The Fight Against HIV and Gender-Based Violence

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Mvemba Phezo Dizolele: Welcome to Into Africa. My name is Mvemba Phezo Dizolele. I'm a senior fellow and the director of the Africa program at the Center for Strategic and International Studies. This is a podcast where we talk everything Africa, politics, economics, security and culture. Welcome.
Found in 1958, Project HOPE, which started out as the first peacetime hospital ship has grown to become one of the leading nonprofit organizations offering healthcare and urgent relief to vulnerable populations around the globe. Project HOPE works in 25 countries, including seven on the African continent, where the organization helps improve access to healthcare and strengthen local health systems.
One of Project HOPE's focus practices in Africa has been addressing HIV AIDS using a holistic approach that also focuses on the intersection of gender-based violence with the disease. According to the World Health Organization, 65% of nearly 48 million people living with HIV AIDS are in Africa.
Over the last two decades, global efforts to reduce the HIV infection rate and limit deaths have made remarkable progress, resulting in a significant decline in cases over the years. However, we are not on track to meet the United Nations' sustainable development target of ending the HIV epidemic by 2030.
This December 1st, Project HOPE was among the many organizations commemorating World AIDS Day, as well as the 16 Days of Activism Against Gender-based Violence, calling for action to address gender-based violence as a barrier to HIV testing and treatment among women and girls, particularly in Eastern and Southern Africa.
Joining me on Into Africa today is Dr. Uche Ralph-Opara, chief health officer at Project HOPE will help us delve into the topic of our discussion today.
Dr. Ralph-Opara, welcome to Into Africa and welcome back.
Dr. Uche Ralph-Opara: Thank you very much, Mvemba. It's great to be here again today.
Mvemba Phezo Dizolele: Thank you. This is not the best of topics, not the most cheerful topic, I don't think, but where is the world when it comes to HIV AIDS, particularly Africa, which, uh, we cover here?
Dr. Uche Ralph-Opara: Yeah, thank you very much again, Mvemba. I'm happy to be here talking about this. Because for me, personally, I've been working in the HIV space for about two decades, which kind of coincides with when we had PEPFAR come in to support Africa towards achieving epidemic control of the HIV virus.
For Project HOPE, we've been implementing HIV programs cutting across HIV prevention care and treatment for the past two decades. And a lot of our programs are in Africa, like you alluded to.
Yes, we have faced a couple challenges and, um, I must even start by saying, you know, thanks to PEPFAR and the really significant strides that have been made in controlling the epidemic since its inception in 2003, we know that over 20 million people are now on lifelong ART. PEPFAR support has also prevented over 5.5 million babies from being born with HIV. So I would say there has been progress with epidemic control, but there's still a lot to do, and we hope that in the coming years we would get on track to meet the 2030 targets.
And just speaking to a couple challenges we currently are having with, you know, meeting these targets, I'll start by saying different countries are at different levels. For instance, you have some countries doing okay, uh, meeting the 95-95-95 targets for testing, treatment and viral suppression.
But we still have a lot more yet to reach those targets, and we know what these issues are. Issues around funding gaps. We're seeing a lot of dwindling in resources for HIV programs.
We're also seeing a lot around competing global health priorities. Recently, we had the COVID-19, and now we have a bunch of other emerging infectious diseases.
There's also stigma. Stigma has been really a problem with access to treatment and testing services, and we're finding a lot more of our adolescent girls and young women at the receiving end.
So, so much is going on in terms of programming, but, you know, there's still a lot to be done in terms of closing the gaps.
Mvemba Phezo Dizolele: You talked about PEPFAR. Just for our audience, PEPFAR is the, uh, President's Emergency Plan for AIDS Relief, which is an initiative that was inaugurated during George Bush Junior's terms in office. We just want to get acronym sometime our audience might not know.
The issue that you mentioned, you mentioned the 95-95 target for testing and suppressing. So that will require people to have access to readily available testing kits, or at least to walk to health, uh, centers to do this.
But then we also talk about funding being a problem and stigma. Let's start with the 95-95-95 target, what has worked and where the challenges are, and then we can go to the issues of stigma and funding.
I presume if people are going to a center, there gotta be a way to keep their privacy so that not everybody thinks that the person is walking there to be tested if stigma is a problem.
Dr. Uche Ralph-Opara: Yeah, absolutely. And we've seen a lot of evolution over the last couple years.
