.It is difficult for countries to registersuccess over disease.

Continued denial of the risk factors,including intravenous drug use andhomosexual sex practices, means thatmany countries are sitting on a timebomb. Practices that fuel the epidemicare on the increase in manydeveloping countries, but politicalleadership is sweeping these factorsunder the carpet in the name of“morality”, with the result thatHIV/AIDS prevention programmesare not user-friendly for people whoengage in these practices.

Hear the people

Many failures, in health anddevelopment policy formulation alike,stem from a failure to hear the voiceof “the people”, and to value humancapital. In principle and in practice, wemust increase people’s voice in healthand development policy formulation,and support integrated developmentplanning that takes into account allthe MDGs.

On the positive side, the HighlyIndebted Poor Countries (HIPC)initiative is coming through to supportresponses to HIV/AIDS and otherhealth goals. In Mozambique, savingsmade from debt servicing have beenused to increase vaccination ofchildren. In Cameroon, the savingshave supported the National AIDSControl Programme. In Nigeria,President Obasanjo is openlycampaigning for debt relief for AIDSand health care such that Nigeria canattain the Abuja Declaration target ofspending at least 15% on health care.However, the HIPC initiative has anexclusion clause that has left six of theseven countries with the highestHIV/AIDS prevalence out of theinitiative.

For there to be hope in a future freefrom AIDS and other diseases, all ofthese issues must be addressed. Hopelies in whether we are able to, now,mount an extraordinary responsethat gets results – that reverses thetrend of the global health anddevelopment crisis caused byHIV/AIDS. The good news is that withthe right intentions, policies andactions, the trend of the epidemic isreversible. ■

Milly Katana is Director of the Health Rights ActionGroup, a Ugandan NGO that advocates againstHIV/AIDS stigma and discrimination and mobilisescommunities to prevent mother-to-childtransmission. She is also a Commissioner of theUN Commission on HIV/AIDS and Governance inAfrica. See: www.uneca.org/chga/1 United Nations Development Programme, HumanDevelopment Report 2002, page 202

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Three young boys - from (left to right) Zimbabwe, Democratic Republic ofCongo, and Rwanda - hold posters with AIDS prevention messages during WorldAIDS Day celebrations at Tongogara Refugee Camp, eastern Zimbabwe

http://www.uneca.org/chga/


TODAY’S ADOLESCENTS, THEchildren 10–19 years of age, standdirectly in the path of the HIV/AIDSepidemic. They can either feed the fireor help bring it under control.

These young people, an estimated onebillion in the developing countries, livein an era of often-unpredictablechange, brought on by rapidurbanisation, economic globalisation, arevolution in global communications,and vastly increased mobility. Thesephenomena present young peoplewith choices about lifestyles, socialrelations and employment – andexpose them to risks and temptations– that earlier generations never had todeal with.

Indications are that it is not alwayseasy to make safe choices. Last year,

67% of new HIV infections indeveloping countries were amongadolescents and young adults, aged15–24. If we are to stop thedestruction by HIV we must do abetter job of working with ouradolescents,both for their own sake andthe sake of the whole human family.

Boys and girls – different risks

In most societies it is duringadolescence that gender distinctions –the social definition of what is“masculine” and what is “feminine” –begin to solidify.These distinctions willinfluence the course of life in profoundways thereafter. In many societies, aboy’s options tend to broaden at thispoint: he is encouraged to take risks(including sexual risks) and learn abouta wider world outside his home andfamily.A girl’s world at this time often

becomes smaller: in many cases, eventhe ways she moves, dresses andexpresses herself are more strictlyregulated. A girl is encouraged to“preserve her innocence”, rather thanto learn about reproductive health,sexuality and even her own body. Bothboys and girls learn that in sexualmatters, it is the male’s prerogative toinitiate, to dominate.

Many girls paya high price fortheir innocencein sexual matters

Girls pay a high price for theirinnocence and lack of sexualautonomy. They fall prey toexploitative employers, boyfriends,even husbands. Indeed, today it is

Adolescents, gender and HIVNafsiah Mboi

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Young people, such as these Cambodian students, hold the key to reducing future HIV infections. These students are part ofan innovative World Vision programme that trains at-risk groups to share HIV/AIDS prevention messages with their peers.


estimated that 64% of the people aged15–24 who are living with HIV orAIDS in developing countries arewomen and girls!

It is true that the push towards risktaking can place an adolescent boy atincreased risk of HIV infection fromunsafe sex, experimentation withdrugs, or excessive use of alcoholwhich may lead to other risk taking.However, the situation of girls isworse. Among adolescents aged15–19, HIV infection rates often runtwo to six times higher among girlsthan among boys of the same age.Examining the situation in countryafter country one finds that gender-based differences – in education,access to information, socialisation,and thus, experience and expectationsin life – are primary factors influencingthe vulnerability of these young peopleto HIV infection.

The theme of the World AIDSCampaign 2004 is Women, Girls, HIVand AIDS. The impact of genderinequities radiates throughout allfacets of life – social relations, issues ofpublic participation, access to publicservices, legal status, and so on. It isnot solely an issue of power relationsin sexual transactions between menand women. In fact, we know that thenature of sexual relations does notimprove substantially without changesalso occurring in other aspects ofgender dynamics.

This is confirmed by data about girlsacross Asia showing that knowledgeabout HIV and how to protectthemselves from infection often doesnot lead to effective action. Evenwhen they know what to do and why,many adolescent girls feel unable toresist the sexual advances of ademanding male, either in or out ofmarriage. Unless they also have anenhanced sense of their right toprotect themselves and the confidenceto believe that they might succeed,most girls will accept sex as and whendemanded by their male partner.

Useful approaches

Is there a specific “plus factor” whichcan help overcome the inequities oftraditional gender relations? Different

settings, different obstacles anddifferent opportunities have produceddifferent kinds of activities, but there isno silver bullet. Nonetheless, most ofthe successful activities are ones thathave contributed one way or anotherto girls’ information, skills, self-confidence, self-respect, self-reliance,or a sense that they were not alone,that they had a support network toconsult or fall back on. For example:

● Extended schooling has hadpositive results for both girls andboys, contributing to delay of entryinto sexual activity, practice of safersex, and delayed marriage.

● Theatre, music, athletics and othergroup activities have helped girls gainconfidence in their right and ability tointeract with a larger world.They givegirls the “protection” of groupmembership as they consider newbehaviour and, maybe, try outleadership in a group of friends. HIVinformation introduced in this sort ofsetting can be well received and is morelikely to be acted upon. Indeed,surveys in a number of places havefound that membership in well-runcommunity youth groups reduces ayoung woman’s chance of being HIV-positive.

