The Global Forum on Men Who Have Sex With Men and HIV (MSMGF) has brought to light a phenomenon that is already common knowledge: the high rejection rate of abstracts on issues and programmes aimed at gay men and men who have sex with men (MSM) for the International AIDS Conference.

A few weeks after the results of abstract review for the conference were made public there is clear evidence that very few abstracts have been approved in this area. The Key Correspondents team has been able to confirm with the Latin American transgender and women sex worker networks that the same has occurred with their abstracts.

The MSMGF stated that: “As in previous years, a considerable number of high quality abstracts on MSM and transgender people have been rejected by the conference. Of the few authors whose work has been accepted, a far lower number have received grants to be able to present them […] In recent years there has been great progress in programs and research into these populations and a negligible part of this work will be included in the conference programme.”

The Forum on MSM and HIV has consequently decided to bring together these abstracts in one publication which will be submitted prior to the Washington conference. The MSMGF invites all those authors or organizations whose abstracts have either been rejected, or accepted but with a grant application then rejected, to send them before May 4th via this link. It is important that these follow the same guidelines as for the conference (it is recommended that authors use the guidelines included in this link).

While it is important to celebrate the Forum’s innovative initiative to overcome this situation, it is also an opportune moment to stop for a moment to analyse what is going on with the participation of persons, programmes, research and organisations dedicated to those populations at greatest risk of contracting HIV. A similar complaint by the Global Network of Sex Work Projects resulted in the organisation of an event in India in parallel to the Washington event.

Are gay men, MSM, transgender people, sex workers and drug users slipping off the agenda of the International AIDS Society? Perhaps it is up to those responsible to provide a response, but there is empirical evidence that confirms this trend.

What is going on?

Some sources close to the International AIDS Society have mentioned, off the record, that there is a strong incidence of a hard line, meaning ‘putting the emphasis on basic medical sciences above other disciplines’. When participating in meetings and committees at previous editions of the conference, I personally have witnessed complaints and demands from some professionals and scientists to make the conferences “more scientific”. And this is consistent with a central aspect of the conference: funding.

The International AIDS Conference could not exist without funding from international pharmaceutical laboratories. Contributions from multilateral and bilateral programs and agencies is marginal compared with the millions invested by laboratories. There is a context where not only are there far fewer resources for AIDS and related events, but there is also strong competition from scientific conferences, particularly the Conference on Retroviruses and Opportunistic Infections (CROI) and the European Congress of Immunology. Even the IAS competes with itself, organising a year earlier the International Conference on HIV Pathogenesis, Treatment and Prevention, which was last held last year in Rome.

That international conferences are big business is nothing new, with a generous sprinkling from the pharmaceutical industry of protocols, research and publications of the results of tests and studies with their products. Conferences are a good opportunity to take out and show the world to (some of) the self-sacrificing health professionals who look out for our viral loads and CD4 cells.

What is increasingly evident is the irremediable loss of any legitimacy and remote possibility of accountability by the International AIDS Society, a scientific organization that has always prided itself on being made up of different sectors and organizing multidisciplinary events in a relatively participative and democratic way. And so, this international society returns to its conservative centre of being a professional association representing scientific and medical corporations. We hope that after this revelation, the scant resources from public and multilateral sectors will not continue to be entrusted to these organisers.

Elena Reynaga, Executive Secretary of RedTraSex, said: “We do not have news of any of the abstracts sent by the organisations of women sex workers in our region being accepted. We do not know how many Latin American women sex workers will make it to Washington. This is a great setback. In 2008 we had hundreds of sex workers from all over the world at the conference, a plenary session on sex work, workshops and spaces in the Global Village. All of this is being lost and it is a shame.”

Spaces are lost and, consequently, we are back to square one in the history of the epidemic. A few years after the first cases of AIDS there was a universal consensus that the only possible response was multi-sectorial: science and society, governments and civil society, scientists and ‘patients’, a notion that appears to be falling into oblivion in the minds of some and in the policies of their organisations. We do not know how much we can go backwards, we only know that we cannot win this war if we fight alone.

If you wish to know the names of the people from the world of science, civil society and the agencies that participate in each of the committees of the Washington conference, visit this link. Perhaps among those names you might be able to find some answers. If you want to participate and express yourself, leave us your comment below.

Todos los artículos pueden ser compartidos y publicados siempre que sean citados los datos de la fuente.

First posted on Corresponsales Clave, the Key Correspondent team in Latin America and the Caribbean.

An AIDS-Free Generation

In November 2011, the global HIV/AIDS community celebrated when Secretary of State Hillary Clinton declared “creating an AIDS-free generation” to be a policy priority for the U.S. Government.  Secretary Clinton stated that the world has a “historic opportunity … to change the course of this pandemic.”

President’s Budget Request

In February 2012, the White House released the President’s Fiscal Year (FY) 2013 budget request.  The HIV/AIDS community saw the budget request as a mixed bag.

The request included a large increase for the Global Fund to Fight AIDS, Tuberculosis, and Malaria from the $1.05 billion appropriated for FY 2012 to $1.65 billion.  With the additional transfer of PEPFAR bilateral funding to the Global Fund for FY 2012, the $1.65 billion would meet the Obama Administration’s three-year, $4 billion pledge to the Global Fund made in October 2010.

However, the request also included a large decrease in PEPFAR bilateral funding of about $500 million to $6.4 billion for FY 2013.  The Obama Administration had cited numerous reasons for the decrease.

The Office of the Global AIDS Coordinator (OGAC) noted that PEPFAR is “improving its efficiency, reducing costs through steps such as lowering commodities costs, switching from air to sea and land freight, and collection and use of economic and financial data in programming” with the costs of supporting an individual on treatment decreasing from more $1,100 to $335 per year with an expectation of further decreases.  The White House and the State Department noted that PEPFAR is “consolidating programs and shifting responsibility to host governments, which lowers costs dramatically and allows us to save more lives.”

