Naina Dhingra's blog

Bill to Strike Abstinence Earmark from PEPFAR

2007-06-06T11:58:33-04:00

Today, Senators Dianne Feinstein (D-CA) and Olympia Snowe (R-ME) introduced groundbreaking legislation, the HIV Prevention Act of 2007, a bill that would remove the ideological 33 percent abstinence-until-marriage earmark from HIV prevention programs in the President's Emergency Plan for AIDS Relief (PEPFAR). The earmark is the primary culprit in denying young people in PEPFAR countries from receiving honest, comprehensive HIV prevention programs. Ten additional Democratic Senators co-sponsored the bill including Senators Clinton, Durbin, and Feingold.

Earlier this year, the Institute of Medicine (IOM), the nation's leading medical authority, released a report calling on Congress to remove the harmful abstinence-until-marriage earmark from PEPFAR, stating that "[PEPFAR's] budget allocations have made spending money in a particular way an end in itself rather than a means to an end—in this instance, the vitally important end of saving lives today and in the future."

The HIV Prevention Act of 2007 also allows for greater flexibility within PEPFAR to respond more quickly and specifically to the local epidemic, and supports public health best practices that are tailored to local needs and culture.

Senators Feinstein and Snowe have taken a bold step toward responding to the IOM's call and remedying the harm caused to young people by the abstinence-until-marriage earmark. Hopefully, the Senate will put ideological differences aside and join them in this noble effort.

The Missing Cohort of the AIDS Epidemic

2007-05-22T09:00:00-04:00

You've heard the statistic countless times. Every day, more than 6,000 young people become infected with HIV. Last winter, as it rolled off my tongue again, I stopped with a start. I realized that I, and the entire AIDS community, have been using that statistic for years. And yet, we continue to discuss young people in the context of prevention without acknowledging the fate of the 6,000 who are infected each day. What happens to them after we use them in our statistics to force policy-makers to invest more in prevention? Who is advocating for their needs?

As I explored this issue, I learned that the statistics are difficult to come by because of a lack of age-desegregated reporting in most countries and because of youth's low use of voluntary counseling and testing (VCT). For example in Ethiopia in 2005, less than two percent of young women ages 15 through 24 had been tested for HIV. Data is better for those who are known to have been infected perinatally (during pregnancy, delivery, or birth or through breastfeeding). The widespread roll-out of antiretroviral therapy has led to many children living with HIV transitioning into adolescence.

Advocates for Youth decided to investigate how, or even if, HIV-positive youth were being served in the President's Emergency Plan for AIDS Relief (PEPFAR). We found that while PEPFAR was making some gains in reaching children living with HIV through treatment, by and large, the needs of adolescents had been ignored.

HIV-positive adolescents are scantly mentioned in PEPFAR's policy on orphans and vulnerable children (OVC). The policy references HIV status only as an additional risk factor instead of acknowledging the different needs of an HIV infected child or adolescent. The OVC policy guidance also overwhelmingly assumes that most OVC are HIV-negative, an incorrect assumption.

Additionally, there is a myth that most OVCs are small children although nearly half of all orphans who have lost one parent and two-thirds of those who have lost both parents are aged 12 through 17. As orphans grow older, they face higher risks of acquiring sexually transmitted infections, including HIV, than do non-orphans. Yet, PEPFAR OVC programs and policies do not acknowledge orphans' age or vulnerability.

PEPFAR also pays no attention to positive prevention for those youth who are infected. Positive prevention includes strategies that increase youth's self-esteem and confidence; support youth in protecting their own sexual health and in avoiding infecting others; and that involve HIV-positive youth in planning and implementing HIV strategies and policies. Nor does PEPFAR acknowledge that reproductive health services and comprehensive life skills education are critical for positive prevention.

If PEPFAR does not equip youth living with HIV with the tools they need to stay healthy and keep their potential and future partners free from infection, then countless new infections will occur. Programs and policies must be developed to help this critical population transition from childhood to adolescence and then to adulthood.

For an in-depth analysis of the needs of HIV-positive youth and how PEPFAR is failing this population, read Advocates for Youth's new policy publication, Improving U.S. Global AIDS Policy for Young People: Assessing the President's Emergency Plan for AIDS Relief.

Improving U.S. Global AIDS Policy for Young People

2007-05-21T09:00:00-04:00

New Policy Report from Advocates for Youth

Last December, I traveled to South Africa and Kenya to get a handle on what programs funded by the President's Emergency Plan for AIDS Relief (PEPFAR) looked like on the ground. Specifically, I wanted to talk to youth themselves to get their perception of PEPFAR and to examine program responses to young people's needs.

Overwhelmingly, I learned that the common sentiment on the ground was that PEPFAR has, so far, largely ignored the realities of young people's lives and the state of the epidemic among youth. It's no surprise, considering the policies that strangle an effective response like the ideological abstinence-until-marriage earmark and the un-scientifically based guidance from the Office of the Global AIDS Coordinator (OGAC).

One Kenyan PEPFAR implementing partner told me, "PEPFAR requires you to present everything about condoms very negatively. You ... shoot yourself in the foot before you start."