● Activities can also be directlyrelated to a girl’s more conventionalprogress towards marriage, but mayopen the door to the possibility ofmore equitable gender relationswithin the family. For example, in oneIndian state, in order to encouragegirls to delay marriage, a sum ofmoney was made available to everygirl who waited until age 18 beforemarrying. The result: when shemarried, a girl came to her husbandwith some money of her own, givingher more confidence and thepossibility of more independence thanif she entered her husband’s homemerely as the result of familynegotiations, a “gift” of her family toher husband’s family.

Girls on the margins

These are innovative activities reaching“mainstream” adolescent girls, urbanand rural. However, significantnumbers of girls are at extra risk andextra efforts are needed to reach

them.These are the girls who becauseof extreme poverty, childhood abuse,adolescent rebellion, employment,armed conflict and other factors areout of sight – adolescent girls inprostitution, trafficked internationallyor within their home country for sexwork or exploitative child labour, girlsin domestic service, street dwellers,girls in regions of conflict, refugeecamps or found among the world’sinternally displaced people (IDPs). Allthese girls are difficult to reach, arebasically unprotected, and areparticularly vulnerable to genderpressures, sexual violence, drug use,and ultimately, HIV infection.

Adolescents deservespecial support in constructing safer ways to live

“AIDS has a woman’s face,” said CarolBellamy, Executive Director ofUNICEF in 2002. Sadly, every year thatis more accurate than the year before.If we do not learn to do better by ouradolescent girls, the numbers willcontinue to increase each year. Girlsand women are vulnerable because oursocieties make them so. Their accessto information and their right to acton it are limited because they arefemale. Without addressing the all-important issue of gender, anyincreased knowledge of personalhygiene, safe sex or reproductivehealth will not be put to use and littleprogress will be made againstHIV/AIDS.

Adolescents, with their lives in frontof them and on the verge ofbecoming sexually active, deservespecial opportunity, encouragement,and support in addressing thischallenge and constructing new saferways to live. ■

Dr Nafsiah Mboi is Senior Adviser to theIndonesian National AIDS Commission, and aMember of the Board of World Vision Indonesia.She was formerly Director of the Department ofWomen’s Health for the World HealthOrganization.


Voices from the villageNigel Marsh

An orphan, a grandfather caring for orphans, and a child with AIDS shed light on life in Africa in the grip of HIV.

Orphan:MaggieMaggie

Maggie lives near Kitwe inZambia with her paternalgrandmother, Eleanor, who isaround 70 years old. Maggiewas 13 when she told us herstory.

“When my mum died in 1998,everything changed. I don’t reallyremember Daddy – I’m told he diedin 1995.They both died of AIDS.

My older sisters had married and lefthome.After Mum passed away I wastaken away with my little sisterJosephine, who was born just afterDaddy died, to the home of mymum’s sister. She lived in a distantvillage, in Northern Zambia. It wassuch a poor place to live.We had nothing.

My aunt was a widow and had herown children.Then she fell sick, andwe all had to look after her, until shedied. Her children, Josephine and I

were left with her aged mother, mymaternal grandmother.That was evenmore terrible.There was neverenough to eat, even though weworked long days in the gardensinstead of going to school.We had noblanket, just a place to sleep on themud floor in the house. Our clotheswere tattered.

Worst of all, I was the only one inthe world to look after Josephine,who was suffering fevers, diarrhoeaand body pains. I recognised thesicknesses as AIDS. I despaired; Ithought we were both going to die.

But I had not been forgotten. My latefather’s mother, Eleanor, heard wewere in trouble. She sold herfurniture to buy a bus ticket so shecould come looking for us. She wasshocked at the way we were living,and agreed to take my two cousinsand I home with her.

Things are so much better here. ButJosephine was too sick to travel, andshe died soon after we left. I am stillsad that my little sister died in thatvillage and never got to come here.

Now, I am doing well in school again.I have clothes to wear, and there’senough to eat.

I’m so happy that my gran came tofind me and bring me back fromthat village. And I’m grateful for theother support that has enabled meto stay in school.

I hope people will continue to providehelp for others like me.There are somany children who need these thingsas much as I do, whose lives havebecome so bad, and who can’t doanything about it. ”

Grandfather caregiver:KKennethenneth

Kenneth Kavwenge is asprightly 75 year-old widowerin Kandani, Malawi. Histendency towards cheerfuloptimism was battered whenMartha, the last of his tenchildren, died, leaving himwith three orphanedgrandchildren. He spoke to ustwo weeks after the funeral.

“Martha had been sick with AIDSfor five months, and her husbanddied the same way in 1997. It wasnot until she was tested and foundto be HIV-positive, only a monthbefore she died, that I realised howmuch AIDS had hurt our family.She told me she knew her days were up, and asked me to takecare of the children.

I felt so sad that this was the onlychoice for the children, because I amvery old. I couldn’t answer her,because I didn’t know how I would

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(Left to right) Maggie’s cousinBright, Maggie, Eleanor

Kenneth and three grandchildrenvisiting Martha’s grave

Abridged from interviews conducted by Nigel Marsh, a journalist who is based in Africa and travels for WorldVision investigating the impact of HIV/AIDS. All interviewees consented to World Vision using their stories andphotos to raise awareness about HIV/AIDS.


take care of the children. Now there’sno-one but me here for them, to tryto make sure they have clothes, soapand food. I’m still strong and healthy,but of course I wonder how long Ican keep it up.

My older grandson is dependableand works hard around the houseand in the gardens.That helps,though it’s a lot of work for a boy of14. He is growing up to be a goodman and he’s doing well at school.

I spend a lot of my time now goingaround the village, talking to peopleabout AIDS, helping to care for thesick. I’m doing what I can to get myfellow church-goers to be more activeabout HIV.

Even in the past it was hard whenthere was nobody to take care of thechildren, and grandparents wouldtake responsibility. This wouldhappen, for instance, when a motherdied in childbirth, and the father diedlater of some disease. But back thenthat was very rare. People weren’tdying as they are nowadays.

AIDS has really spoiled lives in ourcommunity, creating too manyorphans.You don’t see many peopleof my age any more as you go about,but when you find them, you findthem with orphans.

It would be easy to give up, but it’sbetter if I’m here for the childrennow that all their aunties and uncleshave gone.There would be so manymore problems for these children if Iwasn’t still here.”

Young person withHIV/AIDS: KKelvinelvin

Kelvin Mkuntha was 14 yearsold when he spoke about hislife with AIDS, sitting on a matin front of his widowedgrandmother Fulare’s homein Matalala, Central Malawi.He has since died.

“They looked after me well inhospital, but it’s better to be homeand I’m glad to be here.

My blood was tested, and I was toldI had HIV.They said that maybe Igot HIV from my caring for mymother when she was very ill, hereat my gran’s house. I think I wasdoing a good job helping her,keeping the place clean andpreparing her for bathing. She diedof AIDS in the district hospital, whilemy stepsister and I were lookingafter her.

