A WORLD VISION JOURNAL OF HUMAN DEVELOPMENT

Second Quarter, 2004

Alexandre Grangeiro National STD/AIDS Programme, Brazil

Milly Katana Health Rights Action Group, Uganda

Jim Yong Kim World Health Organisation

Lieve Fransen European Community Late to the party

This edition of Global Future has been prepared to coincide with the XV International AIDS Conference. Second Quarter, 2004 It took far too many deaths for the HIV/AIDS world to begin taking HIV/AIDS – where is hope? seriously.To see that it is more than a “health” issue (as critical as that is) and also an economic, political, The children’s suffering is neglected Ken Casey ...... 1 human rights, security and development issue. “If everyone does a little, much will be achieved” Alexandre Grangeiro.. 4 How could this have happened? For The ‘3 by 5’ Initiative – to save life and change history Jim Yong Kim .. 6 the same reason that, still, there is politicking and economising of the Towards a future and some hope Lieve Fransen ...... 8 issue – to the utter exasperation of A sleeping church awakes Christo Greyling ...... 9 those closer to the suffering.

Is enough being done to give hope? Milly Katana...... 10 Denying the problem and stigmatising people living with HIV/AIDS have not helped.Thankfully, there are now Adolescents, gender and HIV Nafsiah Mboi ...... 12 serious efforts to cease medieval- style “plague or punishment” Voices from the village Nigel Marsh ...... 14 attitudes and respond proactively, with level-headedness and Disrupted lives Mark Connolly ...... 16 compassion. Faith-based organisations, including churches, Boys and men – key to reducing girls’ HIV vulnerability Sara Austin..17 have been waking up to their own complicity in this stigma problem, Mobilising the community Claudina Valdez and Ramón J Soto ...... 18 and transforming themselves into vital, values-driven players in the solution. Helping tumbleweeds grow roots Stuart Flavell ...... 20 Meanwhile, millions of children Women and AIDS in Mumbai – a programme evolves Reena Samuel.. 22 orphaned or otherwise made How Chilean children see AIDS Patricio Cuevas ...... 24 vulnerable by HIV/AIDS are on a frightening obstacle course – under ONE in the Spirit – against global poverty and AIDS Jenny Eaton .... 25 siege on all sides. If they have made it through pregnancy and birth without becoming infected themselves, endured lives of AIDS- Global Future is published quarterly by World Correspondence/donations should related poverty and then lost their Vision to encourage debate and discussion on be addressed to: development issues. mothers (often both parents), there’s Global Future a risk they will end up ostracised, Publisher Dean R. Hirsch World Vision International exploited or abused. Editor Heather Elliott 800 W. Chestnut Ave. Contributing correspondents: Kelly Currah, Monrovia, California 91016-3198 Anyone can foresee the dire Melanie Gow, Brett Parris, Matt Scott, Don Brandt, USA situation not too far down the track. Joe Muwonge, Siobhan Calthrop, Ruth Kahurananga, Telephone (1) 626-303-8811 This is why it is critical not only to Haidy Ear-Dupuy, Alan Whaites, Martin Thomas. Fax (1) 626-301-7786 shake off any remaining slumber now, but to empower and equip All opinions expressed in Global Future are e-mail: [email protected] those of the authors and do not represent the OR: younger generations to lead the way opinions of the World Vision organisation. in reducing the epidemic in what is, Articles may be freely reproduced, with World Vision acknowledgement, except where other copyright ultimately, their own future. is indicated. 6 Chemin de la Tourelle 1209 Geneva, Switzerland Is there hope? There is. But whether Global Future is distributed to many NGOs and non-profit organisations in developing countries. www.globalfutureonline.org we follow that path remains to be seen. Donations to support our production and mailing costs are very welcome (US$20 suggested). ISSN 0742-1524 _ Heather Elliott

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 strong long enough to give their beloved granddaughter a chance in life. The children’s suffering is neglected

Ken Casey PHOTO - JON WARREN / WORLD VISION

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

HELEN1 IS 14 YEARS OLD AND AIDS. Her Gogo is the only adult left in It’s going to be a decade before we wants to be a secretary for a the family, and she needs as much care start to see the same scale of humanitarian organisation like the as she gives. orphaning in the rest of the world, but one that has helped people in her as infection rates continue to rise in Asia, village in Malawi. Helen’s grim determination to Latin America and Eastern Europe, it is succeed, and a little bit of help from inevitable that the misery will spread She walks 15 kilometres to get to volunteers organised and trained by further among the world’s children. secondary school each morning, World Vision, may make her dream carrying books and wearing clothes possible. For millions more children Tragic lesson provided by well-wishers. Each in Africa and increasingly around evening she makes the same walk the world, the picture is much Our most important lesson in Africa home and then must help her elderly, more troubling. is that we started far too late to tackle infirm Gogo (grandmother) to cook this overwhelming consequence of for her and a seven year-old cousin, Before long, one in eight of Africa’s AIDS. If we aren’t to make the same John.1 She has little time left for children will be an orphan: the mistake again, what we begin now homework or play. projection is 42 million orphans in must have a global application. Africa by 2010. At least half of these Helen’s parents died of AIDS in the children will have lost a parent to Those orphans have to go somewhere late 1990s. Then the uncle and aunt AIDS-related opportunistic infections. to live and eat. Like Helen, they are who took her in passed away.Recently And tens of millions more children’s often taken in by uncles and aunts, then her only surviving aunt, John’s lives have been made extremely by grandparents. As that generation widowed mum, also died painfully of vulnerable by HIV/AIDS. dies, they find themselves in the care

Global Future — Second Quarter, 2004 1 of older children and strangers. of the list of responses to HIV/AIDS, heroes – actually, mostly heroines – is and often left off the list entirely. already providing an enormous Children in families that take in amount of care to Africa’s orphans orphans, and those where parents are We need to draw a line in the sand, and vulnerable children. Distant sick but not yet dead, suffer the same and say that this neglect of one of the relatives, aged village elders, informal kinds of stress and multiplied poverty least-regarded segments of humanity women’s associations, faith-based as the orphans themselves, creating a is an offence against human dignity. It groups, farmers’ co-operatives; all are category of “vulnerable children” that must stop. playing a part in rearing the children of is probably more numerous than that the HIV generation. of the orphans.The burden of care is It’s not only wrong, but also falling on families who are already the extraordinarily short-sighted. Providing These volunteer carers represent an poorest in the world. Only one family care and support for orphans and enormous network of goodwill that, if in 20 that is caring for these children vulnerable children is an essential provided with good organisation, receives help from any external source. investment in the security and stability training, and minimal resources, could of their communities and countries, as quickly multiply the level of quality well as their capacity to cope with care available. To avoid the same HIV/AIDS in the coming years. mistake, we must After 15 years of practical experience, apply globally the The plight of African children doesn’t listening and learning,World Vision has lessons from Africa fit within the political messaging of developed a broad strategy on many of the activist groups who are HIV/AIDS, called the Hope Initiative. loudest when HIV is on the agenda. Foundational to that is the promotion Since World Vision launched its first Drug companies can’t make money of Community Care Coalitions. specifically AIDS-related projects in from orphans. Under such pressure 1990, the organisation has studied the from powerful constituencies, donor This concords with our philosophy of impact of HIV in the countries where governments have focused most of development: we shouldn’t try to do we work, seeking the best ways that their resources on prevention and for communities what they can do for we and others can take on this treatment. themselves. Even now, and perhaps challenge. There’s a long way to go, especially now.Where local leadership It’s right to invest in prevention, especially in scaling up the best and volunteers are willing to act on treatment and care for the sick. practices that we’ve seen, but we’re behalf of their weakest neighbours, it Often the lives saved or prolonged are starting to produce and use some makes most sense to help them to do those of parents – thereby delaying or tools that seem to have an impact. just that. preventing orphaning. It’s possible World Vision is primarily a child- that, by effectively using enough In areas with little organised help but focused organisation, so it was natural resources, Africa can be saved from a lot of motivation, volunteer to begin there. the primary assault of HIV. caregivers are encouraged to form We see deepened poverty, What are we saving Africa for? The Community Care Coalitions.They are deteriorating nutrition and health, next generation? We are starving provided with training and some curtailed education and emotional that very generation of the resources resources to help them improve the trauma for a quarter of Africa’s it needs now to be able to take on its well-being of the orphans and other children.The pattern is repeating itself role in years to come. We must bal- vulnerable children in their wherever in the world HIV incidence ance these worthy aims, not promote community. increases. The social and economic one or two and ignore others. ramifications of so many children Perhaps we are just too daunted by Care for orphans growing up without adequate and vulnerable nurturing and support are severe. the scale of the challenge, unsure how to face the reality of 42 million children is at the Yet the impact of the pandemic on orphans in five years’ time.The double- bottom of the list this vast and voiceless part of the edged lesson from sub-Saharan Africa human family is rarely talked about. is that it will certainly not be easy, In areas where volunteers are already Indeed, if you didn’t travel to Africa, because of the pre-existing decay of tending to the needs of these you might wonder if it really is an issue. many social and government children, a local forum is set up in institutions due to poverty; but nor which all the parties engaged in A line in the sand will it be as intractable or as expensive combating HIV/AIDS and caring for It’s not active ill will toward these as we might fear. orphans and vulnerable children can children. It’s simply that they are meet and focus their efforts.This can marginal, powerless, and easy to ignore. Unsung heroes help avoid duplication of effort, ensure Care for orphans and vulnerable We don’t have to start from zero, no part of the community is children is consistently at the bottom because an army of unsung voluntary overlooked, give a seamless link to

2 Second Quarter, 2004 — Global Future government efforts and provide a common voice to the population in its appeals for more help.

Within this strategy, the faith community is often an important source of motivated and caring volunteers, and it is one that World PHOTO - JON WARREN / WORLD VISION Vision is making particular efforts to try to strengthen. Around the world, faith-based institutions already provide much of the health care and welfare support. I have met with many of these volunteers and have marvelled at the impact they are having in the lives of these children.

Uphold the carers The potential of community volunteers is enormous. And yet, it’s unfair for the rest of the world to simply regard them as a resource to be tapped. Although there is potential leadership and volunteerism aplenty, there are few seeds and tools, fewer books, and rarely any spare food or medicines that can be useful to the children.

To draw more from the human resources in Africa, for instance, more must be put in. From our experience across more than 20 African countries, I am convinced this will not be a wasted effort anywhere in the world. On the contrary, a little more training and thoughtful input into the community groups caring for orphans and vulnerable children will result in a greatly expanded and sustained care.

Using this strategy and with adequate commitment from the international community, millions more children left behind by AIDS can be ensured the protection, care, and support Olipa Chimangeni of Malawi is living with HIV and is an active advocate and caregiver for orphaned children. Her own daughter, aged 2, has the virus. they deserve.