There was common agreement that PEPFAR HIV prevention programs for youth also lacked sufficient links to reproductive health care. One recipient stated that PEPFAR's current youth prevention policy has resulted in "an absence of condoms and aggressive inattention to STI education and clinical services [for youth] ... this inattention is unethical and disgusting."

I also found a widespread belief that PEPFAR's one-size-fits-all approach to youth HIV prevention ignores the social and cultural factors that contribute to the spread of HIV. One South African PEPFAR implementing partner said,

Another PEPFAR implementing partner told me to be successful in positive behavior change for an individual, "You have to target the community to change attitudes. A young person may want to change behavior, but the environment might not allow them to." I even found some research funded by USAID in Namibia that found that most youth did not understand the concepts of abstinence or faithfulness for HIV prevention. Namibian youth believed that "abstinence" meant "to be absent" and "faithfulness" meant faith in religion; 75 percent of the study population had never heard the word "monogamy."

The findings from my travels to South Africa and Kenya along with several months of research are documented in a new Advocates for Youth publication, Improving U.S. Global AIDS Policy for Young People: Assessing the President's Emergency Plan for AIDS Relief. The report makes a number of recommendations to Congress, including the immediate repeal of the abstinence-until-marriage earmark from PEPFAR and an increase in appropriations for international family planning.

The report also critiques PEPFAR's response to HIV-positive youth which will be featured in a new blog tomorrow.

Leaked Memo from World Bank

2007-04-19T12:01:49-04:00

The World Bank came under fire last week for actions taken by managing director, Juan José Daboub, to remove references to family planning from a Madagascar grant and more broadly from the new health, nutrition, and population strategy. Daboub, a former member of the ruling conservative party of El Salvador, was an appointee of current World Bank head, Paul Wolfowitz. Wolfowitz (who has his own issues due to controversy around his role in securing a hefty pay raise for his girlfriend) and Daboub were scrutinized at last weekend's spring meetings of the World Bank and IMF where Board members expressed outrage over Daboub's actions.

We obtained this confidential letter that Daboub sent to the World Bank board members where he denies any wrong doing. Sorry Daboub, but we're not buying it!

Dear Executive Directors,

In the same spirit with which I have maintained communication with you on matters of mutual interest, I am writing to set the record straight following various press reports regarding the Bank's new health, nutrition and population strategy as well as the contents of the Madagascar CAS, which the Board endorsed on April 3.

Regarding the Madagascar CAS, none of the editorial changes that were made at my direction changed, or intended to change, the Bank Group's program in the area of family planning. These changes were simply intended to clarify what I understood to be the Bank's role in this area, given the roles of other donors. A review of the document shows clearly that family planning continues to feature in the CAS. In particular, paragraph 104 of the document continues to state that "In health, [the Bank] will help the government make further progress on reducing child and maternal mortality by offering access to reproductive services ...". By the same token, the CAS continues to include a Bank-supported health project (see the results matrix on page 47) that supports Government activities in the areas of child immunization, malaria control, and population and family planning, and that management expects to distribute to the Board in late April, as originally planned. Moreover, the Board has already approved over US$625 million for population and reproductive health for FY07 and the final number is expected to be close to US$750 million; these figures represent the highest ticket item in our Health portfolio.

There also has been no change to the Bank's policy on family planning. The health, nutrition and population strategy document that is currently before you for discussion has a results framework (Annex J) which includes an outcome (IV) entitled "Improved maternal, reproductive and sexual health". That results framework also explicitly references multisectoral contributions to intermediate outcomes/outputs that include "improve family planning and sexual health", where the relevant measures are identified as "contraceptive prevalence rate among women of reproductive age", "unmet need for contraception", and "prevalence rate of STIs [sexually transmitted infections] among adults and young people (15-24 years)".

I am here to carry out professionally and faithfully the Bank's policies. The policy on Reproductive Health is clear, had been endorsed by the Board and in place for many years; it has been followed by the President, the Staff and me, as reflected in projects and programs brought and to be brought to the Board. We understand and respect our partner countries' decision on this subject.

Juan José Daboub

Wolfowitz Comes Under Fire for Personal and Political Blunders

2007-04-13T09:00:00-04:00

The annual spring meetings of the World Bank will be held this weekend in Washington, D.C. amidst turmoil and controversy surrounding its head, Paul Wolfowitz. Wolfowitz, better known for his role as a former Bush official central to the planning of the Iraq war, came under fire yesterday for impropriety surrounding the promotion and pay raise of his girlfriend, Shaha Riza. Wolfowitz, who has been outspoken on the need to get rid of corruption in development during his tenure at the World Bank, made the hourly CNN newsfeed for helping Riza secure a high paying special assignment to the State Department when he joined the Bank.

As if he didn't have enough problems, the Financial Times reported last night that reproductive health policies have been under attack under Wolfowitz due to the appointment of Juan José Daboub to managing director. Daboub is a former member of the ruling conservative party of Ecuador. The FT reports that Daboub is "attempting to radically alter a long-standing health strategy at the World Bank" and that "there was a widespread perception within the bank that the emphasis on contraception in preventing disease was being altered following the appointment [of Daboub]."

