A Piece of the Action: Winning the Fight for Access to Women in the HIV/AIDS Epidemic in Africa

1. A Piece of the Action: Winning the Fight for Access to Women in the HIV/AIDS Epidemic in Africa Rachel Chapman, Ph.D. University of Washington, Seattle Department of Anthropology

2. 2013: ConferênciaGénero e Pluralismo TerapêuticoAcesso das Mulheres ao Sector de Saúde Privado em África • Urgent work in a complex moment… • How did we get here? • When did public health care get so private?

3. Recent Roots 1960s-1970s:Primary Health Care (PHC) Movement goes GLOBAL • 1975: WHO recognizes traditional healing as important and valuable • 1978: Alma Ata Conference – Primary Health Care Concept • Health For All by 2000

4. Primary Health Care (PHC) Concept • Low technology • Appropriate technology • Rural based • Prevention • Local providers • Health care is a right

5. African Independence MovementsNationalization of Health, Land, Production Health for All as symbol of social transformation

6. 1980s – PresentMarket Fundamentalism and Austerity • Neo-Liberal Economic Policies (Reagan, Thatcher) • Characterized - Free market, de-regulation • Implemented - Economic Restructuring • Structural Adjustment Programs (SAPs) • Debt Repayment/Foreign Investment • Erosion of social safety nets • Privatization (water, oil, education, health…) • PHC problems financing

7. 1993: World Bank “Investing in Health” 1) Health = commodity International health care = business 2) Justification = Irresponsible debt/consumer responsibility - Cost recovery = FEES • - Cost effectiveness = $ saved per intervention, - life measured in work years lost (DALYs) - weighed in relation to GNP 3) Conditions = governance and democracy = global “business managed democracy” (Beder 2004) 4) World Bank surpasses WHO as health policy

8. What follows the gutting,commoditization and privatizationof health? • Investment in multi-tiered system and growing health inequalities • Rollback in primary health care goals and advances • Contraction of public services • Draining of public resources into private sector (often under the table) • Explosion of NGOs, other private providers to fill the gap (civil society discourse)

9. Aid can be a burden: Tanzania, 2000-2002 Source: Foreign Policy, Ranking the Rich 2004

10. SAPs weakened national health systems in Africa Ministry of Health budgets slashed causing: • Hiring and Salary Caps = Inadequate workforce (numbers, salaries, morale) • Poorly maintained and equipped health facilities • Inadequate transport, communication • Weak procurement and distribution of medicines and supplies, stock ruptures, black market value

11. Global Distribution of Health Workers Selected Countries (WHO minimum 20)

13. Case StudyPrivatization, Gender and Health in Mozambique • Diverting cash resources in strapped households • Need for cash increases micro-exploitation (sex-work, crime) • Sapping highest skilled providers fleeing public sector conditions and salary freezes to private practice and NGOs “white follows green”$$$ • Unsupervised, unsustainable and uneven care through NGO pet projects, • Thriving informal sector “dumbanenge” fordrugs, treatments , providers (markets, traveling vendors, moonlighters)

14. Other forms of private care? Professionalization of Indigenous Healers through AMETRAMO and Monetization of services Proliferation of Pentecostal and Zionist churches offering healing without official “fees”, majority of converts poor women

15. AMETRAMO Prices and Treatment List price women out • Scanned Ametramo list

16. How does HIV/AIDS “gender” poverty and vulnerability? Extended families (women) expected to provide care through • “economy of affection” and • “hidden health care system” • Neither can fill in for eroded social welfare institutions. Both give way under pressure of poverty and disease. Zimbabwe

17. Economy of Affection • social protection • direct face-to-face reciprocities to get things done among family and neighbors • informal and largely invisible political economy • informal parallel institutions that buffer from the whims of the market and protect from falling into the wide gap left by the weakened and fettered arms of the state under neoliberal economic policy (Hydén 2006) • Churches • Fostering • Rotating labor parties • Tithing • Collective farms • Food sharing • Any others?

18. How is austerity gendered? • counter-geographies of survival:micro • “regrouping …around the pooled resources of households and, especially, the survival skills and desperate ingenuity of women” • Hyper-masculinity and the rise of “nightmarish crime and predatory gangs” • explosion of male and female sex-work in urban and rural settings

19. Despite overall MMR decreases:HIV Played a Major Role in Increasing MMR mostly Sub-Saharan AfricaNO SURPRISE… UNAIDS 2010 Report on the global AIDS epidemic

20. Overlapping Global Shadows Global Maternal Mortality (WHO) Global HIV Infection (UNAIDS)

21. Overlapping Shadows? Global Maternal Mortality (WHO) Global HIV Infection (UNAIDS)

22. HIV and Maternal Mortality(UNICEF. 2010. Interagency Estimates of Maternal Mortality Levels and Trends: 1990-2008) • Direct: associated increase in pregnancy complications • anemia, • post-partum hemorrhage • puerperal sepsis • Indirect: increased susceptibility to opportunistic infections • Pneumocystiscarinii • pneumonia, • tuberculosis • malaria.(McIntyre. 2003) Maternal HIV in Sub-Saharan Africa HIV accounts for an estimated 10X increased risk of maternal death, esp. symptomatic women (Moodley, et al. 2011)