PEPFAR Pipeline

In April 2012, the community found out another reason for the decrease in the budget request.  The Global Post released an article and an interview with Global AIDS Coordinator Eric Goosby which revealed that there have been almost $1.5 billion stuck in the PEPFAR pipeline for 18 months or more.

The 22 countries and two regions affected include Kenya ($502 million), Ethiopia ($138 million), Mozambique ($130 million), Zambia ($91 million), Uganda ($57 million), and Haiti ($44 million).  The Alliance has Linking Organizations in all six of these countries.

The Case of Kenya

Kenya alone has about one-third of the pipeline.  The country had already expected a 44% decrease in PEPFAR bilateral funding.  17 civil society organizations (CSOs) – including the AIDS Alliance Linking Organization, the Kenya AIDS NGO Consortium (KANCO) – quickly came together to strategize.  They sent a letter to Ambassador Goosby, who met with Kenyan Minister of Health Beth Mugo in April in Washington.

In late April in Nairobi, hundreds of AIDS activists demonstrated and presented a memorandum to U.S. Ambassador to Kenya Scott Gration, Kenya PEPFAR Coordinator Katherine Perry, and Ministry of Health officials demanding that PEPFAR release the funding stuck in the pipeline.

KANCO Executive Director Allan Ragi states:

Only slightly over 400,000 people are on ARV treatment while we need to scale up to over one million people.  PMCT uptake is low, and hence we need to scale up if we are to realize the Three Zeros [zero new HIV infections, zero discrimination, and zero AIDS-related deaths].  We cannot afford to lose $500 million from PEPFAR.  This will bring us down to our knees.  We need these resources now, and we have the capacity to use the money.

Challenge and Opportunity

While the pipeline situation globally and in individual countries such as Kenya is a political challenge, it is also a programmatic opportunity.  The Alliance sees this opportunity in the context of the Investment Framework for an effective HIV/AIDS response published in The Lancet in June 2011.

The Alliance notes in a discussion paper that the Investment Framework prioritizes basic programmatic activities and “critical enablers”.  The Investment Framework positions human rights-based programming such as advocacy, stigma reduction, and efforts towards supportive laws and practices as not optional or additional but “critical.”

As Secretary Clinton stated in November 2011, successful HIV responses “depend on institutional and social changes like ending stigma; reducing discrimination against women and girls; stopping gender-based violence and exploitation, which continue to put women and girls at higher risk of HIV infection; and repealing laws that make people criminals simply because of their sexual orientation.”

The Investment Framework projects an increase in spending until 2015 followed by a decrease from 2015 to 2020.  This short-term increase would allow 12.2 million new HIV infections and 7.4 million AIDS deaths to be averted.

New OGAC Guidelines and Beyond

The Alliance is pleased that OGAC has already released guidelines on reprogramming explicitly citing the goal of creating an AIDS-free generation.  The guidelines refocus PEPFAR investments toward three major areas:

- Investing in commodities
- Investing in systems (human resources for health, supply chains, and management and use of program, epidemiological, and financial data) and institutions
- Investing in program strengthening for greater impact including: expanding existing programs (treatment, make circumcision, MPTCT, counseling and testing, and condoms), supporting key populations and identifying new investment countries.

The Alliance appreciates in particular the focus on supporting key populations.  In our What’s Preventing Prevention campaign, we call on national governments to:

- Break the barriers that impede access to HIV prevention programs and services for vulnerable and most-at-risk populations and empower those key populations to be at the center of the HIV response
- Respect, promote, and protect the human rights of key populations and remove the political, cultural, social, and legal barriers that affect effective HIV prevention measures, including combating stigma and social discrimination
- Remove legislation that hinders access to HIV prevention for key populations, especially laws that criminalize specific groups or behavior; these include laws targeting sex workers, drug users, MSM, and HIV exposure or transmission

The Eighth Annual PEPFAR Report to Congress stated that “PEPFAR is making smart investments by investing in the interventions that will have the biggest impact on prioritized outcomes … [and] focusing dollars on interventions that have been shown to have the greatest impact.”  This reprogramming exercise is an opportunity for PEPFAR to show its smarts.

The funding in the PEPFAR pipeline is needed now to reach the tipping point laid out in the Investment Framework.  PEPFAR must consult with key stakeholders – including governments and civil society – to quickly develop investment strategies for the affected countries, spend down their pipelines, and help translate the goal of an AIDS-free generation into a reality.

Read this article by a Kenyan based Key Correspondent on the recent demonstrations in Nairobi on this issue.

Lord Fowler is a champion of evidence-informed HIV responses in the UK and internationally. He was instrumental to the UK’s ‘Don’t Die of Ignorance’ campaign, which raised awareness of HIV dramatically during the 1980s.

I am Ukrainian and worked at the International HIV/AIDS Alliance in Ukraine (Alliance Ukraine) before moving to the UK to work at the Alliance secretariat. As such it was a very interesting and enriching experience to facilitate Lord Fowler’s introduction to achievements and challenges of HIV response in Ukraine.

During his visit Lord Fowler met with activists from communities most affected by HIV. They discussed the contradictions of Ukrainian HIV related legislation, and other issues including: human rights abuses, criminalisation, persecution by police as well as stigma and discrimination against people who use drugs, patients of substitution maintenance therapy, sex workers and men who have sex with men.

It was particularly pleasant for me to meet with many HIV activists whom I had worked with before. It was wonderful to see how their professionalism has grown over the years – they are now even sharper, more convincing and persuasive.

Brave questions

Lord Fowler and Elena Tsukerman, an activist for sex workers' rights

One of the activists was Elena Tsukerman, who fights for sex workers’ rights (legalife.com.ua).  At the end of the meeting between Lord Fowler and leaders of communities most affected by HIV she confidently put her hand up to ask a question.

“Lord Fowler, can I please take a picture with you?” She asked, explaining, “For years the Ukrainian government has been refusing to have dialogue with us and I think a photo with you will help us to continue our work and establish dialogue with the government.”