When I started working in the HIV care and treatment space, health facilities had specific days that they would call HIV Clinic Days, for instance. So if anyone's coming to the general hospital on a Wednesday, for instance, it kind of already connotes that this person is HIV-positive and is coming to as- access treatment.
But over time, that has changed. A lot of decentralization is happening, and there's a lot of integration of service delivery. So whether you're HIV-positive or not and you're coming to access, whether it's testing or treatment services, you can just walk into the facilities like any other client or any other patient. So I think with service integration, we're seeing a bit less of the stigma.
But nothing has changed because countries are at different levels, and people are experiencing the stigma, regardless. And that continues to hamper, um, uptake of services.
We also have issues around structural barriers. Health systems are still weak. So even when, that issue with integration is still a challenge. People don't still have universal health coverage. Access to primary healthcare is impeded. So even talking about integrated service delivery, we're not at hundred percent. You still have issues with access.
And this is particularly worse for adolescents and youth, right? Because this is a population or a demographic that we're seeing more new infections amongst. So, for instance, adolescent girls and young women account for 44% of new infections, but are the hospitals organized in such a way that these girls are willing to go not being judged? They already deal with issues around social vulnerabilities. The health facilities are not arranged in such a way that it's youth-friendly or adolescent-friendly.
So those are still barriers, um, to access. And a lot of girls and young women are still struggling with some level of stigma and access, and this is definitely hindering our meeting these 95-95-95 targets.
Mvemba Phezo Dizolele: 95-95-95 target. Is that 95%? What does the 95 represent?
Dr. Uche Ralph-Opara: Okay. So 95-95-95 is a UNAIDS target, which is set to... The first 95 kind of implies we want to get to 95% testing. So we want 95% of people who are living with HIV to know their status, right? So that's the first 95, and that speaks to our testing targets.
The second 95 implies that we want 95% of HIV-positive clients to be on treatment. So we expect that 95% should be on life-saving ART.
And the third 95 implies 95% of these patients should be virally suppressed. Because when we have people adhering to their ARTs consistently and over a long period of time, we expect to see viral suppression. And when they are virally suppressed, the viral load is undetectable and is also untransmissible.
So I, I'm sure we've heard of the U equals to U. So the more they adhere to their medications, the more virally suppressed they are and they're less likely to infect a partner. So that's the 95-95-95.
Mvemba Phezo Dizolele: You talked about integrated services or lack thereof being part of the impediment. What are you calling integrated services? What does that mean within this context of, uh, weak health systems?
Dr. Uche Ralph-Opara: Yeah. So integrated health services is like we want the situation where more person-centered in our approach to care. So a woman or a young girl or anyone accessing care in a health facility is able to receive the full complement of health services.
So, for instance, if someone's going to access HIV care and treatment, we should be able to provide, say if it's a young girl who's sexually active, we should be able to provide family planning services, counseling services, nutrition services. We are looking at this person in her totality or in its totality, so that we're giving all the needs-based care and services so whether it's health services or it's social services.
So it's like a one-stop shop. Integration just means ensuring that the different service delivery is made available for every time they come visiting a health facility.
Mvemba Phezo Dizolele: The rate of infection you gave, 44% of new cases is among youth, particularly girls. Is there a disparity between, one, why we're having this, uh, problem now?
HIV AIDS has been with us for 40 years now, at least officially so people have been sensitized, mobilized. Is the communication around HIV AIDS failing? Are we communicating poorly so that the youth feel that that's no longer a threat? Or are there other causes that you will attribute this to?
Dr. Uche Ralph-Opara: Well, I think, um, this is an important question because, for me, it's kinda looking into how gender inequality has continued to drive HIV transmission, particularly amongst adolescent girls and women in Africa. There are a lot of ways, but I would, I would mention a few.
We know about the power in balances, right? So, for instance, we still see in a lot of communities where we work unequal gender dynamics, which, you know, would reduce women's agency to negotiate condom use or safe sex or safer sex practices. So that dynamic is still happening so we have these girls being more prone to acquiring the infection when they can't negotiate, um, safe sex or condom use.
We also still have a lot of communities that are saddled with early marriage or transactional sex, and who's most affected by that? Girls, right? So they go into relationships with older men due to some economic issues they might be dealing with. And, of course, this would increase their exposure to HIV due to age-related power gaps and also lack of safer sex practices.