23. Early Response: Prevention of Mother to Child Transmission (PMTCT) pregnant women living with HIV in sub-Saharan Africa who received antiretroviral drugs to prevent transmission of HIV to their children: 2005: 15% 2009: 54% Bias: women as Reproducers and Fetal environments

24. Around the world to Mozambique with HAI

25. My Research Project • Why don’t women with access to prenatal care get prenatal care? • What is the cause of underutilization of public prenatal clinic services? • What are all reproductive health options for women in post-war Mozambique? • How does inequality get into Mozambican women’s bodies? • What are the unexamined costs of Western policies of economic austerity and privatization? • What can be done about it?

26. 2003 HAI/MOH HIV Treatment Expansion Plan through NGO/public sector collaboration2003 Tambara Guro Chemba Maringue Macossa HF Providing HAART (new) 1 (1) PLWHA Registered (%) 2,000 (1) Eligible in HAART (%) 94 (0) Cheringoma Muanza Sussundenga Chibabava Machanga Machaze

27. HIV Treatment Expansion Plan2004 Tambara Guro Chemba Maringue Macossa HF Providing HAART (new) 2 (1) PLWHA Registered (%) 7,300 (2) Eligible in HAART (%) 600 (1) Cheringoma Muanza Sussundenga Chibabava 2003 2004 Machanga Machaze

28. 2005 HIV Treatment Expansion Plan2005 Tambara Guro Chemba Maringue Macossa HF Providing HAART (new) 5 (3) PLWHA Registered (%) 18,600 (5) Eligible in HAART (%) 2,500 (4) Cheringoma Muanza Sussundenga Chibabava 2003 2004 Machanga Machaze

29. HIV Treatment Expansion Plan2006 Tambara Guro Chemba Maringue Macossa HF Providing HAART (new) 17 (13) PLWHA Registered (%) 36,270 (9) Eligible in HAART (%) 5,250 (9) Children <15 y in HAART (% of those in HAART) 420 (8) Cheringoma Muanza Sussundenga Chibabava 2003 2004 2005 2006 Machanga Machaze

30. HIV Treatment Expansion Plan2007 Tambara Guro Chemba Maringue Macossa HF Providing HAART (new) 47 (30) PLWHA Registered (%) 63,390 (16) Eligible in HAART (%) 13,225 (22) Children <15 y in HAART (% of those in HAART) 1,323 (10) Cheringoma Muanza Sussundenga Chibabava 2003 2004 2005 2006 Machanga 2007 Machaze

31. HIV Treatment Expansion Plan2008 Tambara Guro Chemba Maringue Macossa HF Providing HAART (new) 53 (7) PLWHA Registered (%) 100,490 (25) Eligible in HAART (%) 23,903 (40) Children <15 y in HAART (% of those in HAART) 3,585 (15) Cheringoma Muanza Sussundenga Chibabava 2003 2004 2005 2006 2007 2008 Machanga Machaze

32. 2009 Treatment PlanManica and Sofala scale-up through of existing public network Tambara Guro Chemba Maringue Macossa Cheringoma Muanza Sussundenga HCB HPC Chibabava HG CS Proj. HR Machanga Machaze • 87 facilities offering HAART • (55 March 2008) • 180,000 PLWHA registered for • HIV care (49% of the infected) • (92,600 March 2008) • 45,000 in HAART (64% of eligible) • (22,000 Mar. 2008, 31% of eligible) • All HUs with TB treatment in • Sofala and Manica testing for HIV • and strengthening of TB screening • in PLWHA • 202 CPN with PMTCT (156 March • 2008)

33. THE PROBLEM - Major loss to follow-up (LTFU): women and exposed infants drop from programs to treat maternal HIV and prevent maternal to child transmission at any step along the “treatment cascade”

34. pMTCT strategy in Mozambique

35. Dueling Hypotheses:Why high loss to follow up rates? Inadequate counseling Authorized and unauthorized fees Poor quality, rude staff Slow or lost tests Too many appointments Poor linkages within programs at the health facility Cost of transport and inaccessibility of clinics Drug stock ruptures Stigma, and discrimination, Gender conflict, violence Lack of basic resources, food, social support Distance and transport fees Religious, cultural healing beliefs and practices Health Systems contributing factors Structural/Social / Cultural contributing factors

36. BOTH INADEQUATE: WHY?Depoliticize, Individualize, Medicalize High Cost of Austerity Economics Cutting public sector Privatization Cutting services Lay-offs, salary cuts and freezes Selective and vertical interventions Remove price subsidies Fees for services Erodes social safety nets Abolish social security Ignore failed structural adjustment programs (SAPS) Overlook free market fundamentalist cost-shifting to women

37. Costs of Austerity to Women’s Health Macro: Erosion of health system budget, facilities, staff, salaries, basic resources, services, morale Meso: Institution of vertical, selective health programs silo-ing focus and resources from Integrated primary care Micro: destroys social fabric as people eek out survival from overburdened household resources, especially social-reproductive labor of women, violence, crime, corruption as individuals seek to resist impoverishment

38. HIV care and treatment scale up exposes costs of Austerity Economics AIDS-related maternal mortality Health systems failures AIDS-related stigma = tangible consequences of “trickle-down” politics which have immiserated African households and public sectors that serve them

39. New Research Question: • What accounts for loss to follow-up? • Where are all the pregnant HIV+ women going after they test positive?