Reflecting about her question later she said she was hesitant, wondering “whether this will be a permissible question to ask, but then I decided to go for it”, and she was very happy when he agreed to be photographed with her.

Advocacy in action

Within a few hours Elena published the photo of Lord Fowler and herself on her blog. There she writes “While officials of the Ministry of Internal Affairs and Ukrainian politicians say that they are not ready to have a dialogue with sex workers, thinking that this harms their reputation, the UK Parliamentarian, Lord Fowler, not only spoke with me, as a representative of sex workers, but even agreed that sex work is WORK…We hope that Lord Fowler’s and our continued work will contribute to reforming Ukrainian legislation related to the sex work and will increase the inclusion of sex workers in the decision making process” (translated from the original Russian).

Supporting HIV activists in Ukraine

It was very encouraging to see how far HIV related activism has come in Ukraine. Part of this progress is thanks to the work Alliance Ukraine has done in strengthening the advocacy capacity of the leaders of communities most affected by HIV. This work was done with the support of the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria as well as USAID funding.

Today activists’ voices are strong and they are able to share experiences about the human rights challenges of HIV response in Ukraine and influence decisions which affect the lives of the communities they represent.

You can read more about Lord Fowler’s visit to Ukraine here.

I tweeted from Ukraine during the visit, you can follow me on Twitter here.

First we look at HIV and TB service integration, and further down the page I have posted answers to questions readers sent in via the Alliance’s social networks.

What is the connection between HIV and TB?

TB is the most common opportunistic infection and cause of death among people living with HIV. In 2010, 1.1 million people with TB were also co-infected with HIV and 350,000 people living with HIV died from tuberculosis as reported in the WHO TB report 2011.

Why is it so important to integrate HIV and TB services?

There is growing evidence that integrating HIV and TB has significant benefits: It improves the survival of people living with HIV, is cost efficient, promotes cross-programme learning and has a major impact on patient outcomes, including increased access to services, reduced mortality among people living with HIV and higher cure rates among TB patients.

However, despite significant overlapping epidemiology globally, efforts to tackle TB and HIV have been largely separate. This makes it difficult to achieve universal and equitable access to HIV and TB prevention, treatment and care services. TB-HIV co-infection is a major cause of sickness and death. For this reason, TB and HIV should be addressed together.

What is the Alliance doing to integrate HIV and TB services around the world?

Integrating TB and HIV is a strategic objective of the Alliance. This started with an organisational TB strategy and a set of capacity building initiatives and implementation tools to increase the ability of our linking organisations to tackle TB.

The Alliance implements a range of activities to tackle TB:

•    Firstly, it supports a range of community based TB activities, including: involvement of people living with HIV in health service delivery; linking communities and health systems to strengthen referral systems and infection control; supporting delivery of community-based DOTS (Directly Observed TB Treatment, Short-course); secondment of community health workers to TB clinics to provide HIV counselling and testing and referrals; and implementing mobile sputum collection as a model for intensified case finding.

•    Secondly the Alliance supports strategic partnerships to tackle TB including collaboration with national TB programmes and initiating collaborative partnership with TB service providers and community-based organisations.

•    Thirdly, the Alliance supports advocacy at international national and local levels through dialogue with policy and decision makers, donor organizations, and working with journalists and key correspondents to advocate for TB services.

•    Fourthly, the Alliance implements anti-stigma programmes including the development of training material, anti-stigma tool-kits, training of trainers and  training on TB/HIV stigma for health care workers.

•    In addition, the Alliance provides care and support to people living with HIV and TB including clinical services to people co-infected with HIV and TB, referrals for TB screening and treatment, community-based DOTS, and capacity-building of local civil society organisations to provide care and support to people with HIV or TB.

•    We support knowledge sharing across the Alliance through communities of practice on TB/HIV and through dissemination of best practices and standards in HIV/TB integration through a variety of publications and case studies.

•    Finally the Alliance provides technical assistance in TB and HIV work within the Global Fund grants.

You can read more about TB and HIV here.

Your questions

Why aren’t confirmed TB cases mandatorily tested for HIV?

From Hari Singh, India, via Linked In

Global WHO policy on collaborative TB/HIV activities recommends that all confirmed and presumed TB cases should be offered routine HIV testing.  However, HIV tests should be offered on a voluntary, rather than mandatory basis. A person who is offered HIV testing may opt not to take the test. Informed consent should be obtained and confidentiality protected. It would be unethical to compel a person with TB to test for HIV infection against their wish and in direct violation of their rights. Consequently, raising awareness of the importance of testing for HIV among people with TB to increase their voluntary uptake of HIV is critical.

I am writing my dissertation on TB within England, a low-risk area, but do we underestimate the risk of TB in Europe?

From Alex Baskerville, UK, via Twitter

Estimation of incidence, prevalence and mortality of TB is based on modelling of information gathered through surveillance systems (such as case notifications and death registrations), expert opinions and consultations with countries, with underlying assumptions.

No country has ever undertaken a nationwide survey of TB incidence because this would be a major undertaking requiring large sample sizes and financing. Thus it’s possible that there are errors in the estimated incidence figures. In addition, the estimation of the risk of TB (i.e relative risk or odds ratio) depends not only on the country but the specific context. Underreporting of TB cases can particularly affect estimated rates. Overall, there is general consensus that the risk of TB is much higher in Eastern Europe compared to England, especially among prisoners and other marginalised populations.

Why isn’t TB literature available at DOTS-ICTC-PPTCT centres? Why aren’t HIV counsellors appointed at ICTC-DOTS? Why isn’t there a TB-HIV toll-free Helpline in India?

From Hari Singh, India, via Linked In

One of the most important barriers to the control of TB in many countries is the lack of knowledge of TB in communities. It is therefore important to promote information, education and communication on TB prevention, treatment and care as provided by national and international standards, such as the international standards for TB care. In addition, the World Health organization policy guidelines for national programmes and other stakeholders on collaborative TB/HIV activities recommend that HIV testing and counselling should be provided to patients with conformed or presumed TB disease.