She was suffering in my hands whilemy stepfather was with otherwomen. He sent my mother and me

away as soon as he realised Motherwas getting sick. He hasn’t helpedGrandmother or me at all. He tookmy stepsister away, and that troublesme, because I loved her and I amlonely now. But I do get visitors, andthat means a lot to me.

My best friend, John, comes oftenand cheers me up. On Saturdays hespends the whole day here; otherdays he only drops in for a shorttime because he has been at school.

I was doing well in school. I’m sorrythat I haven’t been well enough to gofor six months now.The sores in mymouth and pain in the throat areworst, but I’m also coughing a lot andI’ve got bad diarrhoea.

I wanted to study to become amedical doctor.They are good people.We had a medical assistant in thelocal clinic who was kind and lookedafter me very well. Now he has goneto work with an NGO that deals withleprosy, and there is no-one there toreplace him.

I used to like going to church, too; itwas very encouraging. But I’m toosick now. It’s nice when friends comehere to pray with me. I believepeople don’t die forever – there is lifeafter death, and my mother is stillalive in heaven. Heaven is up there, ajoyful place, where there is God, andJesus, and life forever. I’d like to seethat. If I want to get there, I have todie first, don’t I?”

Kelvin Mkuntha

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A 16-YEAR-OLD BOY IN ZAMBIAis left without parents – and threeyounger siblings to look after. A 12-year-old girl in Namibia must drop outof school to care for her mother, whois slowly dying. After their motherdies, 10 year-old sisters in Lesothomove in with their aunt, who is alreadyraising three other orphaned relatives.

Nothing is disrupting the lives ofmasses of children as radically as theHIV/AIDS epidemic. More than 14million children under the age of 15have lost one or both parents toAIDS. By 2010, this number isexpected to exceed 25 million. Withglobal infection rates still rising,HIV/AIDS will continue to causeunprecedented suffering amongchildren for at least the next twodecades. Because of the lag time ofroughly 10 years between HIV infectionand death from AIDS, the numbers oforphans will continue to increase evenin countries where HIV infection ratesnow appear to be declining.

Although HIV/AIDS has reachedalmost every part of the world, noother region has been harder hit thansub-Saharan Africa, where anestimated 11 million children havebeen orphaned by AIDS (and 12% ofall children are orphans). In LatinAmerica and Asia, where the overallorphan population is much greaterthan in Africa, the proportion ofchildren who have lost their parentsto AIDS is much smaller.

Children orphaned by AIDS often sufferthe added pain ofbeing ostracised

Wherever they live, HIV/AIDS createshardship for children well before theyare orphaned. A parent or caregiverwho becomes ill with AIDS often isunable to work.The economic impactis felt by the entire family. Childrenoften have to drop out of school to go

to work, care for their parents, lookafter their siblings and put food on thetable. Families are strained when theyassume the care of nieces, nephewsand other children who have lostparents to HIV/AIDS.

Losing a parent is emotionallydevastating, but children orphaned byAIDS often suffer the added pain ofbeing stigmatised or ostracised bytheir communities. They are oftenmore at risk of becoming victims ofviolence, exploitative child labour anddiscrimination. Girls left on their ownare at higher risk of being sexuallyabused and becoming HIV-positive.

Substitute families

When HIV/AIDS overturns the livesof children already struggling withextreme poverty, armed conflict orexploitation, it can put them on thebrink of disaster. Pulling them backrequires a concerted and widespreadeffort to assist the families and otherpeople caring for children affected byHIV/AIDS.

In sub-Saharan Africa, 90% of thechildren affected by HIV/AIDS areliving with a surviving parent, sibling orother relative. But these families, whoare not receiving any external help,are stressed to the breaking point.Theyare in dire need of support.

Whether the head of the household isa widowed parent, an elderlygrandparent or a young person, familycapacity represents the single mostimportant factor in building aprotective environment for childrenwho have lost their parent(s).Childrendeprived of such an environment areat increased risk of exploitation,abuse, violence and discrimination.

There is an urgent need to developand scale up family-based andcommunity-based care for boys andgirls who are living outside of familycare. Placement in residentialinstitutions is best viewed as a last

resort, when better care options havenot yet been developed, or as atemporary measure pending place-ment in a family.

Strategies for action

The United Nations and many partnerorganisations, including World Vision,have endorsed a framework of actionto provide guidance to donor nationsand the governments of affectedcountries to respond to the urgentneeds of children impacted byHIV/AIDS.The key strategies are:

● strengthen the capacity of familiesto protect and care for children byprolonging lives of parents andproviding economic, psycho-socialand other support;

● mobilise and support community-based responses to provide bothimmediate and long-term support tovulnerable households;

● ensure access of orphans andother vulnerable children to essentialservices, including education, healthcare and birth registration;

● ensure that governments protectthe most vulnerable children throughimproved policy and legislation andby channelling resources tocommunities; and

● raise awareness at all levelsthrough advocacy and socialmobilisation to create a supportiveenvironment of all children affectedby HIV/AIDS.

Until these strategies are realised on amassive scale, HIV/AIDS will continueto rob generations of children of thefuture they deserve. ■

Mark Connolly is Child Protection Adviser forUNICEF. See www.unicef.org/aids/

Disrupted lives Mark Connolly

http://www.unicef.org/aids/


GIRLS ARE HIGHLY VULNERABLEto HIV/AIDS. They are particularlysusceptible to HIV infection, and carrya significant burden of responsibilityto care for family members who haveHIV/AIDS. Girls’ vulnerability to AIDSis tied to social/cultural, economic,biological and political factors, and isintrinsically linked with genderinequality. In some of the countriesworst affected by HIV/AIDS, girls areinfected at a rate five to six timeshigher than boys.1

Addressing the unique issues that girlsface in relation to HIV/AIDS requiresan approach that overcomes a currentgap – between awareness ofHIV/AIDS and changing behaviours toprevent the spread of the virus.

Even if women and girls are aware ofthe factors that put them at risk ofcontracting HIV, they may have littleor no agency to reduce theirvulnerability. It is thus critical thatboys and men be actively engaged ininterventions to change behaviouralpractices that currently promote orperpetuate gender inequality andconsequently the vulnerability of girlsto HIV/AIDS.

