I’ve now been living in Antigua for almost two months. I’m getting used to the sun being unbearably hot by 9am and am getting deeper into work and loving it. On the weekends, I’ve explored different coasts of the island through beautiful hikes, discovering new beaches and some islands off of Antigua. I think I preceded myself a little in my last post by explaining what ARC does without explaining HIV and why ARC works with MSM, SW, and youth who are at risk. HIV is transmitted through 4 body fluids: blood, semen, vaginal fluid, and breast milk. This means that populations engaging in lots of uninhibited, unprotected sex (namely people engaged in transactional sex, sex work or those with more than one sexual partner) are the most at risk for transmitting HIV. As well, prenatal and newly born infants can become infected through mother-to-child transmission (PMTCT) but ARC doesn’t address vertical transmission. Outside sub-Saharan Africa, the Caribbean has the largest HIV prevalence in the world.
HIV epidemics straddle the line between being a public health issue and being a development/social justice/human rights issue. Because of this, it takes whole consortiums of interacting bodies to address it: grant funding, program creation, collaboration and so on. These bodies stem all the way from the Global Fund/the WHO/UNAIDS, to national Ministries of Health (MoH)/their National AIDS Program (NAP), to their NGOs/civil society/clinics/churches. Simple linear relationships right? Not quite.
Samara and I were invited to a 3-day national HIV stakeholders meeting to help design a Monitoring and Evaluation Plan for Antigua’s National Strategic HIV Plan 2012-2016. Though we couldn’t contribute too much (though I did pipe in regarding PMTCT indicators, which I knew from my thesis!), I think attending this meeting provided me with some of the most important takeaways that I’ll have leaving Antigua.
A contracted third party facilitated the meeting. He essentially held up each objective (organized by Priority Areas) and then crowd sourced for the best indicator, where that data would come from and who would collect it. For example, if a Priority Area outcome were, “To reduce HIV infections,” then the group would decide that the indicator to measure this would become, “percentage of men and women HIV infected between the ages of 15-49” and the data source for this would become something like, “number of people tested positive for HIV” and then the facilitator would move the group forward onto the next indicator.
In Antigua, there are two ways to get tested and this is important. A person can go to the NAP office in downtown St. John’s and get “rapid” testing where they find out their status the same day and this information is recorded and kept by the government. Conversely, a person can pay money and access a private clinic that does venus testing (which takes longer) but their results at these clinics never get reported to the government. There is an issue with confidentiality at the NAP, causing marginalized groups in society to either not get tested or seek private testing. This stratification of the population is particularly problematic because it undercuts every effort of the government to document and record people accessing testing, their statuses and any and all programatic interventions.
Between indicators, a dialogue between MoH stakeholders, NGO staff and nurses working for NGOs would commence. Some stakeholders were aware of the divided state of HIV testing but an acknowledgement of the importance of this issue and subsequent efforts to unify the process were somewhat absent. There wasn’t enough time to deeply discuss resource restructuring and it was faster to enter an indicator and move forward. But if this wasn’t the time or place to discuss these issues and these weren’t the people to have that conversation, when was and who was? This example isn’t to denounce governing structures or health care management in this country. Or for that matter any country in the Caribbean or other developing country. I’m well aware that agendas and resource limitations such as these exist in every sector the world across and present themselves at these sort of high level meetings, including in Canada.
However, that meeting cut my idealism in half; no amount of system mapping to identify linkages between organizations and community clinics will amount to success if the (political) will isn’t there. Attending this meeting roughly a month into being here presented my first major learning curve and has challenged the way I view my placement and global health governance on the whole. It’s taken some time to decompress and realign my understanding of what can and cannot change, what I’m doing here (certainly, a lot of learning) and what broad and small-scale global health efforts accomplish.
Amongst other conclusions, what I’ve come back to is that grassroots efforts and notably those being undertaken by ARC are generally effective. Since meeting with the MSM in August, we’ve collected back over 25 outreach forms of men who have been counselled. Through these sessions, they’re encouraging men to get tested, to know their status, to use condoms, and to feel safe talking to somebody about HIV prevention. Again, the data also shows that many men are averse to getting tested due to discrimination. This feedback helps ARC report on and figure out how to overcome these social barriers from the ground up and for example, has inspired a coupon referral program between MSM counsellors and MSM-friendly nurses at the NAP. The program mediates the trust issue until the system is shifted to become one that unanimously offers confidential, MSM-friendly testing.
Lastly, in December around World AIDS Day countries across the world will hold AIDS marches, fairs and the like. Part of the drive usually includes a “Know Your Status” campaign where everyone in society gets tested for HIV. It’s great. It attempts to remove stigma and discrimination because nurses, MSM, bank employees, the guy who bags your groceries and the women who sell mangos just outside the bus station will all get tested together removing the judgement and the prejudice around going for testing. So I leave you with this: get tested and know your status and while you’re at it, consider some of the questions that the MSM outreach educators answer on their pre and post-training tests. If you don’t know the answers, ask or look ‘em up.
Would you sit next to a person living with HIV on the bus?
If you knew that a shopkeeper had HIV, would you buy fresh vegetables from him or her?
Can a person get HIV from kissing? From mosquito bites?
Miscellaneous:
Cyrus Davis. We met Cyrus one day in our neighbourhood with his grandson several weeks ago. Cyrus is probably in his early 80s and has remained in regular communication with us, calling roughly every other day to see how we are and inviting us to church with him and his family. When he left our home a few nights ago after bringing us some sugar fruit, he said a blessing and told us that he just wanted us to know that somebody in Antigua was looking out for the two Canadians and loved us. I’m not terribly religious but I think this is just lovely.
I will kill remove the rooster who lives outside my window and unfailingly wakes me up at 6:30am.
Fruit is so cheap it’s unholy.
We went to a United Progressive Party (UPP, one of the two leading political parties) rally with our friend Keith who works for the Ministry of Tourism. At the rally MPs and Ministers bashed her/his opponents, spoke about past achievements (free school uniforms! lower taxes!), and promised to consider the people and be the people’s voice if re-elected. Politics are the same everywhere in the world.
The best pickup line is still being held by our “fairy godfather” who now asks, “Cinderella where is Snow White?” when he sees me alone in town. She’s at home!
With love,
D
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