On the day Helen’s aunt died, leaving bring some food for the children, or take the best of local intentions and turn her and her young cousin in their do a day’s labour for someone else to them into a response that will give hope ■ Gogo’s care, the 63-year-old woman earn half a kwacha (five US cents).That to millions of children like Helen. remained stoic. “The children will makes all the difference.” come to live with me,” she said. The motivation within local Ken Casey co-ordinates World Vision’s HIV/AIDS “There really is no-one else left in the communities to provide for the needs family who can help.” Hope Initiative and is an adviser to the of vulnerable children is astonishing, International President of World Vision on HIV/AIDS but when an issue of just a few cents is issues. See www.wvi.org/wvi/aids/global_aids.htm “The volunteer visitors who come to so important to a carer, the resources help us have done commendable are clearly still woefully insufficient. 1 “Helen” and “John” are pseudonyms. work,” she added. “Two have been coming every day, and that means I The commitment and investment of the can go and work on my gardens and international community are vital to

Global Future — Second Quarter, 2004 3 “If everyone does a little, and caring for those affected? AG: The major challenge is reaching much will be achieved” people who are far from the urban centres. The epidemic is moving outwards to the peripheries of the Alexandre Grangeiro (interview) cities and to the countryside, where health services and civil society organisations are not yet well- PHOTO - governmental organisation that works established. Our task is to develop on an AIDS-related issue – such as this structure as we have done in the BRAZIL MINISTRY OF HEALTH integrating marginalised people into large urban centres. At present, for the health care system, or example, we are meeting with psychological support. neighbouring Latin American countries (Argentina, Paraguay, GF: How are children and young Uruguay, Bolivia and Chile) to draw up people affected? a common policy for responding to AIDS in the border areas. AG: “Vertical” (mother-to-child) transmissions have fallen by around 80% through good attention to In some municipalities, while the pregnant women.They undergo a pre- numbers are still small, we have seen a natal HIV test, or if this is not possible, six-fold growth in AIDS cases over the are tested during birth. If they show past four years. This shows us clearly positive, they are treated with AZT that the epidemic is not yet beaten – injection.The babies also receive AZT it only changes shape every four years; and a special milk up until the age of and that the fight needs to be constant if we are not to have a GLOBAL FUTURE INTERVIEWS six months (since breastfeeding is suspended to avoid HIV transmission relapse in the advances obtained up Alexandre Grangeiro, Director of till now. Brazil’s National STD/AIDS via breast milk). Around 60% of Programme. pregnant women are being reached with these processes, and vertical GF: Brazil has taken consid- Global Future: What is the transmissions now account for only erable steps towards producing impact of the HIV/AIDS pan- 2% of AIDS cases. generic antiretroviral drugs. demic on Brazil and its people? Could you tell us what led to this, Children who have lost their parents and what have been the results of Alexandre Grangeiro: The AIDS and families – and they are not many Brazil’s actions? epidemic has been under control in – are cared for by institutions that Brazil since the introduction of have financial support from the AG: When Brazil began to antiretroviral therapy in 1996. National AIDS Programme. The manufacture generic AIDS drugs, in However, we have not yet managed to Programme also supports more than 1998, the Brazilian law of patents had move beyond stabilisation at 20,000 600 households that include people not yet been passed. The seven new AIDS cases per year. Our goal is living with AIDS. medicines that Brazil made were not to effectively reduce new infections, patented here and could be copied. In and to this end we have conducted, For adolescents, Brazil began this year the process of manufacturing these since the beginning of 2003, a (2004) a broad programme of sex generic drugs, Brazil acquired the permanent campaign for HIV testing education and distribution of know-how to manufacture any new among the sexually active population. condoms in schools, to contain an increase of cases among young people one. Whenever a new medicine is _ Around 150,000 people diagnosed as aged 13 19 years, primarily girls and released, the state laboratories begin HIV-positive are in treatment. young women. In this age group, there to work on the formula and use this Antiretroviral therapy has reduced by are now twice as many new AIDS resource to negotiate a price 50% mortality from AIDS in Brazil; it cases among females than among reduction with the manufacturers of has had an impact of only 1% on social males. This age group also has a high the other medicines Brazil imports. security (for pensions and birth rate.While the number of cases superannuation) while increasing six is not actually increasing, the profile of When the law of patents was times the survival of patients. People this age group is changing. approved/passed, in 1999, one article living with HIV in Brazil have a normal guaranteed that – in case of public life; they work, they study, and most GF: What do you consider to be health risk or abuse of prices, or the importantly, they are very active. The Brazil’s biggest challenges in formation of a cartel – our country majority are involved in a non- terms of preventing HIV/AIDS can demand the compulsory licence

4 Second Quarter, 2004 — Global Future to a product, or in other words, treatment, as well as including at least Without solidarity between nations, it breach patent. It is also based on this one new drug in the therapy. will not be possible to offer treatment law that Brazil is in a position to to an extra three million people who manufacture generic forms of any And all of the 150,000 Brazilians living are sick with AIDS by 2005, as the drug, if we cannot manage to import with AIDS are getting access to the World Health Organisation seeks. them at just and fair prices. Up until medicines. Brazil’s constitution, and a now, we have not needed to do this. law specifically on AIDS, guarantee Apart from offering this treatment, Brazil obtained a reduction in price of treatment, so Brazil will always need with antiretrovirals manufactured in up to 80% on certain AIDS to allocate resources in its budget to Brazil, the AIDS Programme offers medications because it is quicker and ensure this therapy. This is why such technical training for health cheaper to buy them than to produce efforts are made to ensure that the professionals in countries with which them. But, if needed, we can produce price increases do not compromise we have the accord, and technical co- them in a short period of time. the budget. operation only with other countries that are not receiving the medicines. GF: How will Brazil ensure that GF: Can you tell us something of In Mozambique, Brazil is offering poor Brazilian people who live the support that Brazil is giving technical assistance for the with HIV/AIDS have access to to other countries to combat construction of three state low-cost antiretroviral drugs? HIV/AIDS? laboratories for the manufacture of antiretrovirals, with technology from AG: Brazil’s strategy is to negotiate AG: Brazil offers treatment to 100 the Oswaldo Cruz Foundation, our low prices and learn to manufacture people a year (a quota reviewed largest public laboratory. ■ the drugs. This has enabled us to annually) for 14 countries in Latin maintain the same budget for these America, the Caribbean and Africa. medicines for three years (around 520 The African countries are mostly Alexandre Grangeiro is Director of the National million reais or less than US$250 those with which we have co- STD/AIDS Programme for Brazil’s Ministry of million per year) even with a rise in operation agreements (9 in all). The Health.This interview was translated from the the number of people receiving aim is to demonstrate to the world Portuguese by Global Future. treatment. Each year we have an that, if everyone does a little, much average increase of 10,000 people in will be achieved in combating AIDS. PHOTO - JON WARREN / WORLD VISION

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

Global Future — Second Quarter, 2004 5 The ‘3 by 5’ Initiative – to save life and change history

Jim Yong Kim

HIV/AIDS IS DEVASTATING many parts of our world. Globally, an estimated 40 million people are infected with HIV/AIDS. Every single day AIDS kills 8,000 people and orphans thousands of children. Entire countries face social and economic collapse in a few generations if decisive steps are not taken. PHOTO - - DAVID WALTON / PARTNERS IN HEALTH PHOTO Treatment in the form of antiretroviral therapy (ART) exists, and can transform HIV/AIDS from a death sentence to a manageable chronic disease. However, until now, treatment has been the most neglected area of HIV/AIDS programming. Six million people need Living proof that antiretroviral treatment works: this young man is shown in March 2003 and August 2003 – before and after receiving therapy for TB and ART and three million died in 2003 AIDS at a clinic in Haiti. because they could not get the necessary drugs. Worldwide, only Canada, France, the United Kingdom guidelines and other forms of direct 440,000 people have access to and many other donors who have technical assistance for scaling up treatment; in Africa, where some 70% contributed to the Global Fund to antiretroviral therapy. Because of people with HIV live, ART is avail- Fight AIDS,TB and Malaria; the World procurement and supply chain able to less than 4% of those in need. Bank; and the William J. Clinton management of pharmaceuticals and Foundation. Never before has there diagnostics is such a problem for most Ambitious target been a more opportune moment for poor countries,WHO has established The failure to deliver life-prolonging combined, collaborative and comp- the AIDS Medicines and Diagnostics drugs to millions of people in need has rehensive action to combat HIV/AIDS. Service to help countries with all been declared a global health aspects of selecting, procuring and emergency. On World AIDS Day 2003, We know that HIV/AIDS treatment delivering both HIV medicines and the World Health Organization can be scaled up – successful diagnostic tools to the point of (WHO) and the Joint United Nations examples in Brazil and pilot projects service delivery. Programme on HIV/AIDS (UNAIDS) in other countries have shown that it launched the 3 by 5 Initiative – an is both affordable and effective. We ambitious global target to get three also know that focusing efforts on We have an million people living with AIDS on treating HIVAIDS can strengthen and unprecedented antiretroviral treatment by the end of lead to long-term recovery of health opportunity to alter 2005. This target is a vital step systems. In Brazil and other countries HIV/AIDS’ course towards the ultimate goal of providing that have increased access to universal access to AIDS treatment to treatment, the costs of providing ART all those who need it. have been more than offset by savings To ensure a comprehensive response due to reduced demand for inpatient to HIV/AIDS, treatment and ‘3 by 5’ builds on the ground-breaking services by people who are dying prevention, programmes must work of human rights and treatment from AIDS, as well as by regained enhance and accelerate each other. activists around the world as well as economic productivity. When people have hope that they can on the political and financial be treated and lead productive lives, commitments made by the United The WHO and UNAIDS ‘3 by 5’ their incentive to know their status States under President Bush’s strategy is focused on providing and to protect themselves and their HIV/AIDS Initiative ($15 billion dollars support to developing countries in the partners is much greater.Evidence and for an enhanced AIDS response); form of simplified norms and experience shows that rapidly

6 Second Quarter, 2004 — Global Future increasing the availability of ART increases community awareness about HIV/AIDS, promotes uptake of HIV testing and can lead to more openness about AIDS. Individuals on effective treatment are also likely to be less infectious and less able to PHOTO - KARL GROBL / WORLD VISION spread the virus.