Apparently, both Wolfowitz and Daboub didn't read the World Development 2007 report, recently published by their own institution. The theme of the report is youth aged 12 to 24. If you read the report, you would have been shocked to find the World Bank endorsing reproductive health policies to improve youth's health. The report states:

I know that I nearly fell off my chair. The World Bank? The big mean financial institution led by former Bush ideologue endorsing comprehensive sexuality education in schools? The report also rejects that an abstinence-only message is appropriate for youth:

Wonder how that one got by Wolfowitz! But it seems that Daboub has been trying to put an end to all of that; according to the FT, he recently tried to delete all references to family planning from a country proposal from Madagascar.

The World Bank spring meetings this weekend appear to have a humanitarian focus with a spotlight on empowering women and promoting gender equality. Specifically, they plan to increase women-owned businesses by 10 percent by 2009 and help establish clearer property rights for women. Women's economic empowerment is certainly a just cause, but not as a veil that covers an ideological agenda to strip women of their right to access contraception.

It's clear that Wolfowitz cares more about maintaining his credentials as a Bush ideologue instead of alleviating global poverty. But due to his blunders mixing work with pleasure, it doesn't look like he'll keep his job for long. The advocacy community should join with the media in evaluating Wolfowitz and demanding answers.

IOM Says Abstinence-Until-Marriage Earmark Hinders Global HIV Prevention Efforts

2007-04-02T08:55:00-04:00

Last Friday, the Institute of Medicine (IOM) published their long awaited congressionally mandated report evaluating the implementation of the President's Emergency Plan for AIDS Relief (PEPFAR). For weeks, advocates have been anticipating the findings of the report with little rumor of its outcomes. We were not disappointed. The 314 page report, PEPFAR Implementation: Progress and Promise, was well worth the $37.50 download fee. The IOM found:

The New York Times quotes one of the IOM committee members, "Ruth Macklin, a bio-ethicist at the Albert Einstein College of Medicine in the Bronx and a panel member, called the restrictions "hamstrings or shackles," though Dr. Macklin said the report diplomatically referred to them as "earmarks or budget allocations."

In case Congress needed more proof that the 33 percent earmark for abstinence-until-marriage programs was a dumb idea, the premier medical institution of the country has stated that it makes no scientific sense. The IOM believes that, "by requiring the Country Teams to isolate funding for these [abstinence and be faithful programs] activities, this budget allocation has undermined the teams' ability to integrate prevention programming" (emphasis mine).

The IOM's research confirmed last year's GAO report findings that the abstinence-until-marriage funding requirement created major challenges for PEPFAR implementers. According to the report, "Confusion and frustration in the field caused by the abstinence-until-marriage allocation have persisted ... staff indicated that the allocation did not allow them sufficient flexibility to create the appropriate prevention portfolio based on the available data."

The IOM additionally found that PEPFAR's rigid congressionally mandated budget allocations (earmarks) have resulted in an inability to respond to the local epidemic and that a one-size-fits-all approach does not make sense. The IOM recommends that Congress remove all earmarks. That's right—the IOM is recommending that Congress repeal every single PEPFAR earmark. The report states, "The lack of an evidence base for the budget allocations (earmark) and a rationale linking the allocations to performance targets and goals has adversely affected implementation."

The report made a number of recommendations geared towards moving PEPFAR from an emergency plan to a sustainable initiative. To achieve sustainability, the IOM advises that a stronger emphasis on women and girls is needed. The IOM recommends, "The U.S. Global AIDS Initiative should continue to increase its focus on the factors that put women at greater risk of HIV/AIDS and to support improvements in the legal, economic, educational, and social status of women and girls."

Unfortunately, not everyone was pleased with the report outcomes. The Boston Globe reports, "But Shepherd Smith, president of the Institute for Youth Development, which runs several abstinence programs in Africa, said the report's conclusions on abstinence and fidelity spending ‘make no sense.'" Sorry Shepherd, your days of seeing PEPFAR as a slush fund to spread ideology are coming to a close.

Earlier last week, Representatives Barbara Lee (D-CA) and Christopher Shays (R-CT) introduced the Protection Against Transmission of HIV for Women and Youth (PATHWAY) Act of 2007 (H.R. 1713), a bill that would remove the abstinence-until-marriage funding earmark from PEPFAR and request the President to develop a strategy to respond to the vulnerabilities of women and girls. The findings of the IOM report confirm the urgency of this critical piece of legislation.

The 110th Congress has the power to repeal the abstinence-until-marriage earmark. It's our responsibility to hold their feet to the fire. If your organization has not already endorsed the PATHWAY Act, please do so immediately by clicking here and join the movement to ensure that ideology does not continue to trump science in HIV prevention policy.

ACT UP Turns 20

2007-03-29T09:00:00-04:00

Twenty years ago this month, one of the most powerful activist movements was born—the AIDS Coalition to Unleash Power—better known as ACT UP. ACT UP has accomplished many things in 20 years but perhaps the most powerful is the lessons that it has to offer the reproductive justice movement in the current political climate.

ACT UP was born in New York on March 10, 1987 after activists at a meeting at the LGBT Community Center decided that political action needed to be taken to respond to AIDS. Two weeks later, ACT UP held its first demonstration to protest the high price of AZT—the sole AIDS drug at the time. Activists, made up of those living with HIV and their allies, held a "die-in" on Wall Street and disrupted the opening bell. ACT UP put the national spotlight on the high cost of AIDS drugs. Before long, ACT UP became known for their media-savvy political actions targeted at the pharmaceutical companies to lower drug prices.