An empowering approach

World Vision developed an action-oriented research project to enableboys, girls, men and women to identifythe key factors that make girlsvulnerable to HIV/AIDS, andparticipate in developing interventionsto address these problems. Theresearch was piloted in two countries:Tanzania, where the prevalence ratefor girls aged 15–19 is 4.8% comparedwith 1.5% of boys,2 and Zambia,where the rate for girls aged 15–19 is6.6% compared with 1.9% of boys.3

Research participants included boysand girls aged 8–17, youth aged 18–25,parents/guardians, teachers, religiousand traditional/cultural leaders, and key

local and national government leaders.A critical research strategy was itsemphasis on the resilience andstrength of boys and girls, and on theneed to build their capacity as agentsfor change. The research sought tobuild on children’s existing copingstrategies by facilitating a process thatpromotes children’s right toparticipate in all matters that affecttheir lives. Thus, boys and girls in thetarget communities participated infocus groups to give input to theresearch proposal; in designing theresearch methods; and in theimplementation, analysis and dis-semination.They supported the (adult)research team in an advisory capacitythroughout the research process.

HIV/AIDS preventionfails girls and women unless it addressesgender inequalities

Research findings

The research in Tanzania and Zambiahighlighted that sexual exploitation ofgirls is a significant factor in girls’vulnerability to HIV/AIDS. Girls in thetarget communities were subject to awide spectrum of gender-basedviolence, including: sexual abuse in thehome; sexual abuse by teachers; rape;early sexual activity; commercialsexual exploitation; sexual harassmentin homes, schools, and the community;harmful traditional practices includingearly marriage and female genitalmutilation (in Tanzania) and initiationceremonies (in Zambia).

Conversely, the research alsoindicated that HIV/AIDS isincreasingly a causal factor for specificforms of sexual exploitation of girls.For example, girls who are orphanedor who are caring for parents livingwith AIDS have significant

responsibilities to provide for theirfamilies’ economic needs, and in manycases girls engage in “survival sex” inorder to gain income or othernecessities such as food or educationalmaterials. Another example is the rapeof girls by HIV-positive men as afallacious “cure” for AIDS.

The research highlights World Vision’srecognition that the “ABC”(abstinence, be faithful and usecondoms) message must be part of astrategy that addresses the underlyinggender inequalities, or it will largelyfail girls and women. In culturalcontexts where women and girls arelargely monogamous, but men andboys are not, and where girls andwomen have little to no sexual agency,sole reliance on condoms as aprevention measure is not sufficientfor reducing girls’ and women’svulnerability.

It is therefore recommended thatHIV/AIDS prevention strategies bedirected towards expanding thesubstantive freedoms of girls andwomen, increasing their power tonegotiate their relationships andenvironment, and towards engagingboys and men in this strategy so thatthey are also engaged in the changeprocess.

HIV/AIDS prevention interventionsshould go beyond the conventional“ABC” approach, and address thestructural roots of vulnerability toHIV/AIDS that are bound up in genderinequality, by engaging girls, boys,women and men in critically analysingtheir own context and in proposinglocal solutions. ■

Sara Austin is a Policy Analyst with World VisionCanada.This research was assisted by CoreyWright, Research Intern with World VisionTanzania/Canada, and Gertrude Chanda, Gender,Child Rights and Advocacy Manager with WorldVision Zambia.

1What is vulnerability to HIV? UNAIDS Fact Sheet, June2001 2 Epidemiological Fact Sheets on HIV/AIDS andSexually Transmitted Infections – 2002 Update: UnitedRepublic of Tanzania, UNAIDS,WHO and UNICEF,2002 3 “HIV prevalence rate among young people, byage and gender: Zambia 2001–2002”, HIV/AIDSEpidemiological Surveillance Update for the WHO AfricanRegion 2002 Country Profiles,WHO/AFRO, 2002

Boys and men–key to reducinggirls’ HIV vulnerabilitySara Austin


POVERTY AFFECTS MORE THAN50% of the population of theDominican Republic1 – most dram-atically in the rural and border areasof the country, where 44 of every1,000 children born die before theyreach one year old.2

The first case of AIDS in theDominican Republic was officiallyregistered in 1983, and within a shorttime there was a sustained, rapidincrease in the number of cases. Atthe end of 2001 an estimated 130,000people were living with HIV/AIDS;around 5,000 of these were childrenunder 15. At that time, an estimated33,000 children under 15 wereorphaned because of AIDS. Thegeneral prevalence of HIV infectionwas 2.5%.3

Reports indicate that preventionefforts carried out in recent yearsseem to be stabilising HIV prevalencein the 15–24 year-old age group,4

and the national average of infectionwith the virus seems to have beenlowered to 1%.5 However, inHaitian–Dominican (bateyes) com-munities in the midst of poverty,denial, stigma and discrimination,HIV prevalence is 5.6%.6

While there have been gains in thefight against HIV/AIDS in theDominican Republic, it is criticallyimportant to redouble advocacyefforts – both for access to anti-retroviral medications, and againststigma and discrimination. To this end,World Vision Dominican Republic hashad some success in raising awarenessamong, empowering and mobilisingcommunities and their leaders.

Using participative and reflectivemethodologies, in a spirit of respectand solidarity, these interventionshave focused on educating couples,“multiplying” knowledge of preven-tive measures, and building skills toadvocate and to combat stigma anddiscrimination. The community

involved has been empoweredthrough the training of its traditionalleaders (including teachers, parents,civil authorities, health providers andreligious leaders).

Nurturing young leaders

The project also has led to aburgeoning of new leaders, partic-ularly among the young. One of the

most successful initiatives is the Timeof Hope Project, for adolescents andyoung people. Its acronym PROJETA(Proyecto Tiempo de Esperanza para losJóvenes y Adolescentes) means“Protect” in Spanish. It is helpingyoung participants to developresponsibility for preventing HIV/AIDS, as the following story (see box)speaks eloquently:

Mobilising the communityClaudina Valdez and Ramón J Soto

Hi Josefina!

I’m writing you this letter to tell you howwell I feel, and how different I am, sincewe stopped seeing each other a fewyears ago. Remember how I was a sad,boring person, with very low self-esteem,and very shy in relating to others? Well,I tell you if you saw me now you wouldn’trecognise me.

I’ve joined a project called PROTEJAhere in Villa Altagracia, which has trainedme in prevention of sexually transmitteddiseases and HIV/AIDS, and in sexualand reproductive health.This has helpedme so much; my self-esteem has grownand I’ve even become a youth leader inmy community, promoting healthy andresponsible living.

PROTEJA has given me the opportunityto train other young people in my area.I’ve learnt to work with others andmany of us have become “multipliers”.Now that I’m a real community leader, Ico-ordinate a theatre group which has

helped me achieve amazing goals, formyself and for my community.

We’ve formed a network that importantleaders (like teachers, municipalauthorities, neighbourhood councilmembers, health and church leaders)have joined. Young people are activelyparticipating in this network’s HIV/AIDSprevention campaigns for the health ofthe community.