What are the proper guidelines on TB screening? Which symptoms are key when asking screening questions?

From Wynnette Chinogwenya, South Africa, via Linked In

The objective of screening for TB is to promptly identify people who are either at high risk of TB disease or who already have the disease in order to facilitate early treatment and prevention of transmission. Often, screening is based on symptoms (i.e complaints that patients have) and signs (i.e what a clinician finds upon physical examination on a patient).

-    Examples of TB symptoms: Cough, weight loss, night sweats, fever. Etc
-    Examples of TB signs: Stiff neck, confusion, poor air entry in the lungs, lymph node swelling etc

In general terms if you want to identify all people who might have TB then you would use all of the above signs and symptoms in any combination.

If you use screening that is based on the presence of at least one sign or symptom, you would be over-estimating TB disease because there are many causes of each one of these symptoms. For instance, TB is not the only cause of cough or fever.

On the other hand if you use screening which is based on the presence of all the above signs and symptoms, then you would miss a lot of people who have TB because majority of people with TB present with only a few of these signs and symptoms.

Thus, screening guidelines are a trade off between what combination of signs and symptoms are most predictive of TB in a specified population. This trade off is based on the concept of sensitivity and specificity. Most commonly, this is taken to be a combination of chronic cough of more than 2 weeks, weight loss, night sweats, and fever (all of which cant be explained by any other obvious reason). However, and as noted above, this is not a perfect screening protocol.  In addition, screening protocols can be adjusted based on the nature of the TB epidemic and the population. Other factors such as exposure to someone who has pulmonary TB are often considered.

In conclusion, there is no perfect TB screening protocol, but most use a combination of signs and symptoms that are most predictive of TB disease in a specific setting.

The Caribbean region has the highest incidence of HIV in the Americas and the second highest prevalence in the world after Sub-Saharan Africa. Within the small-island nations of the Eastern Caribbean, the HIV epidemic is believed to be concentrated among certain high-risk populations.

In Kitts and Nevis, the estimated prevalence rate was 0.46 in 2009. The most common route of transmission is unprotected sex, particularly in concurrent relationships. But lack of data makes it difficult for the government to determine the size, determinants and distribution of the epidemic and target an appropriate response.

The response to HIV is threatened by a lack of sustainable financing, on-going stigma and discrimination and the limited capacity of civil society to aid in the response.

Direct donor funding for HIV response-related activities has largely ended in St. Kitts and Nevis. A World Bank funded project on HIV prevention and control ended in 2009, having disbursed US$3.4 million to St. Kitts and Nevis. Along with the other OECS (Organization of East Caribbean States) countries, St. Kitts and Nevis also benefited from a multi-country Global Fund Round 3 grant that ended in 2010. The grant was used for prevention, care and treatment with particular emphasis on voluntary counselling and testing as well as behavior change campaigns. Global Fund support that provides free antiretrovirals in the eastern Caribbean is estimated to end in 2012.

The government of St. Kitts and Nevis has made significant progress in addressing the challenges of HIV over the last decade, but weaknesses in the health system threaten these successes. A Health Systems and Private Sector Assessment conducted by USAID in May 2011 highlighted these challenges including sustainable health financing, stigma and discrimination, and weak civil society engagement.

It is also unlikely that domestic spending on HIV will be able to replace previous levels of donor funding in the near future. There is lack of information about costs and expenditures in the health sector, essential for rational financial sustainability planning.

While funding is one limiting factor, the national HIV response is also hindered by stigma and discrimination. Within the small community of St. Kitts and Nevis (population 50,000), maintaining confidentiality of HIV status or stigmatized behavior is difficult. Non-discriminatory laws currently do not exist to protect people living with HIV or vulnerable groups like men who have sex with men (MSM) and sex workers.

Doctors fail to record AIDS-related deaths to protect families. Few commercial businesses have HIV workplace policies, and not a single grievance has been filed with the Human Rights Desk for HIV in its three years of existence. Further, private practitioners report that their HIV-positive clients avoid referral to the public sector HIV program or clinical care team, preferring to remain with their private physician for confidentiality reasons.

Civil society organizations and private sector entities, including non-profit organizations and provider associations, can play a valuable role in the countries’ response to HIV. They may provide direct services for people living with HIV, outreach to marginalized populations, advocacy for programs to meet their needs or additional financial resources.

In St. Kitts and Nevis, better civil society and private sector engagement are particularly needed as Ministry officials are overstretched. Civil society organizations for health, while welcomed by the government to provide input, currently do not have the capacity to play a supporting role in decision-making or planning. Little external support is available for non-profit groups. The Ministry does not have formal mechanisms for communicating and collaborating with private sector providers.

These challenges must be addressed to ensure the needs of people living with HIV, and those at a higher risk of getting it, in St. Kitts and Nevis are met.

This blog draws on my experience as a human rights activist in Colombia and following my exile. I present some areas that I think are important for future research and LGBT activism in Colombia.  These include some reflections specific to Lesbian women in Colombia. There is a section for comments at the end of the page which I look forward to reading!

The Colombian context for LGBT activism

In Colombia, a country with serious human rights problems, there is a clear gap between official rhetoric and the legal framework and reality.  As a consequence impunity levels are high. Other discontinuities exist too. For instance there are a number of widely recognised gay writers, who are able to participate in public debate and adopt critical positions on the armed conflict and the state responsibility. But Colombia ranks very high in the statistics for the number of transgender women killed because of transphobia.

Tracing the emergence of LGBT activism (how much progress has there actually been?)

Things have moved very fast in the last 10 years. For example 56 pro-LGBT regulations and laws have been published during the period, 3 major cities in Colombia now have LGBT policies, and all the major political parties have LGBT policies. However, the tendencies of the movement in Colombia, or how coherent it is, are still not clear.