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

Old and new partnerships ‘3 by 5’ is one of the most ambitious undertakings in the history of public health and it will be essential to learn by doing. Organisations like World Vision, faith-based and non- governmental organisations, groups of people living with HIV/AIDS, treatment activists, pharmaceutical companies, trade unions and the private sector all have an absolutely vital role to play and can provide valuable lessons about treatment 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 for scale-up in poor settings.We at WHO people at risk of HIV/AIDS. know that we must work with partners old and new, and we believe that if we do so with a common countries and to assist with writing There has never been a more urgent vision, it will be possible to eventually national treatment scale-up plans and call for action to save lives than now. provide treatment for all who need it. funding proposals. Currently,WHO is This is a crucial moment in the history recruiting 40 country co-ordinators of HIV/AIDS and an unprecedented Involvement of communities and to provide full-time ‘3 by 5’ assistance opportunity to alter its course. We community workers is also essential to WHO country offices. have the moral imperative to respond to the success of ‘3 by 5’. There is to the global pandemic and to save significant evidence that with strong Reaching the ‘3 by 5’ target will mean lives. Every one of us has the chance community support, people find it to make a difference.The time to act making the most of the substantial ■ easier to adhere to their medical existing resources in a co-ordinated is now. regimens. Motivating communities to way, and ensuring that patients get know their HIV status in a context of treatment for life.This will mean long- access to ART is altering community term financial commitments from all Dr Jim Yong Kim (MD, PhD) is Director of the responses to HIV/AIDS, encouraging sources – poor countries themselves, HIV/AIDS Department of the World Health greater openness, and helping to donor governments and multilateral Organization. For more information about the 3 by reduce the stigma and denial that has funding agencies.WHO estimates that 5 Initiative, see www.who.int/3by5/en/ enabled the virus to spread so the funding required by countries to disastrously. scale up treatment is around US$5.5 billion over the next two years.WHO Since the launch of ‘3 by 5’ in will need $218 million to provide the December 2003, 52 countries around necessary technical assistance to help the world have appealed to WHO for countries with scale-up of prevention assistance with efforts to increase and treatment. Thanks to generous access to ART. WHO-led missions contributions from donors, especially have already travelled to nearly 30 from Canada, Sweden and the United countries in all regions (the majority Kingdom,WHO is moving ever closer in Africa) to identify key needs within to reaching its funding target.

Global Future — Second Quarter, 2004 7 Towards a future primary goals are: ● to increase the impact of existing and some hope interventions ● to increase the affordability of key Lieve Fransen pharmaceuticals, and ● to encourage research in and development of public goods to THE HIV/AIDS PANDEMIC AND infected with HIV.6 Girls are usually tackle HIV/AIDS,TB and malaria at the its ramifications for children are issues the first to be pulled out of school to national, regional and global levels. of international concern. By working care for sick relatives or look after in co-operation with governments, younger siblings. In high HIV/AIDS- It has a framework of comprehensive NGOs, international agencies, the prevalence countries, girls’ enrolment prevention, treatment and care private sector and people living with in school has decreased over the past strategies directed at the poorest and HIV/AIDS, the European Commission decade, negatively affecting gains made most vulnerable groups. In this context, has been at the forefront of efforts to towards the goal of universal primary it supports initiatives that aim to effectively address the plight of education.7 prevent mother-to-child transmission. children infected, affected or left Within the framework of the orphaned by HIV/AIDS. Programme for Action, the European Children of HIV- Community also focuses on the rights Children born to HIV-infected infected mothers face of children, and in particular, orphans. mothers are at risk of infection during a precarious future Increased funding the pregnancy, birth or breastfeeding. Every year half a million babies, over The European Commission therefore In addition to the regular country 1 90% of them in Africa, acquire HIV supports programmes that target programme support, the Commission from their infected mothers. More children’s rights and their access to will spend EUR 1.1 billion in the than 90% of HIV infections in children education, in an effort to help children period 2003–2006 to support the are acquired through mother-to-child avoid the most dangerous situations Programme for Action’s strategies on transmission; the remainder occur and provide them with a future and HIV/AIDS, malaria and TB. This through blood transfusions or some hope. The Commission also represents a fourfold increase in EC 2 unhygienic conditions in hospitals. funds programmes that provide care funding for these deadly illnesses. and treatment for children, mothers European Community initiatives The European Commission also works and families. through the Global Fund to Fight The European Commission has been a AIDS, Tuberculosis and Malaria. The key player in addressing the issue of HIV/AIDS and poverty Commission is a major donor to the mother-to-child transmission. It has The link between poverty and Global Fund, having pledged EUR 460 initiated and supported some of the HIV/AIDS is the cornerstone of million from 2001–2006 and having first research into this issue in Africa, European Commission policy, as disbursed EUR 374 million to date. By and continues to support projects HIV/AIDS affects the poorest and 2008, Global Fund programmes will that limit this mode of infection. The vulnerable populations the most – have supported over one million European Commission also developed undermining global health and orphans through medical services, the first comprehensive approach to development. For example, mother- education and community care. ■ blood safety in developing countries, to-child transmission is many times and in some cases financially supp- more prevalent in developing countries. orted these projects for over 10 years. Dr Lieve Fransen is head of the Human and Social Currently, only 5% of pregnant Development Unit in the European Commission’s women have access to programmes The 30% of children born to HIV- Directorate-General for Development, and Co- for the prevention of mother-to-child ordinator of the European Union’s Programme for infected mothers who are not transmission (only 1% of the 27 million themselves infected suffer an Action on HIV, Malaria and Tuberculosis. She also annual births in Africa are covered), represents the EC as a voting member on the uncertain future, as one or both and even fewer to treatment. parents become ill and eventually die. Board of the Global Fund. AIDS has orphaned 3 at least 10.4 The Programme for Action, Accelerated 1 Tapper, A, Mothers and children confronting HIV: million children currently under the Action on HIV/AIDS, malaria and TB in Challenges, choices, lessons learnt, 2000, page 11 2 Ibid., 4 age of 15, and every day more than the context of poverty reduction page 16 3 That is, the epidemic has killed their mother 8 6,000 children are left orphaned by (2001–2006) is the European or both parents 4 UNAIDS, via www.unaids.org 5 Ibid. 6 Almost three million children under age 15 are living AIDS, a third of them under five years Community’s response to the need for 7 old.5 These vulnerable children are a broad, coherent and comprehensive with HIV today. Millennium Development Goal Two is for all children everywhere to be able to complete a forced into precarious circumstances approach to HIV/AIDS, TB and full course of primary education. where they are at high risk of malaria, in line with the Millennium 8http://europa.eu.int/comm/development/body/theme/h exploitation, abuse, and becoming Development Goals.The Programme’s uman_social/pol_health3_en.htm

8 Second Quarter, 2004 — Global Future suffering the HIV/AIDS burden, but A sleeping church awakes caused more people to become infected. Christo Greyling As the impact of HIV/AIDS in Africa became impossible to ignore,

PHOTO - BARD LUIPPOLD / WORLD VISION churches and FBOs began to move AIDS. Working closely with faith beyond judgmentalism, towards leaders has shown me that many faith- compassionate, effective programmes. based organisations had (and still At an inter-faith conference on have) a lack of scientifically accurate HIV/AIDS in July 1999 in knowledge; inappropriate attitudes Johannesburg, faith leaders shared towards HIV-infected people; and with each other the realities they cultural and religious taboos. These were facing, and some recognised the perpetuate stigma, discrimination, need for a resource and training denial, silence and inaction by the centre. organisations, and fear and self-stigma in people infected or affected by HIV Someone encouraged us: “God will or AIDS. not call you, prepare you, then say: ‘Sorry, I was joking!’” In 2001, an Breaking the silence NGO representative was moved by our vision of a Christian AIDS bureau, Reverend Christo Greyling As the first opportunistic infections started to manifest, God’s call on my and asked me for my CV. Eight life and the conviction to go public months later, I was appointed to train “ONLY YOU KNOW HOW YOU grew stronger: I did not want to wait World Vision staff in 25 African are going to do it Lord, but let your until I was too ill to be of any use. I countries to mobilise and equip local kingdom come and your will be wanted, from first-hand experience, to churches and FBOs to respond to done…” was the prayer that flowed show that people living with HIV are AIDS. like a mantra from my lips as I drove like anyone else, and to share my hope from the hospital. The rain falling in in the resurrected Christ. Transformed hearts sheets reflected the tears welling up Faith leaders can be effective change within me. I had just heard that I was Unfortunately, my own church was agents, if they themselves undergo HIV-infected. not ready for this in 1992. “AIDS is change: confront their own judg- really not a problem within the mental attitudes or lack of It was September 1987 in Cape Town. Church; perhaps you should talk to information, and grow in The next year, I would finish seven some social workers,” was the understanding of their role. years of theological studies. I knew response to my request to start an God had called me. And now this! AIDS ministry. I did not know that at These days, at HIV/AIDS workshops, I What church would ever want a the exact same time, others – such as see faith leaders on their knees, reverend with AIDS? Rev Gideon Byamugisha in Uganda – crying: “Lord, forgive me for judging had the same vision and were facing others when I am a broken person The years that followed have been no similar struggles. myself!” I stand in awe as 38 Maasai easy road. But what stands out is not church leaders openly repent for the the pain of judgmental attitudes and I learned that the largest insurance way they treated HIV-infected people. physical suffering. It is an expanding company in Africa had a slide series on I see people leave transformed, with hope, nourished by the love of Christ AIDS, and shared my vision with their a new vocabulary.They preach, pray that I received through the amazing Namibia manager. His eyes flooded and minister differently as they realise support of others – especially Liesel, with tears as a new vision started in HIV is no longer “them” versus “us” – who married me knowing the risk she him. Six months later Liesel and I were only “us”. was taking. appointed to develop their community AIDS programme, which My mind goes back to my prayer on “I did not want targeted schools, community the rainy day in 1987, and I see grace to wait until leaders… and faith communities. at work. ■ I was too ill Yet our vision grew that God wanted to be of use” the Church and faith-based The Reverend Christo Greyling is World Vision’s organisations (FBOs) to be instru- Africa Regional HIV/AIDS and Church Relations Sadly, my experience of support and mental in addressing AIDS. It became Adviser. He has been living with HIV for 17 years. love has not been shared by millions increasingly obvious to us that denial of people in Africa living with HIV or and stigma not only hurt those