Many people in the barrio havechanged their way of looking at things.They now talk about HIV/AIDS withoutfeeling shame, and show solidarity andsupport for those who are sick (this justdidn’t happen before). It’s so interestingto see teachers working with otherteachers, doctors with other doctors,housewives with their neighbours, andeven pastors and religious leaders nowacting as “information multipliers” – inthe church services they talk to thepeople about HIV and the importanceof learning about prevention.

This may seem incredible to you, if youremember that in our church nobodyever talked about this kind of thing! Butthanks to these networks, a new socialconscience has been created, and someof the taboos that there used to beamong Christians have been broken.They’ve even created day clinics wherepeople sick from HIV can go and receiveattention, care and good support.

Good news, hey? Well, that’s all for now.Take care,

Joel Vargas Figueroa

Members of the PROTEJA youthnetwork

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Faith-based networks againstHIV/AIDS

The Communities of Faith Network forLife initiative has supported churchleadership in articulating an effectiveresponse to HIV/AIDS. The leadershave learned that church membersare vulnerable to HIV too. More than15 networks in some 500 churcheshave allowed 5,000 people to bereached with messages aboutHIV/AIDS. Once a church becomesaware, it is better equipped togenerate an effective response, as partof its mission and calling.This initiativehas tackled the challenges ofovercoming taboos and prejudiceassociated with HIV/AIDS, throughrelationships of respect andunderstanding.

Lessons learned, future vision

The experience to date has broughtvaluable lessons, including:

● Actively involving communitiesthroughout the process has been amajor success factor.

● Mobilising key actors, includingpeople living with HIV/AIDS, hasbeen fundamental.

● Work with young people hasinvolved the adults in their circles,which has created a more favourableenvironment for the adoption ofhealthy practices by young people.

● A “life and hope” focus on theAIDS epidemic has allowed a quickerapproach to youth and religiousleaders.

● Improving our organisation’scapacity to network and negotiate,along with credibility for ourprogramme work, have enabledWorld Vision to more substantiallyparticipate in various networks in theDominican Republic.

Continuing with our holistic,integrated development strategy thatis centred in the value and dignity ofthe human being, the vision is for abroad community mobilisation tostrengthen the promotion of healthylifestyles, to reduce the number of

people being infected by HIV andlessen the socio-economic andemotional impacts of the epidemic. ■

Claudina Valdez is HIV-AIDS Programme Managerfor World Vision Dominican Republic, and DrRamón J Soto is Regional HIV/AIDS Adviser forWorld Vision Latin America and the Caribbean. JoelVargas Figueroa, aged 15, is a participant in WorldVision’s youth journalism initiative.

1ONAPLAN, 1997 2 World Development Report2000–2001, World Bank 3 UNAIDS/WHO DominicanRepublic, Epidemiological Fact Sheets on HIV/AIDS,2002 Update (www.who.int/emc-hiv/fact_sheets/pdfs/Dominicanrepublic_EN.pdf) 4 UNAIDS/WHO, Situación de la epidemia de SIDA,December 2003 5 ENDESA, Encuesta Demográfica yde Salud 2002 6 Ibid.

Religious leaders meeting to discuss HIV/AIDS

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http://www.who.int/emc-hiv/fact_sheets/pdfs/Dominicanrepublic_EN.pdf

WHAT IS STIGMA? STIGMAcan be defined as a judgment on thepart of society (or the general public)about a type or group of persons thatdevalues or rejects the humanity ofmembers of that group.

More than 20 years into the HIVpandemic, people living withHIV/AIDS (PLWHA) continue toexperience social stigma because oftheir serostatus. The well-documented effects of this stigmarange from PLWHA being denied theuse of common toilet facilities orshunned by fellow communitymembers, through to beatings orattacks on them and their loved ones.

As to the sources of HIV/AIDS-related stigma, the United NationsJoint Programme on HIV/AIDS(UNAIDS) cites ignorance, fear,stereotyping and negative judgmentsabout possible sources of HIVtransmission. HIV transmission ispopularly associated with behavioursjudged as “immoral” – the judgmentabout these behaviours beingextended to the people thought toengage in them. Indeed, popularopinion goes so far as to blame HIV-positive (HIV+) persons forcontracting HIV, assuming theydeserved infection because of “whatthey must have done to get it”.1

Some PLWA facediscrimination even in AIDS organisationsand in the clinical care setting

Multiple stigmaMany PLWHA describe theexperience of being stigmatised as likebearing a taint or stain on the skin.

Indeed, PLWHA belonging to othermarginalised or socially vulnerablegroups usually suffer multipleinstances of stigma. In some cases,such people have even been theobject of officially-sanctioned violenceand killings.

The fight against HIV/AIDS-relatedstigma has thus become a cornerstoneof PLWHA activism. We, the activists,believe we will not succeed in rollingback or even containing the HIV/AIDSpandemic unless we form a strong andunited front against discrimination.Yetsome HIV+ drug users tell us thatAIDS organisations and PLWHAgroups do not fully support theirinvolvement in HIV/AIDS work, andeven discriminate against them.

HIV+ people who experience multipleforms of stigma fare worse in theclinical care setting than their fellowPLWHA. For example, HIV+ drugusers often have poorer access toadequate medical treatment; they areless likely to be offered antiretroviraltreatment, or when treatment isoffered, it is late or inadequate. Thiscan be because medical practitionersevaluate them – without medicalgrounds – as less likely to adhere totherapy, or as undeserving oftreatment.

The stigma against HIV+ drug users issuch that often they will not disclosetheir drug use to their HIV treatmentproviders. This is dangerous, as it canlead to misdiagnosis and harmfulinteractions between HIV treatmentdrugs and “street drugs”.2

Members of the Global Network ofPeople Living with HIV/AIDS (GNP+),the only global voice of people living

with HIV/AIDS, are now calling forPLWHA groups to acknowledge andrespond to the additional stigma-related problems that HIV+ drugusers face.

A vicious cycle

AIDS-related stigma makes us sociallyvulnerable: disempowered, oppressedand marginalised at several levels. Suchinequity weakens people’s capacity toexpress themselves and to controltheir lives. It reduces them to“tumbleweeds” blown here and thereby the winds of their circumstances. Avicious cycle then brings more stigmaon them, precisely because they aresocially vulnerable.

Although HIV/AIDS-related stigmaremains a great problem, the level ofstigma is lower today in many placesthan it was just 10 years ago. This ispartly due to the advent of highlyactive antiretroviral therapy (HAART),which makes it possible for people tomanage their HIV as a chronic disease– cracking the “HIV/AIDS = death”equation. But it has much to do withthe time, effort and risks activists havetaken in fighting stigma.