The LGBT community only began to organise recently, in 2001, with the creation of Planeta Paz. The term LGBT was adopted  from the international movement because it was clear a name was needed  that would help identify them as populations working on identity and on sexual and gender diversity, but the learning curve has been steep as they have sought to catch up with other traditional and new social  movements such as the trade union movement,  civil and political human rights activists, indigenous groups, and even women’s rights groups that preceded them in playing a key role in terms of human rights, (armed) conflict resolution and justice.

The LGBT contribution to human rights in Colombia.

As in other places, the LGBT movement has a clear contribution to make in terms of identity: this is an interest that is common to each one of the four or more populations that integrate the LGBT movement.  In this they have built on and extended the contribution of other new social movements such as the indigenous and black movements.  Like the women’s movement they have helped demonstrate how gender and sexuality are key factors in institutions that are central to society (the family, the church, school) and therefore a key area for negotiation between the state and civil society.

Of particular importance to the Colombian context is the fact that gender and sexuality dynamics are linked to the roots of the armed conflict. Further research into these aspects will therefore eventually contribute to thinking on how to progress in the human rights agenda and peace building.

The ways in which gender and sexuality can be linked to the conflict in Colombia, are well illustrated in Sanchez Baute’s latest novel  Libranos del Bien (Sanchez-Baute 2008). Sanchez Baute is the most prominent openly gay author in Colombia.  He tries to explain the conflict from the perspective of a specific region (the Caribbean), and from his experience as a gay person in Colombia. I end this section by presenting  quoting explains the LGBT Agenda for the Peace Process, produced by the LGBT Sector of Planeta Paz (quoted by Jose Fernando Serrano-Amaya). The statement reflects discussion  about whether or not LGBT people have a special approach to peace building:

“‘Body, the first territory for peace’ is the name of a political agenda that is still in the process of being written by the Sector. This agenda briefly states what is considered to be particular about this approach. Instead of claiming that LGBT are citizens that experience the same conflict as other Colombians, the agenda highlights that there are several types of violence that affect LGBT people in particular but that are not recognised as being important in comparison with other kinds of violence stemming from the violent conflict. They argue that since discrimination, homophobia, and hate crimes mainly target the body it has to be the starting point for any peace proposal.”

Lesbian human rights activism, how far we can go with visibility?

Hate crime and intolerance, added to the fact that there are high levels of impunity, suggest that lesbians should seek to raise their profile in the regions is not the solution. We have seen that increasing visibility seems to have increased levels of attacks against other LGBT members.  Does the increasing visibility of the LGBT movement fit the narrative presented above about the evolution of general or LGBT human rights discourse? It is clear that in the LGBT movement, with a few exceptions, gay men tend to be more visible than lesbians.  This lack of lesbian leadership is more extreme in the regions.  Asked about this, one of the most prominent LGBT leaders in the Caribbean region of Colombia confirmed that leaders tend to be gay middle class men who are not native to the region.  He also said that lesbians seem not to be interested in taking on leadership roles, usually because they frequently remain in the closet but also because they have felt that their invisibility (“lesbians do not exist”) has allowed them to maintain their lesbianism relatively unaffected by violence. It is certainly my experience of violence against women that heterosexual women are permanently at risk; it seems lesbians do not wish to expose themselves to even more violence by coming out. How, then, might we promote a role for lesbians as human rights activists in regions where their security cannot be guaranteed?  On the other hand, there is a lack of research on violence against lesbians. Reports focus principally on violence against gay men, sex workers and transgender women, who tend to be more exposed to “external” violence. But very little is known about the levels of violence against lesbians committed by their relatives and members of their close communities. Research in other countries has shown that lesbians tend to be more vulnerable to attack than heterosexual women in these scenarios.

A methodology that might help to improve our understanding of the situation of the lesbian movement in Colombia

Millie Thayer’s article, “Identity, Revolution and Democracy in Lesbian Movements in Central America: the Costa Rican and Nicaraguan Cases” illustrates very well the particularities and differences marking two countries from the same region, reminding us that all the countries in the region are different. Thayer also uses some of the methodologies proposed by new social movement writers, concluding that social movements are built, and collective identities constructed, by particular people in particular locations at particular moments of history and that the reasons for this can be found by looking beyond global structural shift or formal political institutions.

Observing the case of Costa Rica and Nicaragua I would argue that Colombia might be seen as a hybrid of both:  a country with a strong history of human rights activism and conflict but also a country desperate to become, and be seen as, modern.

Lesbian groups and the HIV response

In the specific topic of LGBT and HIV I want also to add here what I think about the contribution to the HIV response made by lesbian groups and some women’s groups.

One important area relevant to the issue of lesbians as human rights activists is how to integrate with other movements and how this work might be recognised. Women’s human rights activists have supported LGBT rights and a large number of lesbian women in Latin America and the Caribbean have worked on HIV/AIDS. This is not because AIDS is an issue for lesbian women as such, but more as an expression of LGBT solidarity towards gay men and more recently towards Transgender women (the group most affected by HIV in the region).

There is still not enough recognition of what the lesbian and women’s movements and lesbian solidarity have contributed and might contribute  to the future of other members of the LGBT community and to those who are affected by a lack of sexual and diversity rights, including those working on HIV/AIDS.

I hope you have enjoyed reading this blog and I look forward to reading any comments you may have!

This blog was first presented as a paper at the International conference on LESBIAN LIVES ‘Masquerades’(17th- 18th February 2012), University College Dublin (UCD John Hume Institute for Global Irish Studies).  You can download the full paper as a PDF here, which contains a bibliography.

I would like to start this blog by sharing with you the paper I presented at the International conference on LESBIAN LIVES ‘Masquerades’(17th- 18th February 2012), University College Dublin (UCD John Hume Institute for Global Irish Studies).  (It is important to clarify that I was not representing the Alliance at the conference). You can download the full paper as a PDF here, which contains a bibliography.

I hope you have enjoyed reading this blog and I look forward to reading any comments you may have!