In its heyday, there were likely hundreds of chapters around the country. Today, many are struggling or non-existent. But on the East Coast, Philadelphia and New York remain strong. The influence of ACT UP is clear in my mind. Last week at the REAL press event on the Hill, Sean Barry of the Community HIV/AIDS Mobilization Project (CHAMP), and I were reflecting on the influence of ACT UP on our own lives. As student activists with both Advocates for Youth and the Student Global AIDS Campaign several years ago, we interacted with people from both ACT UP Philadelphia and ACT UP New York. We saw ACT UP Philly bring busloads of people with AIDS and their allies to Washington to protest for more money for domestic and international AIDS prevention and treatment. We were inspired by the activists we met, and they helped shape our perspective on putting the people served by the movement first, before the politics.

What can the lessons of ACT UP teach us today? The members of ACT UP held one agenda—to fight for people with AIDS. And they were unafraid to go after whoever they needed to hold them accountable. Republican or Democrat. It made no difference. The story that inspires me the most and shows the power of a small, committed group of activists is the action ACT UP took targeting Vice-President Gore. Gore? Isn't he progressive on everything? Unfortunately, while our new favorite climate change activist has increased his progressive credibility, he didn't always do the right thing.

In the summer of 1999, the Clinton Administration, due to heavy pharmaceutical industry pressure, attempted to gut a South African national law that used legal World Trade Organization (WTO) policies to provide affordable, generic AIDS drugs to their citizens. That's right—the Clinton Administration tried to influence the national law of another country in favor of corporate interests, largely led by Gore. ACT UP decided to respond. In an extremely high profile campaign, ACT UP followed Gore from day one of his campaign announcement in Tennessee throughout the first months of his campaign to demand that he reverse his policy.

A protest several thousand persons strong greeted him at a major fundraising event in Philadelphia. To some, it may have been extreme. But it worked. On September 17, 1999, Gore directed the U.S. Trade Representation (USTR) to cease all action on South Africa. This eventually led to public statements by President Clinton to encourage efforts to increase access to low-cost, generic AIDS medications.

Democrats don't always do the right thing and it's an important lesson to keep in mind when thinking about the new Congress. First and foremost, our values and our commitment should be to the issues of reproductive justice and HIV/AIDS. These values must transcend political parties. ACT UP's legacy is to teach activists working on any issue that commitment to the people served by that movement is crucial to success and credibility. It's up to us to keep up the pressure and ensure that reproductive freedom and justice is available for every woman, man, and young person in this country, regardless of which party is in power.

Global Fund Executive Director Selected

2007-02-12T08:00:00-05:00

The race for the Executive Director for the Global Fund finally ended after several months of uncertainty. The Board of the institution met Thursday in Geneva to review the second round of applications for the position at an emergency meeting that was called for last October after failing to select a candidate. Dr. Michel Kazatchkine, one of the two frontrunners from the first round, was selected.

In October, the Board reached a dead-lock after neither of the two front-runners, Dr. Kazatchkine and Dr. Michel Sidibe of UNAIDS, were unable to achieve the two-thirds majority required of the donor and recipients blocks on the Board. In the second round, Dr. Sidibe chose not to reapply and the two contenders, in addition to Dr. Kazatchkine, were Dr. Alex Coutinho, CEO of the AIDS Service of Organization of Uganda (TASO) and Dr. David Nabarro, currently heading the UN's influenza response.

Last week, Dr. Kazatchkine was able to achieve the required two-thirds majority of the recipient and donor blocks securing him as the leader of the organization. Dr. Kazatchkine is well known in the global AIDS community, having treated people with the disease for over 20 years. He currently serves as France's Ambassador for HIV/AIDS and Communicable Diseases. He also has a long history with the Global Fund; he served as Vice-Chair of the Global Fund's Board of Directors and was the first Chair of the Fund's Technical Review Panel, which is responsible for reviewing the quality grant proposals. As a world-renowned scientist and clinician who has treated people with AIDS worldwide, he brings over two decades of experience to his new position. He has demonstrated strong commitment to fighting for the needs of people living with AIDS and is known for advocating for science over politics when it comes to HIV prevention, particularly with intravenous drug users and needle exchange.

Dr. Kazatchkine will take the reigns to lead the Global Fund after the current executive director, Sir Richard Feachem, steps down after his five-year term on March 31, 2007. With 450 programs in 136 countries, Professor Kazatchkine will lead the largest international financier of TB and malaria programs and one of the three largest funders of HIV/AIDS programs in the world.

The State of the Union and HIV/AIDS

2007-01-24T07:56:00-05:00

I remember the night of January 28, 2003 well. For days prior, there had been a flurry of emails speculating that President Bush might perhaps mention global AIDS and that he just might announce a major new U.S. government initiative to tackle the pandemic in his State of the Union. At the time, I was a college AIDS activist with the Student Global AIDS Campaign (SGAC) at George Washington (GW) University and a member of the International Youth Leadership Council with Advocates for Youth. I lived and breathed the global AIDS movement. SGAC had formed just a few months earlier on the passion and commitments of a small group of students from Harvard, GW, University of Maryland, Yale, and several other universities. We were young, inspired, and believed that we could change the world.