Since the launch of the PLWHAmovement over 20 years ago, peopleliving with HIV/AIDS and their allieshave advocated for visibility, changes insocial attitudes, and a greater and


Helping tumbleweeds grow rootsStuart Flavell

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People living with HIV/AIDS who alsobelong to marginalised groups such as“drug users” face additional stigmaand discrimination


more meaningful involvement in thedesign, implementation and evaluationof AIDS policies and programmes.They remind the world that PLWHAhave the same rights as all humanbeings, and that HIV/AIDS-relateddiscrimination is ultimately a humanrights issue.

As a result of AIDS activists’ hard andcourageous work, a structuredresponse to stigma is increasingly partof more comprehensive responses toHIV/AIDS. The focus of UNAIDS’2002–2003 World AIDS Campaign,Live and Let Live, was stigma anddiscrimination. The InternationalFederation of the Red Cross and RedCrescent (IFRC) leads a campaignagainst stigma, called The Truth aboutAIDS. Pass it on....

GNP+ is a partner with bothUNAIDS and the IFRC in the fightagainst discrimination. At last, keypartners understand how crucial it isto work as equals alongside peopleliving with HIV/AIDS.

There is still considerable work to bedone. Some Ministers of Healthsucceeded in eliminating references tospecific vulnerable groups in thecritical Declaration of Commitment thatcame out of the United NationsSpecial Session on HIV/AIDS in July2001. Implementation of theDeclaration in relation to drug users,for example, remains disturbingly low.Of 80,000 injecting drug users inBelarus and Romania, only 4% canaccess HIV-related health services –this despite the fact that HIV isspreading at alarming rates in EasternEurope, and mostly via the sharing ofsyringes among injecting drug users.3

Ongoing vigilance needed

We must remain vigilant. Stigma anddiscrimination breed each other, andare not yet defeated. The Canadianmagazine +ve reports that HIV testsare to become a fixture in theapplication process for the priest-hood. In the Netherlands, theSupreme Court recently ruled that a

patient can be ordered to submit toHIV testing if a doctor has beenexposed to that patient’s bodily fluids.4

In Switzerland, the Federal HealthOffice is considering implementingHIV testing for all asylum seekers,with the option for them to “opt-out”.5

In order for PLWHA to takeresponsibility for the fight againststigma, we must refuse to betumbleweeds. We must grow rootsand stand fast, building our skills,talents and capacity.

How do we address the fact thatsome AIDS organisations and PLWHAgroups discriminate against certainHIV+ people, such as HIV+ drugusers? David Burrows, an expert inharm reduction and injecting druguse, confirms this discriminationwithin groups established to tackleHIV/AIDS and support PLWHA.6

Activists at the International HIVTreatment Preparedness Summit inMarch 2003 reinforced the claim,arguing there is discrimination withinAIDS advocacy communities aroundinjecting drug users and othermarginalised groups such as sexworkers.7

Groups such as HIV+drug users must be included in responsesto the pandemic

Among the many approaches crucialto fighting the stigma that affects HIV+drug users, which includeguaranteeing equal access to medicaltreatment and care, is a greaterinvolvement of marginalised groupssuch as HIV+ drug users in theresponse to the pandemic. Bridgesneed to be built or reinforcedbetween such groups and the greatercommunity of people living withHIV/AIDS.

The recent 11th InternationalConference for People Living withHIV/AIDS in Kampala, Uganda, hostedclosed (and therefore safer and more

confidential) sessions for HIV+ drugusers to discuss issues of specificconcern to them. Attendees declaredthat there is little involvement of drugusers in the overall response to thepandemic, and that drug use issues arenot a government priority in manycountries. They called for solidarityfrom all communities to address theissues that surround drug use and fora follow-up global consultation in2004.8

As a further example of ourcommitment to addressing stigma anddiscrimination against HIV+ drugusers, GNP+ will, as a co-sponsor ofthe XV International AIDS Conferencein Bangkok, provide a satellite meetingon “Health and Human Rights of HIV-Positive Drug Users”.

All of us must help to create andfacilitate access _ especially forPLWHA _ to the tools and safe spacesnecessary for being involved in theresponse to the pandemic. No-oneshould be left to be a tumbleweed. ■

Stuart A Flavell is International Co-ordinator ofGlobal Network of People Living with HIV/AIDS(GNP+). See www.gnpplus.net

1Aggleton, P & Parker, R, “A conceptual framework andbasis for action: HIV/AIDS stigma and discrimination”,UNAIDS, 2002 2 Burrows, D, “Stigmatisation of HIV-positive injecting drug users”, STIGMA-AIDS, onlinediscussion forum of Health and DevelopmentNetworks, 21July 2003 3UNAIDS, “Follow-up to the2001 United Nations General Assembly Special Sessionon HIV/AIDS: Progress report on the global responseto the HIV/AIDS epidemic, 2003” 4Sheldon,T, “Patientscan be made to have HIV test to protect doctor”,British Medical Journal , 2004 (328): 304 5Neue ZürcherZeitung, 18 January 2004 6Burrows, D, “Care andsupport needs of HIV positive drug users in Australia”,paper presented at the International Conference onAIDS in Asia and the Pacific, Chang Mai,Thailand, 19957Final Report of the International HIV TreatmentPreparedness Summit, 13–16 March 2003, Cape Town,South Africa, posted to www.fcaaids.org.8 See their declaration on www.gnpplus.net

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GITA IS A YOUNG WOMANfrom the slums of Mumbai who is HIV-positive. She does not fall into one ofthe high-risk categories for HIVinfection; she had an arrangedmarriage at a young age and remainedfaithful to her husband. Unfortunately,her husband was not faithful, andbrought HIV into the home. After hedied, Gita and her two year-old sonwere banished by her in-laws – sent tolive in the street. Five months later,she discovered that her husband haddied of AIDS, and had passed thedisease on to her and to their son.

Gita is not alone in her predicament.The virus, first reported in India in1986, has touched every level ofsociety, and given the socio-economicethos prevalent in India, women andchildren are most vulnerable to it.

Initial research

To address the vulnerability ofadolescent girls to AIDS,World VisionIndia initiated a research project inlate 1991. It studied the sexualbehaviour patterns of adolescent girlsin six slum communities in north-westMumbai, to develop an effective modelfor sex education and AIDSprevention. But talking about sex andsexuality was taboo; the initialchallenge was to break the silence.

Only after approaching the mothers,to build their confidence and convincethem of the issues, could the focusmove to adolescent girls.

The research found that ignorancewas a major factor in girls’ HIV-vulnerability; others were unsafe sexpractices, gender discrimination, pooraccess to health services and poornutrition. Sexual abuse, includingincest and rape, were also factors thatcould not be ignored.

Education models

The education model developed foradolescent girls covered topics suchas: being a woman, growing up, dealingwith sexual harassment, reproductivehealth, general health, STDs andHIV/AIDS. It used interactive teachingmethods, films, skits, puppet shows,group discussions, quizzes and roleplay.Since our interaction with mothersrevealed that they too were at risk, in1994 World Vision initiated the Womenand AIDS Project, which grew to focuson both adolescent girls and marriedwomen in 25 slum communities.