I have lived with the complexity of human rights activism in Colombia for the last 30 years. This paper is an attempt to understand and explain how the human rights movement has developed in Colombia (a country that has suffered more than 50 years of internal armed conflict). Rather than explaining the human rights situation in Colombia I want to focus on my experience as a human rights activist exiled in the UK, on the process of coming out as a lesbian, first in the UK and eventually in Colombia, and on the circles I have moved in as an activist. Finally, in the second part of this blog I explore a set of questions that will form a part of my PhD research.

The journey begins

My journey started in Colombia in the 1980s when I worked with poor children in a shanty town outside Bogota while attending a secondary school run by progressive nuns influenced by Liberation Theology. I wrote the dissertation for my law degree (on human rights in Colombia) while working with the country’s first firm dedicated to the defence of human rights– which produced the information that formed the basis of Amnesty International’s pioneering reports on the country.  Later, in 1988, I headed up the Human Rights and International Relations Office of the newly-formed left wing party the Union Patriotica (UP).  The UP was initially formed in 1985 as the political expression of the guerrilla movement the Revolutionary Armed Forces of Colombia (FARC) during peace negotiations with the government. It was  later joined by human rights activists – such as me – and by other left wing activists.

My initial involvement with human rights and left wing activism focused almost exclusively on Civil and Political Rights at a time when Economic, Social and Cultural Rights – including Women’s and Sexual and Reproductive rights – were barely on the human rights agenda. My dissertation had mentioned Economic, Social and Cultural Rights but lacked any women’s rights or gender analysis (my comrades and I used to say that we could work on women’s rights after the revolution).

This focus of human rights activists during the 1980s on civil and political rights was a ‘classic’ response to repression that was primarily carried out by the state. But as the conflict developed and its economic and social aspects became clearer, Economic, Social and Cultural Rights had to be included.  Parallel to this, the indigenous and black movements were growing stronger, a fact recognised in the 1991 Constitution, which introduced the cultural and identity rights that eventually became a door to introduce LGBT or gender identity and sexual diversity rights in Colombia.  The 1991 Constitution is, therefore, a landmark in terms of the recognition, consolidation (and institutionalisation) of New Social Movements in Colombia – that have increasingly influenced the human rights agenda in the country over the last 20 years.

A political exile: coming to the UK

In 1989 I had to leave the country because of my work with the UP (more than 1,000 of whose leaders were killed between 1985 and 1989).  Before leaving the country I had experienced domestic violence at the hands of my then left wing activist partner, was raped, tortured, and spent a short period of time in prison.  Even after these experiences my approach to human rights activism continued to concentrate on civil and political rights.

In exile, while living in a Refugee Centre in London, I started to work with other refugee women.  This was the first time I had focused on working with women and realised such activities were recognised as a vital part of human rights activism (something unimaginable on the left or in human rights work in Colombia at that time).

A survivor, not a victim

Additionally, on arrival in the UK, and when granted refugee status, I received several labels:  I was a victim, a refugee woman, a second language refugee woman, a second language refugee woman from a developing country.  It is possible that the fact I saw myself as (or that ‘they’ made me feel like) a victim, finally allowed me to understand the effects of being a woman, and how – as a woman – my human rights were violated. I was able rapidly to retrieve the status of survivor rather than victim.  It is also possible that because I was feeling safe in the UK, I was able to allow myself to become the real me, something that later contributed to my process of coming out as a lesbian.

Soon afterwards, I joined London University and started my postgraduate courses at the Women’s Studies faculty (Human Rights and Education and MSc Politics of Rights). In this period the move to include women’s rights in the human rights agenda became stronger. Simultaneously I was working (particularly with the Latin American community) in women-only organizations and in a women’s refuge with victims of violence, consolidating my understanding of gender issues. Other human rights activism for different minority groups also came to my attention, particularly issues around LGBT groups. These experiences helped me to begin  to define my sexual identity: another aspect of my life that was probably denied or postponed because of the ‘revolutionary’ idealism I had in my teens and twenties, while living in Colombia and working as a human rights activist.

Homecoming: back to Colombia

Returning to Colombia in 1997, it was clear that I wanted to continue my activism. But this time I was able to do it in a safer way, protected by my new citizenship, a British passport and the support of an International NGO. I got involved in work with internally displaced people, and later focused all my attention on working on the Children and Conflict Programme with Save the Children and on my book about Girls in Armed Conflict in Colombia (Paez-Manjarres 2002).

This work and research allowed me to carry out a gender analysis of the armed conflict in Colombia and to focus on the situation of girls from minority groups.  At the same time I was also able to observe the first steps in the growth and consolidation of the LGBT movement.  Initiatives like Planeta Paz, which brought together key representatives from different social movements working on conflict resolution, included for the first time LGBT representatives. This was probably the first time that sexual diversity had been linked to the social and political conflicts that have dominated Colombian society during the last 50 years.

LGBT movement finally acknowledged

However, at this stage, at the beginning of the 21st Century, it could not be said that LGBT activists were coordinating or liaising with human rights movements, and vice versa.  For instance, the main international reports did not take violations against this group into account.  Two topics that did appear on the agenda at the end of the 1990s and beginning of the 2000s was that of women and armed conflict and gender- based violence. However, the focus was primarily on violence against heterosexual women, rather acts associated with sexuality or gender identity.  I have been examining the topic of gender- based violence and LGBT groups recently (looking in particular but not exclusively at how gender- based violence affects responses to HIV/AIDS); it will comprise a core part of my future doctoral research.

Later (2004), after returning to the UK, I joined WOMANKIND, where I was able to focus on women’s empowerment projects, and gender- based violence.  It was when I went to the Women’s Human Rights Activists International Conference in Sri Lanka in 2005 that I realised how the LGBT movement was finally being acknowledged as a key part of human rights activism.  LGBT representatives were also invited to participate in this event.  It was acknowledged that both heterosexual women and LGBT community members should be recognised as human rights activists, and that there were linkages between the women’s and the LGBT movements, particularly in the area of gender-based violence.