That night, several of us eagerly tuned in to hear what the President had to say. After what seemed like hours of endless applause, the moment we had all been waiting for happened. The President of the United States began to discuss AIDS in Africa in his State of the Union. It was the first time that this international health crisis received this level of attention by a President. While President Clinton has become a leader on global AIDS post presidency, his actions while in office were disappointing, and he certainly never made mention of the pandemic during a State of the Union address.

Bush began by discussing the challenges of AIDS in Africa and the costs of anti-retroviral medicines. He then shocked the American public by saying, "Tonight I propose the Emergency Plan for AIDS Relief—a work of mercy beyond all current international efforts to help the people of Africa. This comprehensive plan will prevent 7 million new AIDS infections, treat at least 2 million people with life-extending drugs, and provide humane care for millions of people suffering from AIDS, and for children orphaned by AIDS." He then asked Congress to commit $15 billion over the next five years to meet the goals.

For a moment, I forgot that this was the same President who had reinstated the global gag rule and de-funded UNFPA. How was it possible for this President to show so much compassion for those affected by AIDS and not realize that the very same people were equally affected by the ideological policies restricting family planning resources? I barely had a moment for reflection though as every cell phone in the room began ringing. We were in awe, not just at what Bush had just said, but at what we saw as the power of a community movement.

For months prior to the State of the Union, a small group of NGOs including activist organizations like Health GAP and progressive faith-based organizations had been lobbying the Administration to launch a major Presidential AIDS Initiative. Inside and outside strategies were used that included high level meetings with senior Administration officials as well as constant badgering of those same officials at public events and in the media. We demanded that the U.S. government do more on global AIDS. While there were certainly other factors that contributed to the decision for President Bush to include global AIDS in the State of the Union, both known and unknown, we were convinced in the power of the people.

It would be several months before we realized that the plan wasn't going to live up to all of our hopes and dreams. The same ideological battles that gave rise to the domestic abstinence-only funding spree by Congress, took over this initiative. Conservative faith-based organizations received special treatment and money was prioritized for abstinence-until-marriage programs that made many of us seriously question if PEPFAR would ever happen.

But here we are—four years later. The American public now expects an annual update on PEPFAR recognizing it as one of the President's monumental initiatives. HIV/AIDS was once again highlighted as one of the eight major policy initiatives in the 2007 State of the Union. While PEPFAR has made dramatic achievements in the rapid scale up of putting HIV+ people on life-extending anti-retrovirals, the American people should hold their applause. PEPFAR's ideological policies, including the abstinence-until-marriage earmark and the prostitution loyalty oath, dramatically hinder the effectiveness of prevention programs targeting women and girls. While the United States, through PEPFAR, is certainly the largest bi-lateral donor to global AIDS, it is known for its "go it alone" approach and for bullying countries to accept its conservative policies.

In 2003, Bush said, "This nation can lead the world in sparing innocent people from a plague of nature." We certainly have the capacity and the responsibility. Now it is up to the new Congress to ensure that we truly have the will.

Finding Hope in Kenya: Growing Up With HIV

2007-01-17T08:00:00-05:00

The drive is one you don't forget: a terrible pot-holed road from town usually filled with bumper to bumper traffic. But the destination is well worth the price. Karen, a wealthy Nairobi suburb of mizungus (Swahili for "white people") is usually not a destination for those working in international development. Kangemi and Kibera, the slums of Nairobi, are more up our alley. But tucked away in Karen is an inspiring program called Nyumbani. Nyumbani, which means "home" in Swahili, is a home for HIV+ children who have been orphaned or abandoned.

Nyumbani was founded in 1992. At the time, the home was essentially a hospice for children dying of AIDS. There was little hope for long-term survival. As Nyumbani grew in size over the years, the staff refused to sit idly by and watch the children die. They broke up adult antiretroviral (ARV) drugs to give to the children based on new pediatric formula recommendations issued by WHO. They were accused of testing on children and using them as guinea pigs. But it was the only way they knew to give them a chance of survival. Miraculously, they saw a remarkable difference that convinced them to make a commitment to ensure that Nyumbani's small residents had access to life-saving ARVs.

Three years ago, I was a volunteer at Nyumbani and was constantly amazed by the commitment of the Kenyan staff to ensure that these children had as normal of a life as possible. There is a misinterpretation that Nyumbani is an orphanage, with Dickensian images coming to mind. But life at Nyumbani is far from the soup lines and harsh discipline of Oliver Twist. The children live in small cottages and have house "moms." These moms are Kenyan staff members who take care of them as a mother would her own children.

I returned to Nyumbani this past December and had to remind myself repeatedly that the children were indeed HIV+. I saw remarkable changes in some of them. Amal, a young Somali girl who had arrived three years ago, was talkative and outgoing. She had come to Nyumbani as a toddler barely able to walk; she had been tied to a bed by her grandmother for fear that the villagers would kill her due to the stigma of AIDS. Three years of love and compassion at Nyumbani had turned Amal into a child with a constant smile and friendly attitude.

Nyumbani had certainly come a long way since 1992. Most of the children came to Nyumbani as infants or toddlers. These children are now becoming teenagers. Living long, relatively healthy lives has now become a reality for the children with better access to pediatric and adult ARVs. The home, which has largely been funded through private contributions, is now receiving all its AIDS medications from the President's Emergency Plan for AIDS Relief (PEPFAR), which has dramatically freed up limited resources.