The education model for adult womenhelped them to articulate theirconcerns about sex, sexuality and healthin general. The work faced resistancefrom elders and community members,and this required cultural sensitivity.

The education process identified thatwomen were aware of safe sexualpractices, but were powerless tomake the decisions. This led to theevolution of a complementaryeducational model targeted at menand adolescent boys – to createawareness and influence theirbehaviour as husbands and partners.By 1995, models were implementedfor all four target groups – men,women, adolescent girls and boys.Over the next four years, the projectcovered 30 slum communities with

approximately 55,000 people. AsWorld Vision worked with thesecommunities, we became convincedthat HIV/AIDS could not be addressedalone; it was linked to other social,economic and political issues. Weoffered adult education programmes,health camps and vocational trainingfor women and adolescent girls.Adolescents were motivated to form astreet theatre to reach communitieswith HIV/AIDS messages.

Meanwhile, across India the numberof reported HIV/AIDS cases wasrapidly increasing, mostly among“high- risk” groups includingcommercial sex workers and drugusers. It was not known at this stagethat the deadly virus had alreadyentered the lives of scores ofinnocent women and children whohitherto were considered “low-risk”.

World Vision’s community base meant it was lookedto for support

In 1996 the first case of an HIV+family in these communities wasreported. Clearly, there was a stigmaassociated with the virus, and bothinfected and affected people neededsupport. World Vision, with its strongcommunity base, was looked to forsupport. A Drop-in Centre with atrained counsellor was openedoutside the community area, whereinfected and affected people could gofor care and advice. Support groupsenabled people to share commonproblems and issues.

An area-wide approach

As HIV infections continued toemerge, a more holistic approach wasneeded.The Mumbai Area DevelopmentProgramme (ADP) was launched in1997 to support communities indeveloping their responses to thenow rapidly-growing AIDS threat. Oneresponse was the Andheri HIV/AIDSPrevention and Care Programme, tofocus on prevention throughawareness, caring for infected andaffected people, and advocacy for


Women and AIDS in Mumbai– a programme evolvesReena Samuel

Girls participating in educationdesigned to empower them to protectthemselves

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their rights.

Meanwhile, the ADP focused ongeneral health, education, economicsand leadership. Slum DevelopmentCommittees were formed toprioritise community needs andpursue solutions; SDCs were trainedto be vocal and to care for peopleliving with HIV/AIDS in theircommunities. These groups havehelped challenge stigma anddiscrimination.

In 2000, the Andheri Programmeextended to 52 slum communities inMumbai, with a population of 200,000.The Drop-in Centre extended itsservices – counselling, children’sschool fees, medical support(including a weekly clinic with femaledoctor), food rations, legal referrals,and a women’s income-generatingSelf-Help Group – to reach moreinfected and affected people.

Three or four new cases come to theDrop-in Centre every month. Of thefemale clients, 98% have been infectedby husbands who have had multiplepartners. Having migrated from ruralareas to marry, then been abandonedby their deceased husband’s families,many have no social safety net and seeWorld Vision as their only hope.Indeed, women who are HIV+volunteer as Care Givers themselves.

To address women’s basic rights froma broader platform, we haveestablished links with like-mindedorganisations.World Vision is active inthe Forum of Those Concerned withHIV/AIDS in Mumbai, Navi Mumbai andPune, which comprises 75 NGOs,

government agencies, academic,research and media groups, andaddresses issues including access toARV therapy, rights of infected womenand children, and mandatoryHIV/AIDS testing.

Programmes needflexibility to evolve with new understandings and changing contexts

World Vision’s long association withthe HIV/AIDS issue in thesecommunities, from the early days ofcreating awareness to a fully-fledgedcommunity development effort, hastaught us the importance of

programmes being flexible to evolvewith new understandings and changingcontexts. We consider the MumbaiHIV/AIDS programme a “centre oflearning”, lessons from which can bereplicated in India and beyond. ■

Reena Samuel is Communications Officer, ExternalRelations, for World Vision in Mumbai, India. Shewas formerly manager of the Mumbai ADP.


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An Indian wedding. Sadly, unfaithfulhusbands have put many Indianwomen at risk of HIV/AIDS.

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REBUILDING BROKEN LIVES

Heather Ferreira has been linkedwith World Vision’s HIV/AIDS initiativein Mumbai since its inception, wearingmany “hats”.

During the early research period, asan educator she helped develop theeducation model for adolescent girlsliving in slum communities. After abrief stint with a UNICEF HIV/AIDSprevention project, she returned toWorld Vision and as a social worker,led mass awareness campaignsamong 30 slum communities. Thenher growing concern for widows livingwith HIV/AIDS led to her helpinginitiate the Drop-In Centre wherewomen could go for support. Heathersays:

"Reflecting on the stories youngwidows have told, I realise how easilyHIV/AIDS can make the life of ayoung woman crumble around her. Itis so rewarding to see the resolveemerge within her to go on, even withlittle emotional support from peoplearound her."

Heather developed a proposal for theAusAID-funded Prevention and CareProgramme for over 50 slumcommunities. In 2002 she became

World Vision’s HIV/AIDS point personin Western India – training andbuilding capacity to ensure all 16ADPs in the region were respondingeffectively to the challenge. She istrained in Economics and PoliticalSciences, and Reproductive andAdolescent Health Monitoring.

Heather now provides technicalsupport for World Vision India onwomen, youth and HIV/AIDS issues.Her passionate concern for theseissues means she is often invited tospeak to other groups. She says:

"Working with HIV/AIDS andespecially women has changed mepersonally. I see how a little emotionalsupport for these women can go along way to rebuild broken lives."

— Reena Samuel


IN CHILE, IT’S OFTEN ASSUMEDthat children from rural areas, andparticularly ethnic minoritycommunities, have less knowledgethan urban children of topics such assexuality or sexually transmitteddiseases like HIV/AIDS. A study byWorld Vision Chile1 measuringchildren’s perception of AIDSindicated that this is not so.

Responses by the Mapuche children ofPuerto Saavedra, a small rural town inthe south of Chile, are a case in point.Of these children, 77% said that HIV isan easily transmitted disease and 65%think it is a problem that affects thewhole of society. In urban areas, onthe other hand, only 55% of childrensurveyed answered that HIV is aneasily transmitted disease, and 47%think that it affects all of society.

The research used closed questionswith multiple choices and involved333 boys and girls between the agesof 11 and 17. The children aresponsored by World Vision throughnine development projects, four inrural areas and five in urban areas.