40. Preliminary Findings • Stigma and fear • Domestic violence surrounds negotiation of disclosure, loss of social support • food and drug insecurity = new hungers, new conflicts and new markets, new resistances • Confusion regarding pregnancy and seropositive status, multiple testing, changing clinics, ghost patients • Shock, memory, negotiating identity post-test, failure of counseling

41. HIV testing and treatment complicates women’s access to clinical care.

42. ≥ Day 3 Day 1 Health Center Munhava ♀g+ PTV Flow SMI nurse prescribes CTZ and biochemical blood tests SMI nurse evaluates the urgency of treatment and determines WHO clinical stage (I-IV) Day 1 Reception activista opens a chart for ♀g+ Reception activista accompanies ♀g+ back to SMI nurse Day 1 ♀g arrives for 1rapre-natal visit with SMI nurse HIV Rapid Test + Blood is sent to lab for CD4 test SMI activista accompanies ♀g+ to reception ≥ Day 3 ♀g+ returns to meet with SMI nurse to get CD4 results Ptv At 28 weeks > 250 ♀g+receives AZT & duNVP CD4 count Stage I-II Labor Starts At Home Postpartum Contractions start III-IV ≤ 250 Children get: sdNVP & AZT ♀g+ takes sdNVP Day 1 no At Hospital Maternity DuringlLabor TARV ? Duovir (AZT+3TC) Day 4 or 5 Day 1 TARV committee reviews case to determine eligibility In The Home ~ 1- 5 weeks later ♀g+starts 3 phases of adherence counseling with a social worker (takes 1-3 weeks) yes Picks up medicines in the pharmacy For one week postpartum AZT ~1-4 weeks after diagnosis Phase 3 Phase 2 Phase 1 Evaluation with a MD or TM (on Fridays only) ~1-4 weeks after diagnosis Social worker gives ♀g+ the TARV prescription DOT for the first 14 days of treatment

43. New collaboration:Option B+ (2012 WHO Guidelines) Starting triple therapy ART directly after testing rather than waiting (test and treat)

44. Option A vs. Option B+ Pregnant woman comes to ANC visit Counseling visits, clinician visits Woman tested for HIV CD4 <350 Start ART HIV chart opened in HIV clinic Draw CD4 Woman HIV+ Counseling visits, clinician visits Start AZT+sdNVP CD4 >350 Continue ART lifelong CD4 <350 Start ART Draw CD4 Stop ART 1 week after breastfeeding CD4 >350

45. Benefits of Option B+ simplification of regimen and service delivery and harmonization with ART programs, protection against mother-to-child transmission in future pregnancies, continuing prevention benefit against sexual transmission to serodiscordant partners, avoids stopping and starting of ARV drugs

46. Not enough!Trojan Horse of ART Scale-Up Quality HIV care and services are only possible within context of building strong, sustainable, public sector health systems and securing household ability to generate basic health

47. action agenda: impeded by the conditions of austerity and clears path for privatization “The is clear. To get Millennium Development Goal 5 on track by reducing the contribution of AIDS to maternal mortality, we must prevent HIV infection in women and girls, prevent unwanted pregnancies, expand HIV testing and counseling, accelerate initiation of antiretroviral treatment in pregnant women who are HIV-positive, and strengthen service delivery and integration of HIV care and obstetric services, along with data collection to track progress.” (Motley, et al. 2011)

48. Why do we need a public system to scale-up ART treatment to pregnant women? • If health care is a right and should be affordable it cannot also be for profit. • The organization, integration and sustainability needed for scale-up cannot be achieved through a patchwork system with different protocols and drug regimes. • The majority of impoverished people use the public sector in some capacity despite quality. • If health care is a right, a public system has some mechanisms for accountability.

49. Is privatization a risk to the scale-up of ART for pregnant women in Mozambique? • Increasing health inequalities in a many - tiered system • Demobilization of support from enfranchised and resourced for the disenfranchised and impoverished • Resources sapped often under the table from public to private sector (moonlighting, brain drain, informal markets for drugs and services, unauthorized fees) • Naturalizes cost shifting from public to domestic sphere through household labor and erosion of labor rights (fees for service, insurance schemes, for-profit NGOs, performance based financing) • Blames failure to produce health on consumers and providers

50. Maybe women are not “lost” to follow-up