Nyumbani is unique because of its insistence on providing ARVs to children before ARVs were available for adults in Kenya. Nyumbani, which houses around 100 children, is a model for abandoned children. But it is not likely to be replicated in wide scale due to the trend in Kenya for children to stay with extended families as stigma reduces around AIDS.

The issues that Nyumbani faces now with its residents becoming teenagers is a case study for what the future holds for the many children receiving ARVs thanks to PEPFAR and other funding sources. A critical factor for donors, NGOs, and national governments will be recognizing the sexual and reproductive health needs of HIV+ youth as they mature into adolescence to keep themselves and their future partners healthy. Abstinence-until-marriage prevention strategies for HIV prevention could end up causing even more harm due to the fact the youth audience is already HIV infected, leading the young person to engage in risky behavior, as the most serious consequence (HIV infection) is already a reality.

When talking with the teenagers at Nyumbani, the first thing you realize is that they are just like any other teenagers. They have hopes, dreams, crushes, uncertainty about their bodies, and insecurities. They no longer can be treated exclusively as AIDS patients for pure survival. Recognizing this, Nyumbani just completed building a new set of cottages on the property that are known as the adolescent homes. Those who are older than fifteen will live in these houses, divided by sex, with a house mom or uncle. The purpose is to give them independence and to learn to take care of themselves by cooking their own meals.

But Nyumbani still faces challenges in dealing with the emotional needs of these teenagers. What will happen to them as they become young adults in their 20s? Nyumbani, like the international community that is working to give HIV+ children a better life, will need to be prepared to offer psychosocial support in the years ahead. This will help to ensure the HIV+ adults of tomorrow are educated about their own sexual and reproductive health and can have healthy relationships in the future.

BREAKING NEWS: Continuing the Search

2006-11-02T08:00:00-05:00

After two days and nearly twenty-two hours of deliberations, the Board of the Global Fund Fight AIDS, Tuberculosis and Malaria was unable to select a candidate for Executive Director and decided to reopen the search. The Board of the Global Fund is unlike any multilateral institution. There are twenty voting board seats divided equally between donors and recipients. There are also seats for foundations and the private sector (counted in the donor block) and for developed country NGOs, developing country NGOs, and people living with the three diseases (counted in the recipient block). In order for a candidate to be selected, a two-thirds majority in both the donor and recipient block was needed. Unfortunately, this consensus was not achieved.

The process for a new Executive Director began at the last Board meeting. A small nomination committee was selected from the Board and along with the help of a global head-hunting search firm; five diverse candidates were presented to the Board. While all five candidates were considered carefully, none were able to achieve the two-thirds majority from both blocks. The Board has therefore decided to re-launch the search process with the goal of identifying a candidate by the April 2007 board meeting.

Reactions at the meeting were mixed. Some felt extremely disappointed in the process and result. But many Board members view this decision as positive as it allows an opportunity for members to work together to select a candidate who will be well-received by the entire Board instead of allowing someone to be elected who many would not support.

This entire process demonstrates the Global Fund's uniqueness in the development system and the shift in traditional power dynamics between developed and developing countries. If we compare this process to the WHO Director General election that is about to take place November 6-8 in Geneva, we can easily see the difference. It is general knowledge that governments use promises of increased development aid, trade, and other favors in order to essentially buy votes, greatly disadvantaging candidates from low-income countries. This outright bribery and lack of transparency does not exist within the Global Fund. For the first time, civil society was in the room and had equal voting power.

The Board nominations committee is now tasked with the new search and the coming months are critical to the future of the Global Fund. NGOs involved with the Global Fund are strongly committed to working with both donor and recipient governments to find a qualified merit-based candidate who will take the institution from start-up to maturity.

The Impact of AIDS in Guatemala

2006-11-01T07:59:00-05:00

I had thought that my visits to Global Fund projects would show me what AIDS looked like in a middle-income Latin American country. In fact, they showed me much more. In a mere one day of visiting projects, I saw not only how AIDS impacts Guatemala, but how sexual exploitation, drug abuse, violence, rape, early fertility, and lack of economic opportunity are inextricably linked to the root causes of the disease.

We started our day by visiting the Hospital Roosevelt, which is one of the largest recipients of Global Fund money in Guatemala. It is a public hospital that provides free treatment and services, with a reputation for treating patients with respect and dignity regardless of socioeconomic class. Approximately sixty percent of its resources come from the Global Fund.

There is a misconception that AIDS in Latin America is a disease of men who have sex with men. But as I stood in the waiting room of the AIDS clinic at the Hospital Roosevelt, the faces that looked up at me were young women. The face of AIDS is changing in Guatemala to be a disease of younger women. These women are at risk of contracting HIV from their male partners who often have sex with other men but do not identify as being gay.

Two months ago, the hospital started testing pregnant women for sexually transmitted diseases and HIV in the emergency room. These women are often the victims of rape, violence, and sexual abuse. Already, ten women have been identified as HIV+ and been given nevarapine treatment to reduce the chance of passing on the disease to their newborn child, demonstrating the program's success. Violence against women and sexual exploitation of girls is pervasive here in Guatemala. I spent the rest of the day with a local NGO called Casa Alianza where I saw this firsthand.