Global Future — Second Quarter, 2004 9 inspiring for those committed to Is enough being done delivering peoples of the world out of the bondage of AIDS. In South Africa, to give hope? as AIDS became a political debate, more and more people got infected, sowing enough “seed” to give that Milly Katana country – which has better social services than almost all other African countries – the tragic distinction of HIV/AIDS IS NOT ONLY A including condoms and antiretrovirals. having the biggest number of people health problem but also a threat to Some international efforts are making living with HIV/AIDS in the world. sustainable development. It is it very difficult for developing undermining the attainment of all of countries to access cheap generic Meanwhile, statistics in some the Millennium Development Goals, drugs on a sustainable basis. countries in Asia are produced in such including reducing poverty, child a way that that annually the numbers mortality and gender disparities. It is Need to gear up do not go beyond certain thresholds. The purpose of epidemiological data reducing social and economic What we need now is new inspiration capacity, with the deaths of people is lost and appropriate action against and motivation to get back on course, the epidemic is not taken. who have many years of training and to create a future that is desirable for expertise behind them. It is resulting us a global community. The past is in the loss of social values, traditions gone; it can only serve as a lesson for In some developing countries, as more and practices that have held societies what we commit to do now. Yet the resources are being made available, together through history. It is big question is: what future do we government officials are seizing the contributing to regional and global want to create? opportunity to flex muscles over who insecurity. should control the resources – The current response to HIV/AIDS is further marginalising frontline actors. Children are losing parents to AIDS. too narrow and inadequately Many of them are growing up resourced. The world’s major source Where does responsibility lie? destitute, without social values. of funding for the three major Squarely with both developing and Desperate adolescents with little or diseases, the Global Fund for AIDS, developed countries. The developing no value for life do not bode well for Tuberculosis and Malaria (GFATM), countries need to step up their efforts secure, healthy future communities. was able to attract US$5 billion in in responding to the disease; The ever-increasing numbers of 2001–4. But the target was $10b per developed nations need to take the deaths and new infections, particularly annum when the UN Secretary bold (and, for most, extraordinary) of women, does not inspire hope General announced the Fund in 2001. step of supporting these efforts. and motivation. Today, the GFATM needs $5b for Commitments made in the past have 2004–5 to be able to renew old not been operationalised. Political We can predict the future with a very programmes and finance new ones. commitments made in connection small margin of error. We are losing Budget limitations have forced the with HIV/AIDS are lagging far behind. the battle to AIDS. There is no GFATM – a fund that was conceived indication that the world – developed as need-driven – to develop exclusion Inconsistencies or developing countries – is geared up criteria for countries. And we are In April 2001, African heads of state for the huge volume of work that living in the 21st century. Shame! needs to be done. Instead, the world made the Abuja Declaration and Framework for Action for the fight against has been rendered helpless in the Yet despite this serious under-funding, face of AIDS. HIV/AIDS, tuberculosis and other related the GFATM has managed to generate diseases. One of the outstanding hope in the lives of many people targets of their Declaration was to The needs-driven across the world. In Uganda – the only allocate at least 15% of their annual Global Fund is “success story” against AIDS in the national budgets to improve the being forced to developing world so far – the GFATM health sector to help address the has promised to provide ARVs in the HIV/AIDS epidemic. However, only exclude countries public sector. This means free two countries attained this target by treatment. It is the first time such a 2003. Health care systems are now Even in some rich countries, we are bold step has been taken by the public struggling, even crumbling, under the seeing a fresh epidemic. We do not sector in Uganda or indeed, in much burden of AIDS. The good news is have women-controlled prevention of Africa. that with international help, a few technologies; there is no hope for a countries are stepping up their vaccine, and no cure in the pipeline. It Politicking AIDS investment in health care. Yet this seems we cannot even equitably use Subjecting HIV/AIDS to routine investment is not enough to turn the the technologies that we know work, power and political struggles is not tide of HIV/AIDS.

10 Second Quarter, 2004 — Global Future PHOTO - CLEVER MAPUTSENI / WORLD VISION Hear the people Many failures, in health and development policy formulation alike, stem from a failure to hear the voice of “the people”, and to value human capital. In principle and in practice, we must increase people’s voice in health and development policy formulation, and support integrated development planning that takes into account all the MDGs. On the positive side, the Highly Indebted Poor Countries (HIPC) initiative is coming through to support responses to HIV/AIDS and other health goals. In Mozambique, savings made from debt servicing have been used to increase vaccination of children. In Cameroon, the savings have supported the National AIDS Control Programme. In Nigeria, President Obasanjo is openly campaigning for debt relief for AIDS and health care such that Nigeria can attain the Abuja Declaration target of Three young boys - from (left to right) Zimbabwe, Democratic Republic of spending at least 15% on health care. Congo, and Rwanda - hold posters with AIDS prevention messages during World However, the HIPC initiative has an AIDS Day celebrations at Tongogara Refugee Camp, eastern Zimbabwe exclusion clause that has left six of the seven countries with the highest HIV/AIDS prevalence out of the Globally, we have conflicting diseases. In Uganda, new HIV initiative. development policies. On the one infections have been reduced from as hand, countries commit to increase high as 30% of pregnant women in the For there to be hope in a future free spending on health care; on the other, late 1980s and early 1990s, to as low from AIDS and other diseases, all of they put recruitment ceilings in the as 5% now. This is a breakthrough. these issues must be addressed. Hope public sector as well as budget ceilings However, the country is struggling to lies in whether we are able to, now, to attain macro-economic stability. care for those living with HIV/AIDS. mount an extraordinary response All this has resulted in a vicious cycle And meanwhile, malaria is getting out that gets results – that reverses the where health care systems are not of hand – killing the young, old and trend of the global health and able to deliver services to the people. middle-aged, and further exacerbating development crisis caused by Decades ago, the Organisation of the impact of HIV/AIDS. South Africa HIV/AIDS. The good news is that with Economic Co-operation and has done very well in managing the right intentions, policies and Development (OECD) countries malaria, but it is struggling with the actions, the trend of the epidemic is committed to providing development heaviest burden of AIDS in the world. reversible. ■ assistance of at least 0.7% of their It is difficult for countries to register gross domestic product. By 2000, success over disease. only five countries had attained this Milly Katana is Director of the Health Rights Action target.This has major implications for Continued denial of the risk factors, including intravenous drug use and Group, a Ugandan NGO that advocates against the level of financing for the global HIV/AIDS stigma and discrimination and mobilises health crisis.1 homosexual sex practices, means that many countries are sitting on a time communities to prevent mother-to-child Countries pledge to bomb. Practices that fuel the epidemic transmission. She is also a Commissioner of the are on the increase in many UN Commission on HIV/AIDS and Governance in increase health developing countries, but political Africa. See: www.uneca.org/chga/ funds, but restrict leadership is sweeping these factors 1 United Nations Development Programme, Human the public sector under the carpet in the name of Development Report 2002, page 202 “morality”, with the result that Some countries have come close to HIV/AIDS prevention programmes making a remarkable dent in the are not user-friendly for people who epidemic of HIV/AIDS, but not other engage in these practices.

Global Future — Second Quarter, 2004 11 Adolescents, gender and HIV

Nafsiah Mboi PHOTO - KARL GROBL / WORLD VISION

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

TODAY’S ADOLESCENTS, THE 67% of new HIV infections in becomes smaller: in many cases, even children 10–19 years of age, stand developing countries were among the ways she moves, dresses and directly in the path of the HIV/AIDS adolescents and young adults, aged expresses herself are more strictly epidemic. They can either feed the fire 15–24. If we are to stop the regulated. A girl is encouraged to or help bring it under control. destruction by HIV we must do a “preserve her innocence”, rather than better job of working with our to learn about reproductive health, These young people, an estimated one adolescents, both for their own sake and sexuality and even her own body. Both billion in the developing countries, live the sake of the whole human family. boys and girls learn that in sexual in an era of often-unpredictable matters, it is the male’s prerogative to change, brought on by rapid Boys and girls – different risks initiate, to dominate. urbanisation, economic globalisation, a In most societies it is during revolution in global communications, adolescence that gender distinctions – Many girls pay and vastly increased mobility. These the social definition of what is a high price for phenomena present young people “masculine” and what is “feminine” – with choices about lifestyles, social begin to solidify.These distinctions will their innocence relations and employment – and influence the course of life in profound in sexual matters expose them to risks and temptations ways thereafter. In many societies, a – that earlier generations never had to boy’s options tend to broaden at this Girls pay a high price for their deal with. point: he is encouraged to take risks innocence and lack of sexual (including sexual risks) and learn about autonomy. They fall prey to Indications are that it is not always a wider world outside his home and exploitative employers, boyfriends, easy to make safe choices. Last year, family.A girl’s world at this time often even husbands. Indeed, today it is

12 Second Quarter, 2004 — Global Future estimated that 64% of the people aged settings, different obstacles and them.These are the girls who because 15–24 who are living with HIV or different opportunities have produced of extreme poverty, childhood abuse, AIDS in developing countries are different kinds of activities, but there is adolescent rebellion, employment, women and girls! no silver bullet. Nonetheless, most of armed conflict and other factors are the successful activities are ones that out of sight – adolescent girls in It is true that the push towards risk have contributed one way or another prostitution, trafficked internationally taking can place an adolescent boy at to girls’ information, skills, self- or within their home country for sex increased risk of HIV infection from confidence, self-respect, self-reliance, work or exploitative child labour, girls unsafe sex, experimentation with or a sense that they were not alone, in domestic service, street dwellers, drugs, or excessive use of alcohol that they had a support network to girls in regions of conflict, refugee which may lead to other risk taking. consult or fall back on. For example: camps or found among the world’s However, the situation of girls is internally displaced people (IDPs). All worse. Among adolescents aged ● Extended schooling has had these girls are difficult to reach, are 15–19, HIV infection rates often run positive results for both girls and basically unprotected, and are two to six times higher among girls boys, contributing to delay of entry particularly vulnerable to gender than among boys of the same age. into sexual activity, practice of safer pressures, sexual violence, drug use, Examining the situation in country sex, and delayed marriage. and ultimately, HIV infection. after country one finds that gender- ● based differences – in education, Theatre, music, athletics and other Adolescents deserve access to information, socialisation, group activities have helped girls gain special support in and thus, experience and expectations confidence in their right and ability to in life – are primary factors influencing interact with a larger world.They give constructing safer the vulnerability of these young people girls the “protection” of group ways to live to HIV infection. membership as they consider new behaviour and, maybe, try out “AIDS has a woman’s face,” said Carol leadership in a group of friends. HIV The theme of the World AIDS Bellamy, Executive Director of information introduced in this sort of UNICEF in 2002. Sadly, every year that Campaign 2004 is Women, Girls, HIV setting can be well received and is more and AIDS. The impact of gender is more accurate than the year before. likely to be acted upon. Indeed, If we do not learn to do better by our inequities radiates throughout all surveys in a number of places have facets of life – social relations, issues of adolescent girls, the numbers will found that membership in well-run continue to increase each year. Girls public participation, access to public community youth groups reduces a services, legal status, and so on. It is and women are vulnerable because our young woman’s chance of being HIV- societies make them so. Their access not solely an issue of power relations positive. in sexual transactions between men to information and their right to act and women. In fact, we know that the ● Activities can also be directly on it are limited because they are nature of sexual relations does not related to a girl’s more conventional female. Without addressing the all- improve substantially without changes progress towards marriage, but may important issue of gender, any also occurring in other aspects of open the door to the possibility of increased knowledge of personal gender dynamics. more equitable gender relations hygiene, safe sex or reproductive within the family. For example, in one health will not be put to use and little progress will be made against This is confirmed by data about girls Indian state, in order to encourage HIV/AIDS. across Asia showing that knowledge girls to delay marriage, a sum of about HIV and how to protect money was made available to every Adolescents, with their lives in front themselves from infection often does girl who waited until age 18 before of them and on the verge of not lead to effective action.Even marrying. The result: when she becoming sexually active, deserve when they know what to do and why, married, a girl came to her husband special opportunity, encouragement, many adolescent girls feel unable to with some money of her own, giving and support in addressing this resist the sexual advances of a her more confidence and the challenge and constructing new safer demanding male, either in or out of possibility of more independence than ways to live. ■ marriage. Unless they also have an if she entered her husband’s home enhanced sense of their right to merely as the result of family protect themselves and the confidence negotiations, a “gift” of her family to to believe that they might succeed, her husband’s family. Dr Nafsiah Mboi is Senior Adviser to the most girls will accept sex as and when Indonesian National AIDS Commission, and a Member of the Board of World Vision Indonesia. demanded by their male partner. Girls on the margins She was formerly Director of the Department of These are innovative activities reaching Useful approaches Women’s Health for the World Health “mainstream” adolescent girls, urban Organization. Is there a specific “plus factor” which and rural. However, significant can help overcome the inequities of numbers of girls are at extra risk and traditional gender relations? Different extra efforts are needed to reach

Global Future — Second Quarter, 2004 13 Voices from the village

Nigel Marsh

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

were left with her aged mother, my maternal grandmother.That was even more terrible.There was never enough to eat, even though we worked long days in the gardens instead of going to school.We had no blanket, just a place to sleep on the PHOTO - JON WARREN / WORLD VISION PHOTO - JON WARREN / WORLD VISION mud floor in the house. Our clothes were tattered.

