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"AllI Eat is ARVS" Living wfuh HIV/AIDS at the Dawn of the Treatment Era in Crntral Mozambique L.oy Ippolpos AndreasKalofonos DISSERTATION : Subminedin panial satisfactionof the requirementsfor the degreeof DOCTOR.OT PHILOSOPFIY in the GRADUATEDIVISION of the UNIVERSITY OF CALIFORNIA SA].TFRANICSICO ANTD UNIVERSITYOF CALIFORMA" BERKELEY Copyright (2008) By Ippolytos Andreas Kalofonos ii for my parents iii Acknowledgements Many people in Mozambique and North America have helped produce the ideas voiced in this dissertation, though I bear full responsibility for mistakes and errors. I am thankful for the collaboration and generosity of all the organizations, institutions, and individuals that welcomed me as a researcher. Though confidentiality and space prevents me from naming everyone I’d like to thank, I am indebted to those who opened their homes and their lives to me. I am especially grateful to the many people living with HIV/AIDS I met in associations, clinics, and homes all over Mozambique. I cannot mention their names, but I owe them the greatest thanks. In central Mozambique, I’d like to especially thank the groups I call Upenhu, Simba, and APTAM for welcoming me and guiding me through their work and daily lives. Individuals within these groups spent countless hours with me, and their contributions form an immeasurable portion of the dissertation. Ana Rita Boane provided the indispensable service of translation and transcription. She also served as an able guide through Chimoio’s bairros and became a good friend. I am grateful to the staff of the Provincial Health Directorate and the Day Hospitals in Chimoio, Beira, Gondola, Manica, and Catandica, especially Dr. Jaqueta, Salabai, Jorgina, Mario Capece, Araujo, Americo Chimoio, Teresa, Margarida Tomas, Sara, the late Ernesto Aniva, Tomas, Augusto Cunguara, and Dr. Diederike. The field staff of Health Alliance International (HAI) helped me navigate the necessary bureaucratic procedures for conducting research in Mozambique, and offered office space and their own valuable insights and experience gained from over two decades working on health issues in the region. Many thanks go to Nancy Ibraimo, Kenny Sherr, the late Apolinario Soares, Wendy iv Johnson, Pablo Montoya, Wendy Prosser, Maria Ana Chadreque Correia, and James Pfeiffer, and from Seattle, Steve Gloyd and Mary Anne Mercer. In Maputo I’d like to thank Alfredo Vergara for his generosity in helping me get started on my initial trip. Sandy McGunegill welcomed me to Maputo and provided a lot of practical advice and orientation. I am also grateful to Julie Cliff and Felisbela Gaspar for their assistance in understanding the dynamics of health and disease in Mozambique. I benefited from discussion and exchange with Erling Høg when we were both initiating our research, and I thank him for his generosity in providing me with documents I have used here. I am grateful for the many colleagues and friends I have found in the UCSF – UCB Joint Program in Medical Anthropology. My dissertation committee has inspired me through their own work as well as through their advice and support. I thank Vincanne Adams for providing rigorous, enthusiastic, and attentive guidance throughout my study and for instruction in medical anthropology that has challenged me to think and see in new ways. Philippe Bourgois has been a source of moral as well as intellectual support; his passion, sincerity, and integrity kept me sane through many personal and professional challenges I faced during this process. Nancy Scheper-Hughes’ work inspired me to major in anthropology as an undergraduate at UCSD. Her close engagement and insightful feedback clarified the stakes of this project, and her critical commitment continues to serve as a challenge and inspiration. I am also grateful for Vinh-Kim Nguyen’s many contributions and encouragement. His example as a theoretically and pragmatically engaged physician-scholar is tremendously inspiring and invaluable to those of us trying to follow a similar path. Janet Wojcicki from my orals committee helped guide me through the preparation for my research, offering valuable advice. v I may never have considered getting a PhD in anthropology were it not for the example of Paul Farmer, and I may not have actually pursued it were it not for the persistent advice of Harvey Weinstein, my advisor in the Joint Medical Program. Harvey encouraged me to pursue this path, and he serves as a role model through his own engaged research and teaching. Seth Holmes also deserves thanks for blazing the trail that I followed at UCSF, and for friendship, advice, and support from his vantage point two steps ahead. Judith Justice has been an indefatigable supporter and friend, and our discussions