Casa Alianza runs shelters and outreach programs that work directly with street children and girls who have been raped or sexually exploited. Many of the girls are not just girls; they are young mothers. I sat with a sixteen year old girl who was already a mother of a three year old and nursing an infant; nearby was an eighteen year old girl pregnant with her second child. Often, these pregnancies and children are the result of rape and sexual abuse. The girls told me their challenges in motherhood and the difficulty in growing to love their child. Many of their friends who became pregnant in the same way ended up giving their children up for adoption. But these girls want to be good mothers and give their children a better life. Casa Alianza helps them learn how to be a mother while teaching them vocational skills, such as baking, so that they may leave the shelter and support themselves.

These young mothers made a decision to leave the streets and seek the support of Casa Alianza. But not all children are ready to leave the streets. I spent the rest of the day observing how the outreach workers work with street children. As I looked out on a group of children sprawled all over a field watching a theatre demonstration on HIV prevention, it was hard to determine what social ill they were more at risk from. The boys had visible injuries and scars all over them, representing the violent nature of living on the streets, and the girls were dressed provocatively - a result of their reliance on prostitution to survive. These children are not only at great risk of HIV infection; they suffer from drug abuse, STDs, violence, and exploitation.

An outreach worker dressed as a clown tested the children's knowledge on HIV. "It's a disease with no cure," one boy responded. "You get very sick," said another. While many joked throughout the presentation, they all were in rapt attention during the condom demonstration. The outreach workers handed out condoms, cleaned up infected wounds, and provided a safe space for children to relax for a few hours off the street.

Global Fund resources support the salaries of these critical street outreach workers. While it is a seemingly small amount of money when compared to resources going to governments, it shows how a large multi-billion dollar organization can trickle down to support community-based organizations working on the frontlines. Five years ago, the vision of the Global Fund was to make a dramatic difference in the fight against AIDS, tuberculosis, and malaria, but these programs demonstrate that the Fund isn't just impacting these diseases - it is truly an instrument of poverty reduction and social change.

Who Will Be the Next Leader of the Global Fund?

2006-10-30T08:00:00-05:00

What do the President of MTV International, the former Norwegian Minister of International Development, and a senior Republican Congressman from Arizona have in common? They all are candidates for the top job at the Global Fund to Fight AIDS, TB, and Malaria. As I wrote in my last blog, it truly is election season this November.

The 14th Board meeting of the Global Fund starts this week in Guatemala City and the most important decision Board members will make is the selection of who will take the reigns and lead this start-up development institution to maturity. The Global Fund was born just five years ago as an experiment in development and health financing. At the outset, the vision of the Global Fund was to serve as financing mechanism rather than an implementing agency by putting countries in the driver's seat to develop programs to combat HIV/AIDS, tuberculosis, and malaria. History has proven that the experiment and the vision worked. In just five years, the Global Fund has raised $9.6 billion and committed $5.8 billion in 132 countries to programs that are saving people's lives. Today, because of the Global Fund, nearly eight million bed nets have been purchased to protect against malaria; one million people with TB have been treated through DOTS, and 400,000 people have been put on life-extending anti-retroviral therapy for HIV.

The Global Fund's track record has been so successful that companies like American Express, Armani, Gap, Motorola and Apple teamed up to launch the RED Campaign in the U.K, France, and the U.S. to raise money for the Global Fund (special note for uninspired Christmas shoppers- GAP's inspiRED t-shirts make fabulous Christmas gifts at just $28 a pop!).

But back to the Board Meeting - the current Executive Director, Richard Feachem has led the Global Fund from its birth with practically no staff to a robust development institution with nearly 200 staff members. Who can fill the shoes of this British professor? The candidates are (in no particularly order):

Michel Sidibe: A citizen of Mali and the current Director of the Country and Regional Support Department (CRD) at UNAIDS.
Jim Kolbe: Eleven term Republican U.S. Congressman representing the eighth congressional district of Arizona. Outgoing Chairman of the Foreign Operations sub-committee of the House Appropriations committee.
Hilde Johnson: Former Norwegian Minister of International Development (1997 -2005) and currently Senior Adviser to the President of the African Development Bank.
Bill Roedy: Vice Chairman MTV Networks and President of MTV International. Also serves as a UNAIDS AIDS Ambassador and Chair of the United Nations Global Media AIDS Initiative.
Michel Kazatchkine: French AIDS Ambassador and former Chair of the Global Fund Technical Review Panel. Also served as chair of the International AIDS Society.

So who are the frontrunners? Well, unlike the WHO Director General (DG) election, I've been sworn to secrecy and can't fill you in on the gossip. The Global Fund Board agreed to a transparent, merit-based process to avoid the highly political deal-making that dictates the WHO DG election. While the Global Fund has broken down many rules of old-school development, it certainly hasn't figured out how to make decisions in a non-political fashion due the very nature of its board structure. So, it will remain to be seen how much politics actually stay out of the selection process.

Stay tuned next week for reports from my field visits to Global Fund projects in Guatemala and to find out who is selected as the next Executive Director!

Election Mayhem

2006-10-02T08:00:00-04:00

There is no doubt that the outcome of the upcoming U.S. Congressional elections will have a major impact on the sexual and reproductive health of women and youth worldwide. Consequently, policy advocates are closely watching each race.