Worst of all, I was the only one in the world to look after Josephine, who was suffering fevers, diarrhoea and body pains. I recognised the (Left to right) Maggie’s cousin sicknesses as AIDS. I despaired; I Kenneth and three grandchildren Bright, Maggie, Eleanor thought we were both going to die. visiting Martha’s grave Orphan: But I had not been forgotten. My late Grandfather caregiver: father’s mother, Eleanor, heard we Maggie were in trouble. She sold her Kenneth furniture to buy a bus ticket so she Maggie lives near Kitwe in could come looking for us. She was Kenneth Kavwenge is a Zambia with her paternal shocked at the way we were living, sprightly 75 year-old widower grandmother, Eleanor, who is and agreed to take my two cousins in Kandani, Malawi. His around 70 years old. Maggie and I home with her. tendency towards cheerful was 13 when she told us her optimism was battered when story. Things are so much better here. But Martha, the last of his ten Josephine was too sick to travel, and children, died, leaving him she died soon after we left. I am still with three orphaned “When my mum died in 1998, sad that my little sister died in that grandchildren. He spoke to us everything changed. I don’t really village and never got to come here. two weeks after the funeral. remember Daddy – I’m told he died in 1995.They both died of AIDS. Now, I am doing well in school again. “Martha had been sick with AIDS I have clothes to wear, and there’s for five months, and her husband My older sisters had married and left enough to eat. home.After Mum passed away I was died the same way in 1997. It was not until she was tested and found taken away with my little sister I’m so happy that my gran came to Josephine, who was born just after to be HIV-positive, only a month find me and bring me back from before she died, that I realised how Daddy died, to the home of my that village.And I’m grateful for the mum’s sister. She lived in a distant much AIDS had hurt our family. other support that has enabled me She told me she knew her days village, in Northern Zambia. It was to stay in school. such a poor place to live. were up, and asked me to take care of the children. We had nothing. I hope people will continue to provide help for others like me.There are so My aunt was a widow and had her many children who need these things I felt so sad that this was the only own children.Then she fell sick, and as much as I do, whose lives have choice for the children, because I am we all had to look after her, until she become so bad, and who can’t do very old. I couldn’t answer her, died. Her children, Josephine and I anything about it. ” because I didn’t know how I would

14 Second Quarter, 2004 — Global Future Abridged from interviews conducted by Nigel Marsh, a journalist who is based in Africa and travels for World Vision investigating the impact of HIV/AIDS. All interviewees consented to World Vision using their stories and photos to raise awareness about HIV/AIDS. take care of the children. Now there’s away as soon as he realised Mother no-one but me here for them, to try was getting sick. He hasn’t helped to make sure they have clothes, soap Grandmother or me at all. He took and food. I’m still strong and healthy, my stepsister away, and that troubles but of course I wonder how long I me, because I loved her and I am can keep it up. lonely now. But I do get visitors, and that means a lot to me. PHOTO - JON WARREN / WORLD VISION My older grandson is dependable and works hard around the house My best friend, John, comes often and in the gardens.That helps, and cheers me up. On Saturdays he though it’s a lot of work for a boy of spends the whole day here; other 14. He is growing up to be a good days he only drops in for a short man and he’s doing well at school. time because he has been at school.

Kelvin Mkuntha I spend a lot of my time now going I was doing well in school. I’m sorry around the village, talking to people that I haven’t been well enough to go about AIDS, helping to care for the for six months now.The sores in my sick. I’m doing what I can to get my Young person with mouth and pain in the throat are fellow church-goers to be more active HIV/AIDS: Kelvin worst, but I’m also coughing a lot and about HIV. I’ve got bad diarrhoea. Kelvin Mkuntha was 14 years Even in the past it was hard when old when he spoke about his I wanted to study to become a there was nobody to take care of the life with AIDS,sitting on a mat medical doctor.They are good people. children, and grandparents would in front of his widowed We had a medical assistant in the take responsibility. This would grandmother Fulare’s home local clinic who was kind and looked happen, for instance, when a mother in Matalala, Central Malawi. after me very well. Now he has gone died in childbirth, and the father died He has since died. to work with an NGO that deals with later of some disease. But back then leprosy, and there is no-one there to that was very rare. People weren’t “They looked after me well in replace him. dying as they are nowadays. hospital, but it’s better to be home and I’m glad to be here. I used to like going to church, too; it AIDS has really spoiled lives in our was very encouraging. But I’m too community, creating too many My blood was tested, and I was told sick now. It’s nice when friends come orphans.You don’t see many people I had HIV.They said that maybe I here to pray with me. I believe of my age any more as you go about, got HIV from my caring for my people don’t die forever – there is life but when you find them, you find mother when she was very ill, here after death, and my mother is still them with orphans. at my gran’s house. I think I was alive in heaven. Heaven is up there, a doing a good job helping her, joyful place, where there is God, and keeping the place clean and It would be easy to give up, but it’s Jesus, and life forever. I’d like to see preparing her for bathing. She died better if I’m here for the children that. If I want to get there, I have to of AIDS in the district hospital, while now that all their aunties and uncles die first, don’t I?” my stepsister and I were looking have gone.There would be so many after her. more problems for these children if I wasn’t still here.” She was suffering in my hands while my stepfather was with other women. He sent my mother and me

Global Future — Second Quarter, 2004 15 resort, when better care options have Disrupted lives not yet been developed, or as a temporary measure pending place- ment in a family. Mark Connolly Strategies for action The United Nations and many partner A 16-YEAR-OLD BOY IN ZAMBIA to work, care for their parents, look organisations, including World Vision, is left without parents – and three after their siblings and put food on the have endorsed a framework of action younger siblings to look after. A 12- table. Families are strained when they to provide guidance to donor nations year-old girl in Namibia must drop out assume the care of nieces, nephews and the governments of affected of school to care for her mother, who and other children who have lost countries to respond to the urgent is slowly dying. After their mother parents to HIV/AIDS. needs of children impacted by dies, 10 year-old sisters in Lesotho HIV/AIDS.The key strategies are: move in with their aunt, who is already Losing a parent is emotionally raising three other orphaned relatives. devastating, but children orphaned by ● strengthen the capacity of families AIDS often suffer the added pain of to protect and care for children by Nothing is disrupting the lives of being stigmatised or ostracised by prolonging lives of parents and masses of children as radically as the their communities. They are often providing economic, psycho-social HIV/AIDS epidemic. More than 14 more at risk of becoming victims of and other support; million children under the age of 15 violence, exploitative child labour and have lost one or both parents to discrimination. Girls left on their own ● mobilise and support community- AIDS. By 2010, this number is are at higher risk of being sexually based responses to provide both expected to exceed 25 million. With abused and becoming HIV-positive. immediate and long-term support to global infection rates still rising, vulnerable households; HIV/AIDS will continue to cause Substitute families unprecedented suffering among ● ensure access of orphans and When HIV/AIDS overturns the lives children for at least the next two other vulnerable children to essential of children already struggling with decades. Because of the lag time of services, including education, health extreme poverty, armed conflict or roughly 10 years between HIV infection care and birth registration; exploitation, it can put them on the and death from AIDS, the numbers of brink of disaster. Pulling them back ● orphans will continue to increase even ensure that governments protect requires a concerted and widespread in countries where HIV infection rates the most vulnerable children through effort to assist the families and other now appear to be declining. improved policy and legislation and people caring for children affected by by channelling resources to HIV/AIDS. Although HIV/AIDS has reached communities; and almost every part of the world, no In sub-Saharan Africa, 90% of the ● raise awareness at all levels other region has been harder hit than children affected by HIV/AIDS are through advocacy and social sub-Saharan Africa, where an living with a surviving parent, sibling or mobilisation to create a supportive estimated 11 million children have other relative. But these families, who environment of all children affected been orphaned by AIDS (and 12% of are not receiving any external help, by HIV/AIDS. all children are orphans). In Latin are stressed to the breaking point.They America and Asia, where the overall are in dire need of support. Until these strategies are realised on a orphan population is much greater massive scale, HIV/AIDS will continue than in Africa, the proportion of Whether the head of the household is to rob generations of children of the children who have lost their parents a widowed parent, an elderly future they deserve. ■ to AIDS is much smaller. grandparent or a young person, family capacity represents the single most Children orphaned important factor in building a Mark Connolly is Child Protection Adviser for by AIDS often suffer protective environment for children UNICEF. See www.unicef.org/aids/ who have lost their parent(s). Children the added pain of deprived of such an environment are being ostracised at increased risk of exploitation, abuse, violence and discrimination. Wherever they live, HIV/AIDS creates hardship for children well before they There is an urgent need to develop are orphaned. A parent or caregiver and scale up family-based and who becomes ill with AIDS often is community-based care for boys and unable to work.The economic impact girls who are living outside of family is felt by the entire family. Children care. Placement in residential often have to drop out of school to go institutions is best viewed as a last

16 Second Quarter, 2004 — Global Future responsibilities to provide for their Boys and men– key to reducing families’ economic needs, and in many cases girls engage in “survival sex” in order to gain income or other girls’ HIV vulnerability necessities such as food or educational materials. Another example is the rape Sara Austin of girls by HIV-positive men as a fallacious “cure” for AIDS.