Education is another thing we're seeing. We're seeing mostly in sub-Saharan Africa, girls with less education and, of course, would be at higher risk due to reduced access to information and resources about HIV prevention.
But we do have a lot of programs that have been built to kind of take care of these kind of issues. So, for instance, at Project HOPE for the last 10 to 15 years, we've been implementing some very impactful adolescent girls and young women programs in Namibia, recently in, um, Malawi and a couple of other countries, including Nigeria. And we've been able to ensure that we're looking at the gender dynamics and also trying to, like you mentioned, communication, ensure that these girls are educated, empowered to be able to negotiate safer sex.
We've also integrated GBV, that's gender-based violence programming within HIV programs so that survivors can get the post-exposure prophylaxis and things like that.
And one very important piece of this adolescent girls and young women programming is the economic dependence, economic empowerment, making sure that these girls are empowered to make the right decisions. They are helped and supported to go to schools or become entrepreneurs. Because the more they have in terms of, by gaining by power economically, the less likely they are exposed to these kind of harmful practices that expose them to HIV.
Mvemba Phezo Dizolele: I understand how older people may infect the younger women and that safe sex negotiation that you're mentioning, Dr. Ralph-Opara.
When it comes to teenagers and young girls and young boys being in this situation, that means they're infecting each other. Is the rate different between young women and young men, or is still at par?
Dr. Uche Ralph-Opara: So young women definitely are contributing to more of the new infections, like I said, and from a lot of our programs, we're seeing it's as a result of the relationships with older men. Because of the economic situation, a lot of them living in poverty, would need to, well, say, make ends meet and then they go about engaging in these harmful practices.
Boys, of course, are also part of our programs because especially if we're talking about gender-based violence, we need to educate the boys. And we do have sessions for boys as well as part of the program. It's called Coaching Boys to Men, just so that they are also aware, and they are also allies to the girls.
So in terms of percentages or proportions, girls are still more responsible for most of the new infections we're seeing in Africa with regard to HIV.
Mvemba Phezo Dizolele: So the one element is the older men, uh, the other element is just the practice. But is there something different physiologically between, uh, men and women in this regard?
Dr. Uche Ralph-Opara: Oh, yes. Women, (laughs) of course, we know based on how the reproductive system or organs are structured, there's more reception from the women in terms of the ability to acquire infections more readily than the men. So I think biologically and physiologically, women or girls are more at risk in that, you know, if you're looking at it from that point of view.
Mvemba Phezo Dizolele: The issue of funding you raised earlier and the issue of stigma, I want to come to in a little bit, but you talk about this protocol for prevention like PrEP and the other one. What is it called? There's PrEP and the second one.
Dr. Uche Ralph-Opara: PrEP is pre-exposure prophylaxis.
Mvemba Phezo Dizolele: Exactly. And the post?
Dr. Uche Ralph-Opara: Exposure, that's after an incidence of rape or something, then we're doing... Or exposure of any form, it could even be a needle prick. So post-exposure is given after the exposure.
Mvemba Phezo Dizolele: And what is an acronym for that as well?
Dr. Uche Ralph-Opara: It's pre-exposure is PrEP.
Mvemba Phezo Dizolele: Yes. And there's the post one is Pe- oh, P-E-P, just PEP. Okay. So PrEPs and PEP.
I was in Botswana a few months ago, and Botswana had been held and touted as a model of the way a country should, uh, handle this kind of situation. Botswana was pretty much on the brink of serious calamity. People were dying, the Ministry of Education couldn't train more new teachers because people were just dying. Schools were depleted of teachers, and the government was able to take action and put in place a successful program that saved the country.
But today there is a resurgence of HIV AIDS, and it's among the youth primarily, but in this case is not just a question of negotiating safe sex. That is a problem, not just a question of all the men going after younger ladies. There's also an issue of the lack of fear.
So when they talk to young women and the young people or boys as well, and they ask them why they are not taking the right precautions, they say they don't really fear it anymore because there is all these protocols that they can take, pre and posts-intercourse. And that they're more afraid of pregnancy than they're about AIDS because they don't see people dying in the way it used to be in the early '90s or the 2000s.
How are you as an organization coping with that kind of development in the areas that you are engaged in?
Dr. Uche Ralph-Opara: Yeah, thanks Mvemba. (laughs) That's an interesting dynamic and... So one of the core components of our programs is behavior change communication, right? So a lot of our messaging is tailored to address the specific needs. So you're seeing this trend in Botswana, and we're seeing something maybe slightly different or the perceived risk or the reasons why people are still engaging in harmful practices.