Working at the Alliance

In 2006, I started to work at the International HIV/AIDS Alliance, with the Latin America team.  The Alliance employs a stigma and discrimination approach and more recently has adopted a more human rights –HIV focus.  The approach is explained by the fact the countries where I work face concentrated epidemics.  It has been recognised that one way to avoid generalised epidemics in these countries is through working with and empowering the most affected population, among them gay men, other men who have sex with men, and transgender women.

This is where most of my work has been focused over the last few years. It has also coincided with me coming out as a lesbian at work. Over the last five years I have observed the growing visibility of the LGBT movement and its different manifestations within Latin American countries. Issues such as civil partnership, gay marriage, non-gender identity, sexual orientation and discriminatory access to services have been discussed and in some cases recognised by legislatures in different countries of the region.  Additionally, and more recently, LGBT people have become more pro-active as human rights activists.

LGBT: growing visibility, growing violence

It appears that this increased recognition of LGBT rights and the growing visibility of LGBT people as human rights activists and members of a movement have led to increased levels of violence against the LGBT populations in Colombia.  In recent years, well know activists have had to leave the country because of their gay activism;  they are listed among the targeted groups that right wing paramilitaries have identified as a threat to society, alongside trade unionists and other human rights activists.  Since 2005 the organisation Colombia Diversa has published biannual a reports (pioneering in Latin America) on human rights violations against LGBT people in Colombia.  The reports compile data on the systematic violations perpetrated against LGBT people in the country.

The murder of Wanda Fox, 2009

It is in this context that Wanda Fox, a transgender woman human rights activist with whom I worked as part of the programme I was coordinating in Colombia, was killed in 2009. She was killed while doing her work as a human rights activist.  She was working on promoting gender identity rights for transgender women with other transgender women and local authorities, as well as promoting the image of transgender women in the marginalized community where she lived.  She believed that her community (predominantly very low income families, sex workers and the homeless) saw transgender women not only as sex workers but as playing a role to benefit the community. Not only did she believe they would tackle discrimination but that they had the potential for change.  It is possible that this politicisation and desire to change the status quo could not be tolerated in a society that seems still to have a long way to go in assimilating changes in equal opportunities or anti discriminatory laws in Colombia.

You can read Part 2 of this blog here. In it I explore a set of questions on LGBT rights and human rights in Colombia that will form a part of my PhD research.

We find her busy making chapattis with the help of her daughter and nephew. She does not look anything like the woman we met when we visited her six months ago (see One foot in the grave, July 2011). The only thing that has not changed about her is her bright and welcoming smile. She is Elizabeth Wambui Nthumbi, a 32-year-old from Kenya’s Kawangware slum who barely a year ago had one foot in the grave and was wondering why death was not knocking in her door despite the fact that she was ready for it.

Elizabeth, 32, is a living testimony that tuberculosis (TB) can be cured if you properly adhere to treatment. She had been suffering from extra-pulmonary tuberculosis and had twice defaulted on her treatment, which led to the re-occurrence of the disease. She was also an acute alcoholic who drank cheap local brews in the many Kangemi dens. She was jobless at that time and she was at times forced to steal from her boyfriend to sustain her habit. She continued her drinking sprees at the expense of her family and children.

The second time her TB reoccurred, community health workers and TB supporters from Kangemi put their feet down and made sure that she adhered to her treatment religiously.

Elizabeth was delusional and could not walk the second time TB attacked her and was completely bedridden. So the community workers, led by Joyce Wambui, began delivering TB medication to her and even engaged a nurse who would give her the daily injections that are mandatory for a re-treatment case. Her cousin, Grace Waithira, never left her side and, whenever she could, would bring her food and take care of her personal hygiene. Besides this health workers made sure she was enrolled for food supplements that are normally prescribed for people whose immunity is compromised.

At the time, Elizabeth could have been mistaken for someone in the fourth and final stage of HIV as her body was displaying the HIV wasting syndrome but she was and is not living with HIV. Rather she had extra pulmonary TB of the bones, an infection caused when TB bacteria spreads beyond the lungs. Just like pulmonary TB, extra pulmonary TB is usually treated with a combination of four medicines for six months but in the case of a re-treatment the period of taking drugs extends a further two months thus making it to eight months in total. Extra pulmonary TB occurs less commonly than pulmonary TB. According to a 2010 Kenyan ministry of health report, Kenya of all recorded TB cases in the country, just 16% were cases of extra pulmonary TB.

Health workers supervising Elizabeth’s medication ensured that alcohol was not sneaked in to her by siblings and friends. Like all other medication TB drugs and alcohol do not mix. Alcohol abuse not only place individuals at increased risk of acquiring a number of diseases it also places those with these diseases at higher risk of poor outcome and death as it suppresses the immune system. Alcohol can also complicate treatment, since people with drinking problems are less likely to be able to adhere to medication regimes.

According to Evelyn Kibuchi, the KANCO TB Advocacy Manager, people who are addicted to drugs should be well counseled before being initiated to TB treatment in order to understand the affect the drugs they are using will have on the efficacy of their treatment.

“Alcohol should be discouraged when one is on TB treatment because it increases the frequency of urination thus making drugs pass out in the urine before they are absorbed,” she adds.

Echoing this sentiment, Dr Joseph Sitienei, the head of TB Division, said: “Alcohol and TB do not go together and a person should not compromise because the two are can potentially be toxic to the liver.”

The doctor also emphasized how important it is for anyone with TB to adhere to treatment, adding that this is paramount to avoiding further complications and the emergence of multi drug resistance TB.

In TB management, as with the management of other long term illnesses, adherence to treatment is a problem. However, TB treatment presents particular challenges for adherence because the treatment is long and involves taking a number of medications. Side effects are also common and the patient feels better long before treatment has been completed.

TB patients are expected to adhere to 90% of treatment for it to be a success and cure them of TB. Failure not only increases the risk of development of drug resistant strains it also increases the change that TB will spread in the community, which in turn increases the burden of TB in the country.