The research highlights World Vision’s GIRLS ARE HIGHLY VULNERABLE local and national government leaders. recognition that the “ABC” to HIV/AIDS. They are particularly A critical research strategy was its (abstinence, be faithful and use susceptible to HIV infection, and carry emphasis on the resilience and condoms) message must be part of a a significant burden of responsibility strength of boys and girls, and on the strategy that addresses the underlying to care for family members who have need to build their capacity as agents gender inequalities, or it will largely HIV/AIDS. Girls’ vulnerability to AIDS for change. The research sought to fail girls and women. In cultural is tied to social/cultural, economic, build on children’s existing coping contexts where women and girls are biological and political factors, and is strategies by facilitating a process that largely monogamous, but men and intrinsically linked with gender promotes children’s right to boys are not, and where girls and inequality. In some of the countries participate in all matters that affect women have little to no sexual agency, worst affected by HIV/AIDS, girls are their lives. Thus, boys and girls in the sole reliance on condoms as a infected at a rate five to six times target communities participated in prevention measure is not sufficient higher than boys.1 focus groups to give input to the for reducing girls’ and women’s research proposal; in designing the vulnerability. Addressing the unique issues that girls research methods; and in the face in relation to HIV/AIDS requires implementation, analysis and dis- It is therefore recommended that an approach that overcomes a current semination.They supported the (adult) HIV/AIDS prevention strategies be gap – between awareness of research team in an advisory capacity directed towards expanding the HIV/AIDS and changing behaviours to throughout the research process. substantive freedoms of girls and prevent the spread of the virus. women, increasing their power to negotiate their relationships and Even if women and girls are aware of HIV/AIDS prevention environment, and towards engaging the factors that put them at risk of fails girls and women boys and men in this strategy so that contracting HIV, they may have little unless it addresses they are also engaged in the change or no agency to reduce their gender inequalities process. vulnerability. It is thus critical that boys and men be actively engaged in HIV/AIDS prevention interventions interventions to change behavioural Research findings should go beyond the conventional practices that currently promote or The research in Tanzania and Zambia “ABC” approach, and address the perpetuate gender inequality and highlighted that sexual exploitation of structural roots of vulnerability to consequently the vulnerability of girls girls is a significant factor in girls’ HIV/AIDS that are bound up in gender to HIV/AIDS. vulnerability to HIV/AIDS. Girls in the inequality, by engaging girls, boys, target communities were subject to a women and men in critically analysing An empowering approach wide spectrum of gender-based their own context and in proposing World Vision developed an action- violence, including: sexual abuse in the local solutions. ■ oriented research project to enable home; sexual abuse by teachers; rape; boys, girls, men and women to identify early sexual activity; commercial the key factors that make girls sexual exploitation; sexual harassment Sara Austin is a Policy Analyst with World Vision vulnerable to HIV/AIDS, and in homes, schools, and the community; Canada.This research was assisted by Corey participate in developing interventions harmful traditional practices including Wright, Research Intern with World Vision to address these problems. The early marriage and female genital Tanzania/Canada, and Gertrude Chanda, Gender, research was piloted in two countries: mutilation (in Tanzania) and initiation Child Rights and Advocacy Manager with World Tanzania, where the prevalence rate ceremonies (in Zambia). Vision Zambia. for girls aged 15–19 is 4.8% compared with 1.5% of boys,2 and Zambia, Conversely, the research also 1What is vulnerability to HIV? UNAIDS Fact Sheet, June 2 where the rate for girls aged 15–19 is indicated that HIV/AIDS is 2001 Epidemiological Fact Sheets on HIV/AIDS and 6.6% compared with 1.9% of boys.3 increasingly a causal factor for specific Sexually Transmitted Infections – 2002 Update: United Republic of Tanzania, UNAIDS,WHO and UNICEF, Research participants included boys forms of sexual exploitation of girls. 2002 3 “HIV prevalence rate among young people, by and girls aged 8–17, youth aged 18–25, For example, girls who are orphaned age and gender: Zambia 2001–2002”, HIV/AIDS parents/guardians, teachers, religious or who are caring for parents living Epidemiological Surveillance Update for the WHO African and traditional/cultural leaders, and key with AIDS have significant Region 2002 Country Profiles,WHO/AFRO, 2002

Global Future — Second Quarter, 2004 17 Mobilising the community

Claudina Valdez and Ramón J Soto

POVERTY AFFECTS MORE THAN involved has been empowered most successful initiatives is the Time 50% of the population of the through the training of its traditional of Hope Project, for adolescents and Dominican Republic1 – most dram- leaders (including teachers, parents, young people. Its acronym PROJETA atically in the rural and border areas civil authorities, health providers and (Proyecto Tiempo de Esperanza para los of the country, where 44 of every religious leaders). Jóvenes y Adolescentes) means 1,000 children born die before they “Protect” in Spanish. It is helping reach one year old.2 Nurturing young leaders young participants to develop The project also has led to a responsibility for preventing HIV/ The first case of AIDS in the burgeoning of new leaders, partic- AIDS, as the following story (see box) Dominican Republic was officially ularly among the young. One of the speaks eloquently: registered in 1983, and within a short time there was a sustained, rapid increase in the number of cases. At helped me achieve amazing goals, for the end of 2001 an estimated 130,000 myself and for my community. people were living with HIV/AIDS; around 5,000 of these were children We’ve formed a network that important under 15. At that time, an estimated leaders (like teachers, municipal authorities, neighbourhood council 33,000 children under 15 were members, health and church leaders) orphaned because of AIDS. The have joined. Young people are actively general prevalence of HIV infection 3 participating in this network’s HIV/AIDS was 2.5%. PHOTO - WORLD VISION DOMINICAN REPUBLIC prevention campaigns for the health of the community. Reports indicate that prevention efforts carried out in recent years Many people in the barrio have seem to be stabilising HIV prevalence changed their way of looking at things. 4 Members of the PROTEJA youth in the 15–24 year-old age group, network They now talk about HIV/AIDS without and the national average of infection feeling shame, and show solidarity and with the virus seems to have been Hi Josefina! support for those who are sick (this just lowered to 1%.5 However, in didn’t happen before). It’s so interesting Haitian–Dominican (bateyes) com- I’m writing you this letter to tell you how to see teachers working with other munities in the midst of poverty, well I feel, and how different I am, since teachers, doctors with other doctors, denial, stigma and discrimination, we stopped seeing each other a few housewives with their neighbours, and years ago. Remember how I was a sad, HIV prevalence is 5.6%.6 even pastors and religious leaders now boring person, with very low self-esteem, acting as “information multipliers” – in and very shy in relating to others? Well, While there have been gains in the the church services they talk to the I tell you if you saw me now you wouldn’t people about HIV and the importance fight against HIV/AIDS in the recognise me. Dominican Republic, it is critically of learning about prevention. important to redouble advocacy I’ve joined a project called PROTEJA This may seem incredible to you, if you efforts – both for access to anti- here in Villa Altagracia, which has trained remember that in our church nobody me in prevention of sexually transmitted retroviral medications, and against ever talked about this kind of thing! But diseases and HIV/AIDS, and in sexual stigma and discrimination. To this end, thanks to these networks, a new social and reproductive health.This has helped World Vision Dominican Republic has conscience has been created, and some me so much; my self-esteem has grown had some success in raising awareness of the taboos that there used to be and I’ve even become a youth leader in among, empowering and mobilising among Christians have been broken. my community, promoting healthy and communities and their leaders. They’ve even created day clinics where responsible living. people sick from HIV can go and receive Using participative and reflective attention, care and good support. methodologies, in a spirit of respect PROTEJA has given me the opportunity to train other young people in my area. and solidarity, these interventions Good news, hey? Well, that’s all for now. I’ve learnt to work with others and have focused on educating couples, Take care, many of us have become “multipliers”. “multiplying” knowledge of preven- Now that I’m a real community leader, I tive measures, and building skills to co-ordinate a theatre group which has Joel Vargas Figueroa advocate and to combat stigma and discrimination. The community

18 Second Quarter, 2004 — Global Future PHOTO - WORLD VISION DOMINICAN REPUBLIC

Religious leaders meeting to discuss HIV/AIDS

Faith-based networks against ● Mobilising key actors, including people being infected by HIV and HIV/AIDS people living with HIV/AIDS, has lessen the socio-economic and ■ The Communities of Faith Network for been fundamental. emotional impacts of the epidemic. Life initiative has supported church ● Work with young people has leadership in articulating an effective involved the adults in their circles, Claudina Valdez is HIV-AIDS Programme Manager response to HIV/AIDS. The leaders which has created a more favourable have learned that church members for World Vision Dominican Republic, and Dr environment for the adoption of Ramón J Soto is Regional HIV/AIDS Adviser for are vulnerable to HIV too. More than healthy practices by young people. 15 networks in some 500 churches World Vision Latin America and the Caribbean. Joel have allowed 5,000 people to be ● A “life and hope” focus on the Vargas Figueroa, aged 15, is a participant in World reached with messages about AIDS epidemic has allowed a quicker Vision’s youth journalism initiative.

HIV/AIDS. Once a church becomes approach to youth and religious 1 2 ONAPLAN, 1997 World Development Report aware, it is better equipped to leaders. 2000–2001, World Bank 3 UNAIDS/WHO Dominican generate an effective response, as part ● Improving our organisation’s Republic, Epidemiological Fact Sheets on HIV/AIDS, of its mission and calling.This initiative 2002 Update (www.who.int/emc- capacity to network and negotiate, has tackled the challenges of hiv/fact_sheets/pdfs/Dominicanrepublic_EN.pdf) along with credibility for our 4 UNAIDS/WHO, Situación de la epidemia de SIDA, overcoming taboos and prejudice 5 programme work, have enabled December 2003 ENDESA, Encuesta Demográfica y associated with HIV/AIDS, through 6 World Vision to more substantially de Salud 2002 Ibid. relationships of respect and participate in various networks in the understanding. Dominican Republic. Lessons learned, future vision Continuing with our holistic, The experience to date has brought integrated development strategy that valuable lessons, including: is centred in the value and dignity of the human being, the vision is for a ● Actively involving communities broad community mobilisation to throughout the process has been a strengthen the promotion of healthy major success factor. lifestyles, to reduce the number of

Global Future — Second Quarter, 2004 19 with HIV/AIDS, are now calling for Helping tumbleweeds PLWHA groups to acknowledge and respond to the additional stigma- grow roots related problems that HIV+ drug users face.