regarding the realities and the politics of international health are invaluable. Dan Ciccarone and Niranjan Karnik have also been important mentors at crucial points in my education. Mariane Ferme was instrumental in my preparation for work in Mozambique, as was the UCB Center for African Studies. I thank Martha Saavedra and Amma Oduro for their hard work supporting students working in the African Studies. Funding came from the following sources: the Regent’s Fellowship, UCSF Graduate Division; the UCSF School of Medicine Rainer’s Fund; the UCB Center for African Studies Rocca Research Awards; the UCB Foreign Language and Area Studies Award; the Fulbright- Hayes Fellowship; the UC President’s Dissertation Year Fellowship; and the Roskilde University Guest PhD Fellowship. I also was a HAI volunteer researcher for the summer of 2004 in Chimoio. Claire Dunne and Kimberly Bissell provided critical institutional support and their close contact kept me a part of the departmental community throughout my travels. Maureen Mitchell and Ron James have been extremely supportive in helping me navigate the various divisions, school, and programs at UCSF. I have been fortunate to present parts of this work and receive feedback in the following seminars and conferences: the Symposium on AIDS, Citizenship, and Governance in Southern Africa in Cape Town; The Social Impacts of ARV Scale-up at Columbia vi University; UCSF Social Medicine Grand Rounds; the UCSF Department of Anthropology, History, and Social Medicine Dissertation Talk; Religious Engagements with AIDS in Africa in Copenhagen; and the PhD seminar of the Graduate School of International Development Studies at Roskilde University. Special thanks to my hosts in Roskilde, especially Lisa Richey, Christian Lund, and Inge Jensen, who provided me with a stimulating environment conducive to writing. Perhaps the most important and certainly one of the happiest developments of the PhD process has been the emergence of a network of colleagues, friends, and confidants with whom to share work and experiences. Thurka Sangaramoorthy and Jennifer Liu have been constant companions every step of the dissertation process, from preparation for seminars and oral exams to virtual dissertation writing groups and conference calls, and I can’t imagine having finished without their support. Michael Walker has been a steady colleague and friend in Mozambique and in the US. Thanks also to Elise Carpenter, Adia Benton, Julie Livingstone, Lisa Richey, and Susan Reynolds-Whyte for close readings and critical feedback of portions of this dissertation. I appreciate the copy-editing from Liza Buchbinder, Johanna Crane, Ben Hickler, Robin Higashi, Saida Hodzic, Kelly Knight, Grace Ma, Meg Stalcup, Elise, and Adia. Thank you, friends! Over the past six years, I have called many places home, and I am grateful to all who have provided me with an environment of care and support. In Berkeley: the Bus Stop Co- op and the Oxford Street Greek Compound; in San Francisco: Tom and Liz Hall; in Mozambique: Wendy Prosser, Stephan Spatt, Claudia Szivatz, Remko Berkhout, Alexandre Lourenço, Pedro, Jorge Rafael, Linda Milhone, Clara Chinacaj, Mãe Fatima, Mãe Rupia, Pastor Munachos, Rosa Paolo, Lurdes, Ernesto Pechisso, Henrique Matando, Suzanne vii Smith, and Erin Murtagh; in Copenhagen: Lisa Richey and Rasmus Holmgård; in NYC: Garth, Anthony, Amit, and Manasi. My family has been a steady source of faith, optimism, and care: thanks Mimi, Mami, Po, Karen, Eggy, Hilliary, Jackie, Dave, and the Princesses. Final thanks go to Katy, for inspiring me to create, for accompanying this work from near and from far, and for always believing in me. viii ABSTRACT “All I Eat is ARVs” Living with HIV/AIDS at the Dawn of the Treatment Era in Central Mozambique by Ippolytos Kalofonos Antiretroviral (ARV) treatment first became publicly available in Mozambique in June of 2004. The steadily rising count of “lives saved” seems to represent a success story of high-tech treatment being provided in one of the poorest contexts in the world, and in some ways it does, as people with AIDS are experiencing dramatic recoveries and living longer. But the numbers say little about how life has changed for people with the disease. This ethnographic study uses participant observation and in-depth interviews to offer accounts of people living with HIV/AIDS at the start of the “treatment era” in central Mozambique. In a context of chronic underemployment and threadbare public infrastructure, the HIV positive status offered eligibility for free medical care and other material benefits. The number of those eligible for benefits far outnumbered availability, however, triggering intense competition amongst the HIV positive and widespread cynicism about the entire AIDS effort. Extraordinary