So one of the things we do across our programs, not just the HIV programs, is ensuring that we're integrating the right messaging to these populations, the youth, so boys, girls, women, accordingly. So yes, we are seeing people more interested.
I was recently supporting one of our programs, and I sat in one of the sessions and, you know, I've seen a girl who came in to get her PrEP because she was in a relationship that she knew was high risk, and she was also pregnant for the second time, and she was just 17.
So for me, it told me a lot. For them, "I want to just take the PrEP and prevent it. I don't mind getting pregnant." Because when we're counseling about reproductive health, family planning and things, there's little or no interest. So as I'm seeing... What you're seeing in Botswana was slightly different from what I'm seeing. Yeah. They're more scared of getting the infection, so they're worried that they're stock out of PrEP, but they don't mind getting pregnant.
So I think we just need to understand and meet these young people where they're at, and that's why I talk about the person-centered approach. It's different for different people, and then we tailor our messaging to kind of fits the need.
So for this person, we need to continue to counsel for family planning. Also counsel her to go back to school if she needs to because at 17, second pregnancy, that's not what we want for her, and I'm sure that's not what she wants for herself. But, you know, there are a lot of other socio-cultural dynamics that come into play here. So messaging is very critical for this population to be able to ensure that programming is as impactful as possible.
Mvemba Phezo Dizolele: How is the, uh, African continent, uh, doing compared to other parts of the world?
Dr. Uche Ralph-Opara: (laughs) In terms of HIV transmission?
Mvemba Phezo Dizolele: Correct.
Dr. Uche Ralph-Opara: I think that the African continent, we're not where we want to be, that's all I'll say. Because if you look at the countries that's still far from achieving epidemic control, majority of those countries in the yellow and the red that's not doing so well, or is, are still struggling to be on track are in Africa. Compared to the rest of the world, Africa is still lagging in terms of HIV. Even if, like I said, over the last 20 years, there's definitely been an improvement.
But if we don't work to address the issues of new infections being driven by young people and other priority populations, we might find ourselves back to where we were a decade or two ago. So we're really working towards ensuring that we're not having new infections.
Mvemba Phezo Dizolele: The, uh, issue of funding you raised when we started this conversation. Can you talk a little bit about what the challenges are in that space?
Dr. Uche Ralph-Opara: Yeah. So funding, um, (laughs) it's, it's very interesting because a lot of African countries are still heavily dependent on external donor funding.
So, for instance, like we know PEPFAR is the biggest funder of HIV programs including Global Fund. And over the course of the years, we're seeing some dwindling in the resources for HIV programs and that could, like I mentioned earlier, be exacerbated by competing global health priorities. For instance, we're having a lot of emergence of infectious diseases and outbreaks and emergencies and all of that. So that might account for the dwindling of donor resources.
But then, again, we're looking to the governments, the national governments of these countries to kind of be accountable. How are they putting their money where their mouths are? How are they budgeting to include HIV programs as part of their health budgets? Because we don't want a situation where countries remain a hundred percent dependent on donor funding.
So I think there's been a call for national governments to step up to put money towards achieving this epidemic control so that you're not heavily reliant on what the external donors are bringing because we just never can tell where that would land. So a lot of work around policy advocacy, getting governments to kind of drive the response versus sit and wait for external funding from donors.
So I think different countries are at different levels, like I'll say. Some are definitely more responsive than the others.
Mvemba Phezo Dizolele: So how are you coping then?
Dr. Uche Ralph-Opara: Coping in terms of?
Mvemba Phezo Dizolele: Finance and keeping programs? I mean, you are just one organization in this space, and I bet your peers are trying to navigate the same, I don't know if we should call, we... Let's call it challenges. It's a better word. We don't wanna call it crisis, but let's call it challenges of funding.
Dr. Uche Ralph-Opara: Yeah. So, so (laughs) definitely we still do have donors funding HIV programs, like I mentioned. There's PEPFAR through USAID and CDC, and there's also the Global Fund.
In addition, a lot of partners are looking to engage in private sector. We believe that the private sector also has a role to play in supporting the epidemic control. So there's a lot of private sector engagements in addition to the institutional donors.
And then, like I said, policy advocacy we're continuing with to get the national governments fund some aspect or, as much as possible, a large extent of HIV programming in their country so looking to multiple funding streams.