Kenya currently ranks 13th among the high burden countries. Any further increases in the burden of TB would overstretch the health system, which his already laden with TB patients. The problem will be worse with the multi-drug (MDR) and extensively drug resistance (X-DR) TB cases, which are likely to develop with non-adherence, and are difficult and expensive to treat.

Elizabeth, who finished her treatment on the 10 January 2012, has not touched alcohol since starting her re-treatment and vows never to even go near it again. She thanks God that she is alive and hopes that God will give her the strength to do something better and meaningful in her life. She plans on becoming a TB advocate who will sensitize people about TB and issues related to it.

See Sidi’s KC profile for more stories on Kenya.

For successes, it was the year that, for the second time round, the Kenyan Government allocated over Kshs 900 million towards procurement of ARVs. It was the year that TB control received a new diagnostic technology, the geneXpert, after relying on the microscopy for decades.

Challenges

The year 2011 saw Global Fund Round 11 cancelled due to donor’s laxity to live up to their promises towards the kitty.

It was the year that the Kenyan government was faced with many civil strikes including the doctors’ strike. Among other demands, doctors asked for the meeting of the 15% allocation to health in accordance with the Abuja declaration, an increase in the number of medical staff and improvement in the health infrastructure. 2011 is gone and 2012 opens many windows of opportunities for advocacy to cover the gaping holes left in the past year.
2012 is an election year. Elections provide opportunities to vote in new leaders who will shape the future and direction of the country, it is a make or break moment.

Health advocates should lead in educating the public on the best choice of leaders. We need leaders who are sensitive to health and who will prioritize health in all spheres including budget allocation, policy formulation and advocacy.

Advocacy call

Among other issues, advocates must join the doctors in pushing for the 15% allocation to health. The health of Kenyans must not be compromised. Innocent lives must not continue being lost due to inadequate allocation and other curable and preventable causes like TB.

Kenya continues to grapple with the rising cases of multi-drug resistant TB (MDR-TB). As at the close of the year, there are over 500 cases of MDR-TB. The most unfortunate thing is that the country has been relying on funding from the Global Fund for treatment and management of the drug resistant strain.

With dwindling funds from the Global Fund, the government must take full responsibility of those infected with the strain. It should not only provide free treatment for all those infected, but should also provide sustained social support to all those under treatment.

We are closing the year still calling for the completion of the MDR-TB isolation facility at Kenyatta National Hospital. Started in 2008, the ward still remains incomplete even with an investment of over Ksh 44 million from Global Fund Round 5.

In the coming years, there is need to push for the completion of the ward to admit those infected to reduce chances of infecting others and to demonstrate value for the money received from the Global Fund.

There is need too to continue agitating the government to invest in the roll out of the newest TB diagnostic technology, the genexpert. The technology has been proven to increase case detection by 30%.

The technology is also able to detect resistance to the two key anti-TB drugs. Advocates should agitate for increased funding for TB in the next year to be able to roll out the genexpert to the entire country. South Africa has taken the lead and rolled it out.

We also need more commitment from the government to cover the over USD 5.2 million funding gap for TB control in the next year.

Health advocates from the African region therefore have a huge responsibility in the coming year to ensure more commitment from their National governments.

The era of relying on donor funds should be buried with 2011. African governments should realize the health of their citizens entirely lies with them.

You cannot give birth and leave your neighbour to fend for the baby! This is my parting shot!

Evelyne Kibuchi is the Senior Advocacy Manager for the TB Advocacy Project at KANCO, the Alliance’s Linking Organisation in Kenya.

His visit has highlighted a number of important issues for the HIV response in Ukraine and resulted in a number of significant steps forward.

Dr. Kazatchkine met with Mykola Azarov, the Prime Minister of Ukraine, and they had a discussion which he described as “frank and productive”. Dr. Kazatchkine called on the Ukrainian authorities to increase government funding of HIV programmes, expand opioid substitution therapy, and ensure HIV prevention takes place in prisons. He also acknowledged the success of substitution therapy in Ukraine, calling it the leader in this area in Eastern Europe.

Dr. Kazatchkine meets with Mykola Azarov, the Prime Minister of Ukraine

The Prime Minister has now expressed his personal commitment to scaling-up substitution therapy for people who inject drugs, and confirmed an ambitious new target to enrol 20,000 patients. This commitment to scaling-up should mean a 100% increase in patients over 2012-13. The Prime Minister has now assigned the Minister of Health to take control over increasing the number of patients.

Dr. Kazatchkine has also been key to the Cabinet of Ministers’ approval of a draft law exempting Global Fund support from tax, which will have a significant impact on funding over the next few years.

During the visit Dr. Kazatchkine saw the work of a number of projects supported by Alliance-Ukraine, including a substitution therapy site, the prevention work done by the organisations ‘Eney’ and ‘Vertical’ and the Convictus community centre.  During the meeting with civil society activists Dr. Kazatchkine appreciated cooperation of civil society organizations with Ukrainian state institutions to prevent epidemics in the country and the impact achieved.

Dr. Kazatchkine visits an Alliance Ukraine project

Dr. Kazatchkine acknowledged the work done by Alliance Ukraine, stating that: “The Global Fund partnership with the International HIV/AIDS Alliance in Ukraine greatly contributed to paving the way for a breakthrough in the control of the HIV/AIDS epidemic in the Eastern Europe region. The number of new HIV infections among injecting drug users in Ukraine has stabilized and HIV prevalence among them has been reduced. Harm reduction programs among most-at-risk populations were key in achieving this progress. And while much remains to be done, best practices of prevention programs among most vulnerable populations in Ukraine have become best practices where are shared globally”.

The visit was widely reported by international media outlets including New York Times, Washington Post, Associated Press, the Ukrainian government official web-site and local media, such as  ICTV and others.

We hope that the outcomes of this trip will make a significant impact HIV prevention and on the lives of the 350,000 people estimated to be living with HIV in Ukraine.