On the risk of HIV infection

The research indicates that:

● 64% of the children believe thatyoung people are at major risk ofbeing infected with the virus; and

● 57.5% believe there is a greaterchance of being infected by the virusin cities than in the countryside.

On transmission of the virus

● A high percentage of childrenbelieve that the disease cannot betransmitted by ordinary contact suchas shaking hands and sharing knives,spoons or forks.

● 61.9% of urban children believethat sexual relationships are theprincipal method of becoming

infected – almost twice the numberof those in rural areas who believethe same (33%).

● 65.8% believe that condoms arethe most effective protection againstAIDS.

● Yet the research showed that thechildren do not have a clear idea ofhow alcohol or drug consumptionaffects the transmission of AIDS. Ofthe children studied, 53% either haveno knowledge of this topic or thinkthat consumption of thesesubstances has no impact ontransmission.

● One of the established mythsregarding the spread of HIV is that ifa mosquito bites an HIV-infectedperson, it can transmit the virus toanother person.This belief is morecommon in urban areas (60.9%)compared to rural areas (38.1%).

On discriminatory attitudes

● Some 59% of children gave thediscriminatory (and incorrect)response that AIDS affects thehomosexual population more.Thisview is more frequently expressed byboys in urban areas.

● On the other hand, 61.7% thinkthat people with AIDS do not haveto be isolated or segregated butneed to be taken care of.This non-discriminatory response is seen moreoften among rural children thanurban ones.

HIV/AIDS in Chile

In Chile, the first case of AIDS wasreported in 1984. Since December2001 (the date of the last officialstudy) there have been 4,646 cases ofAIDS, 5,228 HIV-positive cases, and3,012 deaths reported. The annualtrend has been an increase, reaching4.51 cases per 100,000 people in 1999.Studies carried out by the National

Committee on AIDS indicate a clearpattern of HIV/AIDS transmissionin Chile:

● an increasing rate of the diseaseamong women, with the gap in theinfection rate between men andwomen getting smaller;

● an increased transmission rate inheterosexual relationships comparedto homosexual relationships;

● a major increase of infectionamong people with a lower level ofeducation; and

● that the disease has moved to therural areas, and is no longer exclusiveto cities.

These findings clearly show that HIV/AIDS is a problem that affects the wholeof society, as the majority of childrensurveyed by World Vision perceived.

Chile should not wait to experienceterrible numbers before having apublic policy and a level of citizenawareness that stops the spread ofthis disease.That way we will not haveto say in 2020: “Why didn’t we dosomething in 2000, when we hadtime?” Let’s assure Chile’s children ofaccess to a complete and propereducation and to the necessaryresources for protection, so that theycan have healthy and long lives withthe full exercise of their rights. ■

Patricio Cuevas is Communications and Advocacy

Co-ordinator for World Vision Chile.1 The research took place in the context of a strategicrelationship between World Vision Chile and theNational Committee on AIDS (CONASIDA), agovernment entity responsible for preventing andreducing the impact of HIV/AIDS in Chile.

How Chilean children seeHIV/AIDSPatricio Cuevas

World Vision sponsored childrenparticipating in the survey about theirperceptions of HIV/AIDS

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THE APOSTLE PAUL WROTEto the Corinthians, “Now there arevarieties of gifts, but the same Spirit…varieties of activities, but it is the sameGod who activates all of them ineveryone”.1 Paul was teaching thisearly church community that whileeach person is called to a unique role,there is unity through the Spirit. Now,more than ever, we are all called withour particular gifts, services andactivities to join together as ONEagainst global poverty and the AIDSpandemic.

The emergency is unprecedented.Thisis the worst plague to hit humanity in500 years. Before long, more will havedied from AIDS than in all the wars ofthe 20th century combined.2

HIV/AIDS kills children, parents,teachers, doctors, nurses, farmers,business people, bureaucrats –devastating entire communities thatare already crippled by poverty andunfair international trade or debtpolicies. If we do nothing, there will bean estimated 25 million orphans inAfrica by the end of the decade.

Seized by the vision of ONE voice andONE goal – to eradicate poverty andHIV/AIDS in Africa – DATA’s co-founder Bono, gospel musiciansMichael W. Smith and Jars of Clay,World Vision US and Bread for theWorld, jointly launched The ONECampaign in a rally in Philadelphia.Bono called upon all NorthAmericans to commit to actualisingjustice, equality, and liberty – pointingout that in the stark light of history,we will be judged by our children andby our God for our response to thisgreat pandemic.

Following the rally, a worship servicewas held in the PhiladelphiaCathedral. As the song “We are onein the Spirit” echoed through theCathedral, the doors were flungopen, symbolically welcoming all tojoin – voices for awareness andhands for action – across national,racial, religious and political lines.

With our varied gifts, roles andcallings, in ONE spirit, we canconquer this pandemic. ■

Jenny Eaton is Faith Outreach Co-ordinator forDATA (Debt AIDS Trade Africa), an internationalnon-profit organisation co-founded by Bono of U2– see: www.data.org, or to join The ONE campaign,go to: www.theonecampaign.org

1 I Cor. 12:4–5, New Revised Standard Version 2 UNAIDS, at Security Council Session on the AIDSCrisis (based on a count of 33 million people dying inwar in the 20th century; 22 million cumulative AIDSdeaths at the start of this century; and a projectedthree million deaths per year)

WORLD VISIONis a Christian relief and developmentpartnership that serves more than 85million people in nearly 100 countries.World Vision seeks to follow Christ’sexample by working with the poorand oppressed in the pursuit of justiceand human transformation.Children are often most vulnerable tothe effects of poverty. World Vision

works with each partner communityto ensure that children are able toenjoy improved nutrition, health andeducation. Where children live inespecially difficult circumstances,surviving on the streets, suffering inexploitative labour, or exposed to theabuse and trauma of conflict,WorldVision works to restore hope and tobring justice.World Vision recognises

that poverty is not inevitable. OurMission Statement calls us tochallenge those unjust structures thatconstrain the poor in a world of falsepriorities, gross inequalities anddistorted values. World Vision desiresthat all people be able to reach theirGod-given potential, and thus worksfor a world that no longer toleratespoverty. ■

ONE in the Spirit – against global poverty and AIDSJenny Eaton

BACK COVER : HIV/AIDS prevention programme in action, in Vietnam. Long-distance bus and truck drivers have been identified as a “high-risk” group. PHOTO - SANJAY SOJWAL / WORLD VISION

Bono launching the ONE Campaign at Philadelphia’s Independence Hall in May 2004

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http://www.data.org

http://www.theonecampaign.org

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Documents

A WORLD VISION JOURNAL OF HUMAN DEVELOPMENT · Second Quarter,2004 A WORLD VISION JOURNAL OF HUMAN DEVELOPMENT Alexandre Grangeiro National STD/AIDS Programme,Brazil Milly Katana