And I think the most important thing is sustainability, right? Because the last thing we want is to have people on therapy and they have to stop because, for instance, the ARTs are no longer available because no one's procuring. We just need to be able to balance that.
So for now, it's multiple streams from PEPFAR, from Global Fund, also from the private sector. And hopefully, we transition to get full government ownership of the programs.
Mvemba Phezo Dizolele: What are ARTs again, uh, in terms of acronym?
Dr. Uche Ralph-Opara: Oh, so sorry. (laughs) Antiretroviral therapy. So that's the treatment for HIV.
Mvemba Phezo Dizolele: So the streams, uh, of funding that you just talked about, PEPFAR is US, USID, Global Funds, of course, is glo- is the world and the private sector.
We will be curious to know a little bit, uh, about how do the conversation with local governments or national governments on the continent go? What is it like to engage... You talk about policy advocacy with governments on the ground.
Dr. Uche Ralph-Opara: Yeah. So like I said, it's not a one-size-fits-all kind of situation we're seeing, right? Different countries at different levels, and some governments are more responsive than the others.
As implementing partners, we're working very closely with the national governments. I think the first thing is do they have a health plan? Do they have a HIV response plan? Whatever it is we're doing as implementing partners going into those countries is ensuring that we are aligning with those plans.
We are also advocating for them to ensure that there's an actual budget allocation. Because it's one thing to have a plan, right? It's another thing to fund the plan and to implement the plan. So our policy advocacy efforts is more driven towards ensuring there's a plan, ensuring that there's a budget to support HIV response and that it's actually released and the programs are actually implemented. So different countries are at different levels and more governments are holding themselves more accountable than others.
So our role as implementing partners is to support that process and ensure that they kind of prioritize these kind of programs depending on what the burden is, right? Some countries have higher burden than others, so they would want to prioritize versus others that have other more pressing disease burdens that they want to address. So sometimes it gets tricky, like why do we prioritize HIV and not diarrheal diseases or something else, for instance?
Just knowing what the disease burden is and at the national level and also sub-national levels also drive some level of budget allocation and prioritization for programs.
Mvemba Phezo Dizolele: There was a time where there was a denial movement because, you know, it was a stigma on the country. It was an issue of national security and national pride. Are you finding any such thing these days?
Dr. Uche Ralph-Opara: Um, not a lot. I think a lot of people have come to terms and I think data, we're using data now. We're collecting better data, and we're not just collecting. We're using the data to inform our programming.
So a lot of countries do have data that tell them where they are in terms of epidemic control, right? And even within countries, some regions or districts or provinces have higher burden.
But the only way you can engage in this regard is if you have data. The data would speak to what the situation is. And that way, governments are able to prioritize.
With more data collection, reporting and use, we're able to kind of know what the trends, the patterns are, and we're able to provide that support and prioritize interventions accordingly.
Mvemba Phezo Dizolele: I've always wondered why we have 16 Days of Activism. Why 16 when this is a live issue?
Dr. Uche Ralph-Opara: (laughs) Yeah. So it just carved out in the year, but I believe every day is a day to advocate for (laughs) gender-
Mvemba Phezo Dizolele: There we go.
Dr. Uche Ralph-Opara: ... to be activists. So these days are just carved out for more campaigns and more engagement, but yeah. And it kind of coincides with Human Rights Day, I think, when it ends, and the Day of Violence Against Women, I think, something like that. So it's very important.
And this year is actually a landmark year because I see even on the theme something around plus 30 years after the Beijing thing. But I don't want to have that conversation, Mvemba, (laughs) so don't take me there.
But yes, I don't know where we are 30 years later in terms of the gender dynamics inequities and things like that, but I believe we're getting there. And if we don't address the issues of the gender inequalities, then we'll continue to deal with issues of HIV transmission alongside other issues and health outcomes.
Mvemba Phezo Dizolele: Very sobering, uh, but also encouraging on so many fronts.
Dr. Uche Ralph-Opara, it's a pleasure to have you back. Thank you for enlightening us.
Dr. Uche Ralph-Opara: Thank you very much, Mvemba. Thanks for having me.
Mvemba Phezo Dizolele: Thank you for listening. We want to have more conversations about Africa. Tell your friends. Subscribe to our podcast at Apple Podcasts. You can also read our analysis and report at csis.org/africa. So long.
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