Stuart Flavell A vicious cycle AIDS-related stigma makes us socially vulnerable: disempowered, oppressed WHAT IS STIGMA? STIGMA Indeed, PLWHA belonging to other and marginalised at several levels. Such can be defined as a judgment on the marginalised or socially vulnerable inequity weakens people’s capacity to part of society (or the general public) groups usually suffer multiple express themselves and to control about a type or group of persons that instances of stigma. In some cases, their lives. It reduces them to devalues or rejects the humanity of such people have even been the “tumbleweeds” blown here and there members of that group. object of officially-sanctioned violence by the winds of their circumstances. A and killings. More than 20 years into the HIV vicious cycle then brings more stigma pandemic, people living with on them, precisely because they are The fight against HIV/AIDS-related HIV/AIDS (PLWHA) continue to socially vulnerable. stigma has thus become a cornerstone experience social stigma because of of PLWHA activism.We, the activists, their serostatus. The well- believe we will not succeed in rolling documented effects of this stigma back or even containing the HIV/AIDS range from PLWHA being denied the pandemic unless we form a strong and use of common toilet facilities or united front against discrimination.Yet shunned by fellow community some HIV+ drug users tell us that members, through to beatings or AIDS organisations and PLWHA SANJAY SOJWAL / WORLD VISION attacks on them and their loved ones. groups do not fully support their involvement in HIV/AIDS work, and PHOTO - As to the sources of HIV/AIDS- even discriminate against them. related stigma, the United Nations Joint Programme on HIV/AIDS (UNAIDS) cites ignorance, fear, HIV+ people who experience multiple stereotyping and negative judgments forms of stigma fare worse in the about possible sources of HIV clinical care setting than their fellow transmission. HIV transmission is PLWHA. For example, HIV+ drug users often have poorer access to People living with HIV/AIDS who also popularly associated with behaviours belong to marginalised groups such as judged as “immoral” – the judgment adequate medical treatment; they are “drug users” face additional stigma about these behaviours being less likely to be offered antiretroviral and discrimination extended to the people thought to treatment, or when treatment is offered, it is late or inadequate. This engage in them. Indeed, popular Although HIV/AIDS-related stigma can be because medical practitioners opinion goes so far as to blame HIV- remains a great problem, the level of evaluate them – without medical positive (HIV+) persons for stigma is lower today in many places grounds – as less likely to adhere to contracting HIV, assuming they than it was just 10 years ago. This is therapy, or as undeserving of deserved infection because of “what partly due to the advent of highly 1 treatment. they must have done to get it”. active antiretroviral therapy (HAART), which makes it possible for people to Some PLWA face The stigma against HIV+ drug users is manage their HIV as a chronic disease such that often they will not disclose – cracking the “HIV/AIDS = death” discrimination even their drug use to their HIV treatment in AIDS organisations equation. But it has much to do with providers. This is dangerous, as it can the time, effort and risks activists have and in the clinical lead to misdiagnosis and harmful taken in fighting stigma. care setting interactions between HIV treatment drugs and “street drugs”.2 Since the launch of the PLWHA Multiple stigma movement over 20 years ago, people Many PLWHA describe the Members of the Global Network of living with HIV/AIDS and their allies experience of being stigmatised as like People Living with HIV/AIDS (GNP+), have advocated for visibility,changes in bearing a taint or stain on the skin. the only global voice of people living social attitudes, and a greater and

20 Second Quarter, 2004 — Global Future more meaningful involvement in the patient can be ordered to submit to confidential) sessions for HIV+ drug design, implementation and evaluation HIV testing if a doctor has been users to discuss issues of specific of AIDS policies and programmes. exposed to that patient’s bodily fluids.4 concern to them. Attendees declared They remind the world that PLWHA In Switzerland, the Federal Health that there is little involvement of drug have the same rights as all human Office is considering implementing users in the overall response to the beings, and that HIV/AIDS-related HIV testing for all asylum seekers, pandemic, and that drug use issues are discrimination is ultimately a human with the option for them to “opt-out”.5 not a government priority in many rights issue. countries. They called for solidarity In order for PLWHA to take from all communities to address the As a result of AIDS activists’ hard and responsibility for the fight against issues that surround drug use and for courageous work, a structured stigma, we must refuse to be a follow-up global consultation in response to stigma is increasingly part tumbleweeds. We must grow roots 2004.8 of more comprehensive responses to and stand fast, building our skills, HIV/AIDS. The focus of UNAIDS’ talents and capacity. As a further example of our 2002–2003 World AIDS Campaign, commitment to addressing stigma and Live and Let Live, was stigma and How do we address the fact that discrimination against HIV+ drug discrimination. The International some AIDS organisations and PLWHA users, GNP+ will, as a co-sponsor of Federation of the Red Cross and Red groups discriminate against certain the XV International AIDS Conference Crescent (IFRC) leads a campaign HIV+ people, such as HIV+ drug in Bangkok, provide a satellite meeting against stigma, called The Truth about users? David Burrows, an expert in on “Health and Human Rights of HIV- AIDS. Pass it on.... harm reduction and injecting drug Positive Drug Users”. use, confirms this discrimination GNP+ is a partner with both All of us must help to create and within groups established to tackle _ UNAIDS and the IFRC in the fight 6 facilitate access especially for HIV/AIDS and support PLWHA. _ against discrimination. At last, key Activists at the International HIV PLWHA to the tools and safe spaces partners understand how crucial it is Treatment Preparedness Summit in necessary for being involved in the to work as equals alongside people March 2003 reinforced the claim, response to the pandemic. No-one ■ living with HIV/AIDS. arguing there is discrimination within should be left to be a tumbleweed. AIDS advocacy communities around There is still considerable work to be injecting drug users and other done. Some Ministers of Health marginalised groups such as sex Stuart A Flavell is International Co-ordinator of succeeded in eliminating references to Global Network of People Living with HIV/AIDS workers.7 specific vulnerable groups in the (GNP+). See www.gnpplus.net critical Declaration of Commitment that Groups such as HIV+ 1Aggleton, P & Parker, R,“A conceptual framework and came out of the United Nations basis for action: HIV/AIDS stigma and discrimination”, Special Session on HIV/AIDS in July drug users must be UNAIDS, 2002 2 Burrows, D,“Stigmatisation of HIV- 2001. Implementation of the included in responses positive injecting drug users”, STIGMA-AIDS, online discussion forum of Health and Development Declaration in relation to drug users, to the pandemic Networks, 21July 2003 3UNAIDS,“Follow-up to the for example, remains disturbingly low. 2001 United Nations General Assembly Special Session Of 80,000 injecting drug users in Among the many approaches crucial on HIV/AIDS: Progress report on the global response to the HIV/AIDS epidemic, 2003” 4Sheldon,T,“Patients Belarus and Romania, only 4% can to fighting the stigma that affects HIV+ can be made to have HIV test to protect doctor”, access HIV-related health services – drug users, which include British Medical Journal , 2004 (328): 304 5Neue Zürcher 6 this despite the fact that HIV is guaranteeing equal access to medical Zeitung, 18 January 2004 Burrows, D,“Care and support needs of HIV positive drug users in Australia”, spreading at alarming rates in Eastern treatment and care, is a greater paper presented at the International Conference on Europe, and mostly via the sharing of involvement of marginalised groups AIDS in Asia and the Pacific, Chang Mai,Thailand, 1995 7 syringes among injecting drug users.3 such as HIV+ drug users in the Final Report of the International HIV Treatment Preparedness Summit, 13–16 March 2003, Cape Town, response to the pandemic. Bridges South Africa, posted to www.fcaaids.org. Ongoing vigilance needed need to be built or reinforced 8 See their declaration on www.gnpplus.net We must remain vigilant. Stigma and between such groups and the greater discrimination breed each other, and community of people living with are not yet defeated. The Canadian HIV/AIDS. magazine +ve reports that HIV tests are to become a fixture in the The recent 11th International application process for the priest- Conference for People Living with hood. In the Netherlands, the HIV/AIDS in Kampala, Uganda, hosted Supreme Court recently ruled that a closed (and therefore safer and more

Global Future — Second Quarter, 2004 21 approximately 55,000 people. As Women and AIDS in Mumbai World Vision worked with these communities, we became convinced that HIV/AIDS could not be addressed – a programme evolves alone; it was linked to other social, economic and political issues. We Reena Samuel offered adult education programmes, health camps and vocational training for women and adolescent girls. Adolescents were motivated to form a GITA IS A YOUNG WOMAN Only after approaching the mothers, street theatre to reach communities from the slums of Mumbai who is HIV- to build their confidence and convince with HIV/AIDS messages. positive. She does not fall into one of them of the issues, could the focus the high-risk categories for HIV move to adolescent girls. infection; she had an arranged Meanwhile, across India the number marriage at a young age and remained The research found that ignorance of reported HIV/AIDS cases was faithful to her husband. Unfortunately, was a major factor in girls’ HIV- rapidly increasing, mostly among her husband was not faithful, and vulnerability; others were unsafe sex “high-risk” groups including brought HIV into the home. After he practices, gender discrimination, poor commercial sex workers and drug died, Gita and her two year-old son access to health services and poor users. It was not known at this stage were banished by her in-laws – sent to nutrition. Sexual abuse, including that the deadly virus had already live in the street. Five months later, incest and rape, were also factors that entered the lives of scores of she discovered that her husband had could not be ignored. innocent women and children who died of AIDS, and had passed the hitherto were considered “low-risk”. disease on to her and to their son. Education models Gita is not alone in her predicament. The education model developed for World Vision’s The virus, first reported in India in adolescent girls covered topics such community base 1986, has touched every level of as: being a woman, growing up, dealing society, and given the socio-economic with sexual harassment, reproductive meant it was looked ethos prevalent in India, women and health, general health, STDs and to for support children are most vulnerable to it. HIV/AIDS. It used interactive teaching methods, films, skits, puppet shows, Initial research group discussions, quizzes and role In 1996 the first case of an HIV+ play.Since our interaction with mothers family in these communities was To address the vulnerability of revealed that they too were at risk, in reported. Clearly, there was a stigma adolescent girls to AIDS,World Vision 1994 World Vision initiated the Women associated with the virus, and both India initiated a research project in and AIDS Project, which grew to focus infected and affected people needed late 1991. It studied the sexual on both adolescent girls and married support. World Vision, with its strong behaviour patterns of adolescent girls women in 25 slum communities. community base, was looked to for in six slum communities in north-west support. A Drop-in Centre with a Mumbai, to develop an effective model The education model for adult women trained counsellor was opened for sex education and AIDS helped them to articulate their outside the community area, where prevention. But talking about sex and concerns about sex, sexuality and health infected and affected people could go sexuality was taboo; the initial in general. The work faced resistance for care and advice. Support groups challenge was to break the silence. from elders and community members, enabled people to share common and this required cultural sensitivity. problems and issues. PHOTO - REENA SAMUEL / WORLD VISION The education process identified that women were aware of safe sexual An area-wide approach practices, but were powerless to As HIV infections continued to make the decisions. This led to the emerge, a more holistic approach was evolution of a complementary needed.The Mumbai Area Development educational model targeted at men Programme (ADP) was launched in and adolescent boys – to create 1997 to support communities in awareness and influence their developing their responses to the behaviour as husbands and partners. now rapidly-growing AIDS threat. One By 1995, models were implemented response was the Andheri HIV/AIDS for all four target groups – men, Prevention and Care Programme, to Girls participating in education designed to empower them to protect women, adolescent girls and boys. focus on prevention through themselves Over the next four years, the project awareness, caring for infected and covered 30 slum communities with affected people, and advocacy for