But these are not the only elections that will determine the future of sexual and reproductive health. Two of the most important international public health jobs are currently in the midst of highly-political selection processes: the Director-General (DG) of the World Health Organization (WHO) and the Executive Director of the Global Fund to Fight AIDS, TB, and malaria.

Because of the United States' anti-family planning and condom positions, the WHO DG position is particularly important for sexual and reproductive health. The unexpected death of Dr. J.W. Lee requires the election of a new DG and the last few years have shown how critical it is to have a high level of support for sexual and reproductive health issues from the DG who will stand up to ideological pressure from the U.S. While it’s not a secret that the U.S. promotes an anti-ICPD agenda at international conferences, what is less apparent is their work in the shadows to promote an anti-reproductive health agenda within United Nations agencies. This anti-ICPD agenda has been most apparent at the WHO. Dr. Lee was elected into his position primarily with the support of the U.S. leading them to have an unprecedented level of influence. In 2005, it was heavily rumored that the DG made a deal with the U.S. to cut the budget of the Department of Reproductive Health and Research in order to receive approval of an overall budget increase. On the whole, there has been a chilling effect among reproductive health staff due to the lack of support from the former DG.

So how does it all work? WHO member states nominate potential candidates and the thirty-four member Executive Board will make the selection. Thirteen candidates have been nominated, and the Board will hold a special meeting in early November to make the selection. The rumored frontrunners are:

Dr. Julio Frenk: Nominated by Mexico and currently serving as the Minister of Health. Frenk was also a DG candidate in the 2002/03 election and has WHO experience having served as the WHO Executive Director for Evidence, Information, and Policy.

Dr. Margaret Chan: Nominated by China and currently serving as WHO Assistant Director-General for Communicable Diseases. Chan previously served as the Director of Hong Kong’s Health Department.

Dr. Pascal Mocumbi: Nominated by Mozambique and Africa’s only candidate for the post. Mocumbi was also a frontrunner in the 2002/03 election and is the former Prime Minister along with having a medical training background.

Norway, a staunch supporter of sexual and reproductive rights has put their full support and weight behind Dr. Julio Frenk. The U.S. has not indicated which candidate it will support. November could bring about big changes for the sexual and reproductive health of women and youth worldwide. Civil society must monitor and influence the WHO DG election to ensure that the new DG is supportive of sexual and reproductive health and can stand up to U.S. pressure.

Abstinence or Abstinence-Only?

2006-09-08T09:00:00-04:00

At Wednesday's government reform hearing convened by Congressman Chris Shays on the abstinence-until-marriage earmark, Ambassador Mark Dybul, U.S. Global AIDS Coordinator, testified that the U.S. government does not fund "abstinence-only" programs. Repeatedly, U.S. government officials have stated that PEPFAR prevention programs are not abstinence-only and follow an evidence-based ABC approach.

Sorry, Ambassador Dybul, but we're not buying it.

After reviewing the policy directive designed to clarify the ABC approach within PEPFAR, "ABC Guidance #1: For United States Government In-Country Staff and Implementing Partners Applying the ABC Approach to Preventing Sexually-Transmitted HIV Infections Within The President's Emergency Plan for AIDS Relief," we found that the U.S. government is definitely not following an evidence-based approach.

Advocates for Youth has published a policy brief titled, "Improving U.S. Global HIV Prevention for Youth," critiquing this guidance. The OGAC (Office of the U.S. Global AIDS Coordinator) Guidance states that the ABC approach to HIV prevention need only be comprehensive at the country level and that sub-populations within a country should be targeted with specific components of the approach (A, B, or C) based upon OGAC's perception of their needs. Young people are identified as a sub-population that need not be provided with all three components of the ABC approach. Segmenting the ABC approach by population is fundamentally flawed and defeats its effectiveness. A sole "AB" strategy for preventing HIV infection for young people is effectively an abstinence-only approach.

Underlying the OGAC guidance regarding programs for youth are the following scientific inaccuracies:

Youth easily fall into two categories-those that have had sex and those who have not and neither needs information about condoms.
Promoting abstinence-until-marriage will increase abstinence and secondary abstinence for those who already have had sex.
Marriage is an effective HIV prevention tool because young people in PEPFAR countries have the power to choose when to have sex
Providing young people with information about condoms will confuse youth and encourage them to have sex.

While abstinence is the best option for protection for youth not yet sexually active and should be included in all comprehensive youth HIV prevention programs, these programs must also take into account the fact that a large share of unmarried adolescents in PEPFAR countries are already sexually active and require information that will enable them to make informed choices and to protect themselves if they choose to remain sexually active.

Research clearly indicates that all young adults-abstinent or not-benefit from full disclosure of medically accurate, age appropriate information about both abstinence and condoms. Providing comprehensive information about HIV that is linked with sexual and reproductive health that includes honest, accurate information about condoms is a proven strategy for reducing HIV infection in young people.

Advocates for Youth is urging OGAC to revise the ABC guidance to more accurately reflect evidence-based best practices. Revising the guidance will enhance PEPFAR's efficacy and will encourage PEPFAR implementing partners to replicate effective strategies for HIV prevention among youth.