22 Second Quarter, 2004 — Global Future their rights. government agencies, academic, programmes being flexible to evolve research and media groups, and with new understandings and changing Meanwhile, the ADP focused on addresses issues including access to contexts. We consider the Mumbai general health, education, economics ARV therapy, rights of infected women HIV/AIDS programme a “centre of and leadership. Slum Development and children, and mandatory learning”, lessons from which can be Committees were formed to HIV/AIDS testing. replicated in India and beyond. ■ prioritise community needs and pursue solutions; SDCs were trained Programmes need to be vocal and to care for people Reena Samuel is Communications Officer, External living with HIV/AIDS in their flexibility to Relations, for World Vision in Mumbai, India. She communities. These groups have evolve with new was formerly manager of the Mumbai ADP. helped challenge stigma and understandings and discrimination. changing contexts

In 2000, the Andheri Programme World Vision’s long association with extended to 52 slum communities in the HIV/AIDS issue in these Mumbai, with a population of 200,000. communities, from the early days of The Drop-in Centre extended its creating awareness to a fully-fledged services – counselling, children’s community development effort, has school fees, medical support taught us the importance of (including a weekly clinic with female doctor), food rations, legal referrals, and a women’s income-generating

Self-Help Group – to reach more PHOTO - REENA SAMUEL / WORLD VISION infected and affected people. REBUILDING BROKEN LIVES Heather Ferreira has been linked

PHOTO - UNKNOWN with World Vision’s HIV/AIDS initiative in Mumbai since its inception, wearing many “hats”. During the early research period, as an educator she helped develop the education model for adolescent girls living in slum communities. After a Heather Ferreira brief stint with a UNICEF HIV/AIDS World Vision’s HIV/AIDS point person prevention project, she returned to in Western India – training and World Vision and as a social worker, building capacity to ensure all 16 led mass awareness campaigns An Indian wedding. Sadly, unfaithful ADPs in the region were responding husbands have put many Indian among 30 slum communities. Then effectively to the challenge. She is women at risk of HIV/AIDS. her growing concern for widows living trained in Economics and Political with HIV/AIDS led to her helping Sciences, and Reproductive and initiate the Drop-In Centre where Three or four new cases come to the Adolescent Health Monitoring. Drop-in Centre every month. Of the women could go for support. Heather female clients, 98% have been infected says: Heather now provides technical by husbands who have had multiple support for World Vision India on "Reflecting on the stories young partners. Having migrated from rural women, youth and HIV/AIDS issues. widows have told, I realise how easily areas to marry, then been abandoned Her passionate concern for these HIV/AIDS can make the life of a by their deceased husband’s families, issues means she is often invited to many have no social safety net and see young woman crumble around her. It speak to other groups. She says: World Vision as their only hope. is so rewarding to see the resolve Indeed, women who are HIV+ emerge within her to go on, even with "Working with HIV/AIDS and volunteer as Care Givers themselves. little emotional support from people especially women has changed me around her." personally. I see how a little emotional To address women’s basic rights from support for these women can go a a broader platform, we have Heather developed a proposal for the long way to rebuild broken lives." established links with like-minded AusAID-funded Prevention and Care organisations.World Vision is active in Programme for over 50 slum — Reena Samuel the Forum of Those Concerned with communities. In 2002 she became HIV/AIDS in Mumbai, Navi Mumbai and Pune, which comprises 75 NGOs,

Global Future — Second Quarter, 2004 23 Committee on AIDS indicate a clear How Chilean children see pattern of HIV/AIDS transmission in Chile:

HIV/AIDS ● an increasing rate of the disease among women, with the gap in the Patricio Cuevas infection rate between men and women getting smaller; ● an increased transmission rate in IN CHILE, IT’S OFTEN ASSUMED infected – almost twice the number heterosexual relationships compared that children from rural areas, and of those in rural areas who believe to homosexual relationships; particularly ethnic minority the same (33%). communities, have less knowledge ● a major increase of infection ● than urban children of topics such as 65.8% believe that condoms are among people with a lower level of sexuality or sexually transmitted the most effective protection against education; and diseases like HIV/AIDS. A study by AIDS. ● that the disease has moved to the World Vision Chile1 measuring ● Yet the research showed that the rural areas, and is no longer exclusive children’s perception of AIDS children do not have a clear idea of to cities. indicated that this is not so. how alcohol or drug consumption affects the transmission of AIDS. Of These findings clearly show that HIV/ Responses by the Mapuche children of the children studied, 53% either have AIDS is a problem that affects the whole Puerto Saavedra, a small rural town in no knowledge of this topic or think of society, as the majority of children the south of Chile, are a case in point. that consumption of these surveyed by World Vision perceived. Of these children, 77% said that HIV is substances has no impact on an easily transmitted disease and 65% transmission. think it is a problem that affects the whole of society. In urban areas, on ● One of the established myths the other hand, only 55% of children regarding the spread of HIV is that if surveyed answered that HIV is an a mosquito bites an HIV-infected easily transmitted disease, and 47% person, it can transmit the virus to think that it affects all of society. another person.This belief is more common in urban areas (60.9%)

The research used closed questions compared to rural areas (38.1%). PHOTO - PATRICIO CUEVAS / WORLD VISION with multiple choices and involved 333 boys and girls between the ages On discriminatory attitudes of 11 and 17. The children are ● Some 59% of children gave the sponsored by World Vision through World Vision sponsored children discriminatory (and incorrect) participating in the survey about their nine development projects, four in response that AIDS affects the perceptions of HIV/AIDS rural areas and five in urban areas. homosexual population more.This view is more frequently expressed by Chile should not wait to experience On the risk of HIV infection boys in urban areas. terrible numbers before having a The research indicates that: ● On the other hand, 61.7% think public policy and a level of citizen ● 64% of the children believe that that people with AIDS do not have awareness that stops the spread of young people are at major risk of to be isolated or segregated but this disease.That way we will not have being infected with the virus; and need to be taken care of.This non- to say in 2020: “Why didn’t we do discriminatory response is seen more something in 2000, when we had ● 57.5% believe there is a greater often among rural children than time?” Let’s assure Chile’s children of chance of being infected by the virus urban ones. access to a complete and proper in cities than in the countryside. education and to the necessary HIV/AIDS in Chile resources for protection, so that they On transmission of the virus can have healthy and long lives with ● A high percentage of children In Chile, the first case of AIDS was the full exercise of their rights. ■ believe that the disease cannot be reported in 1984. Since December transmitted by ordinary contact such 2001 (the date of the last official Patricio Cuevas is Communications and Advocacy as shaking hands and sharing knives, study) there have been 4,646 cases of Co-ordinator for World Vision Chile. AIDS, 5,228 HIV-positive cases, and spoons or forks. 1 3,012 deaths reported. The annual The research took place in the context of a strategic ● 61.9% of urban children believe relationship between World Vision Chile and the trend has been an increase, reaching National Committee on AIDS (CONASIDA), a that sexual relationships are the 4.51 cases per 100,000 people in 1999. government entity responsible for preventing and principal method of becoming Studies carried out by the National reducing the impact of HIV/AIDS in Chile.

24 Second Quarter, 2004 — Global Future Seized by the vision of ONE voice and ONE in the Spirit – against ONE goal – to eradicate poverty and HIV/AIDS in Africa – DATA’s co- founder Bono, gospel musicians global poverty and AIDS Michael W. Smith and Jars of Clay, World Vision US and Bread for the Jenny Eaton World, jointly launched The ONE Campaign in a rally in Philadelphia. Bono called upon all North

PHOTO - C. TAYLOR CROTHERS Americans to commit to actualising justice, equality, and liberty – pointing out that in the stark light of history, we will be judged by our children and by our God for our response to this great pandemic.

Following the rally, a worship service was held in the Philadelphia Cathedral. As the song “We are one in the Spirit” echoed through the Cathedral, the doors were flung open, symbolically welcoming all to join – voices for awareness and hands for action – across national, racial, religious and political lines.

With our varied gifts, roles and callings, in ONE spirit, we can conquer this pandemic. ■

Jenny Eaton is Faith Outreach Co-ordinator for Bono launching the ONE Campaign at Philadelphia’s Independence Hall DATA (Debt AIDS Trade Africa), an international in May 2004 non-profit organisation co-founded by Bono of U2 – see: www.data.org, or to join The ONE campaign, THE APOSTLE PAUL WROTE The emergency is unprecedented.This go to: www.theonecampaign.org to the Corinthians, “Now there are is the worst plague to hit humanity in varieties of gifts, but the same Spirit… 500 years. Before long, more will have 1 I Cor. 12:4–5, New Revised Standard Version varieties of activities, but it is the same died from AIDS than in all the wars of 2 UNAIDS, at Security Council Session on the AIDS God who activates all of them in the 20th century combined.2 Crisis (based on a count of 33 million people dying in 1 war in the 20th century; 22 million cumulative AIDS everyone”. Paul was teaching this HIV/AIDS kills children, parents, deaths at the start of this century; and a projected early church community that while teachers, doctors, nurses, farmers, three million deaths per year) each person is called to a unique role, business people, bureaucrats – there is unity through the Spirit. Now, devastating entire communities that more than ever, we are all called with are already crippled by poverty and our particular gifts, services and unfair international trade or debt activities to join together as ONE policies. If we do nothing, there will be against global poverty and the AIDS an estimated 25 million orphans in pandemic. Africa by the end of the decade.

WORLD VISION works with each partner community that poverty is not inevitable. Our is a Christian relief and development to ensure that children are able to Mission Statement calls us to partnership that serves more than 85 enjoy improved nutrition, health and challenge those unjust structures that million people in nearly 100 countries. education. Where children live in constrain the poor in a world of false World Vision seeks to follow Christ’s especially difficult circumstances, priorities, gross inequalities and example by working with the poor surviving on the streets, suffering in distorted values. World Vision desires and oppressed in the pursuit of justice exploitative labour, or exposed to the that all people be able to reach their and human transformation. abuse and trauma of conflict,World God-given potential, and thus works Children are often most vulnerable to Vision works to restore hope and to for a world that no longer tolerates the effects of poverty. World Vision bring justice.World Vision recognises poverty. ■

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 ❖ Africa Regional Office PO Box 50816 Nairobi Kenya ❖ Asia Pacific Regional Office SSP Tower, 19th Floor 555 Sukhumvit 63 (Soi Ekamai) Bangkok 10110 Thailand ❖ Communications & Public Affairs 1 Vision Drive Burwood East,Victoria 3151 Australia ❖ EU Liaison Office 22 Rue de Toulouse B-1040 Brussels Belgium ❖ International Liaison Office 6 Chemin de la Tourelle 1209 Geneva Switzerland ❖ Latin America & Caribbean Regional Office Apartado 133, 2300 Curridabat San José Costa Rica, Central America ❖ Middle East/Eastern Europe Regional Office Engelsberggasse 4 A-1030 Vienna Austria ❖ Partnership Offices 800 W. Chestnut Avenue Monrovia, CA 91016-3198 USA ❖ World Vision UN Office 222 East 48th Street New York, NY 10017 USA

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