Mary Hansen '10 on the HIV/AIDS Crisis in Africa

Questioning Authority recently caught up with Mary Hansen '10 to ask her about the HIV/AIDS crisis in Africa, the subject of her senior thesis. She is now a member of the Peace Corps and will leave her home in Denver today, February 24, to travel to Malawi, where she will serve as a community health advisor for HIV/AIDS prevention.

QA: How did you become interested in the HIV/AIDS crisis in Africa?

MH: In 2007 I received an international internship from the McCulloch Center for Global Initiatives, which allowed me to work at a hospital and pharmaceutical company in Arusha, Tanzania, for two months. After this experience I began studying African history, politics, and Swahili. During the spring of my junior year, I studied abroad at the University of Dar es Salaam and conducted seven months of ethnographic research while working with three different HIV/AIDS organizations. I wrote my senior thesis about the ineffectiveness of current HIV/AIDS prevention programs with which I had worked. Now I will be returning to Sub-Saharan Africa with the Peace Corps as a health extension worker.

QA: Why has the AIDS crisis in Africa been in the news in recent months? Has it reached a new stage?

MH: I asked myself this same question when I received three emails from friends and professors telling me about the New York Times article that appeared last May. I do not believe the AIDS epidemic has reached a new stage. I think it actually has very little to do with the AIDS crisis itself and everything to do with the economic crisis. The economic crisis has led many Americans and the government to reevaluate their values and, sadly to say, foreign aid seems to be at the bottom of their priorities. Thinking of foreign aid as an economic investment, Sub-Saharan African and the HIV/AIDS epidemic is not a good return on investment.

QA: To what extent is AIDS/HIV an economic problem, a scientific/medical problem, and/or a cultural/sociological problem?

MH: All of these factors have compounded to contribute to and perpetuate the HIV epidemic in Sub-Saharan Africa. However I believe that the root cause is economic. Poverty of individuals, communities, and governments has a far-reaching impact that seems obvious, yet is rarely fully considered and hardly ever addressed by funders, NGOs, or government policy makers. The two most funded HIV prevention programs are Voluntary Counseling and Testing (VCT) and Abstinence, Be Faithful, and Condom Use (ABC). The main idea behind both of these interventions is education. VCT assumes that once individuals are tested they will change their behavior to protect themselves and their partners. ABC programs assume that once an individual knows how to protect himself from becoming infected, he will initiate the proper behavior changes.

This ideology seems completely rational and easy to facilitate. Yet, over the last ten years, even with billions of dollars from America earmarked for HIV interventions in Africa, there has not been a significant decrease in HIV infection. I believe this is because knowledge is not necessarily power. There are larger structural barriers to individual behavior change than a lack of information. Everyone I met in Tanzania and Uganda understood the risk of HIV infection and had heard of the ABCs of protection, and yet very few East Africans I know use condoms to protect themselves from HIV. These people are not ignorant. They are making informed, rational decisions for the environment in which they live.

QA: What has the U.S. government policy been, and what is it now?

MH: George W. Bush’s administration started the United States President’s Emergency Fund for AIDS Relief (PEPFAR), which changed international HIV interventions in a number of important ways. First, PEPFAR was fundamental in bringing attention and funds to HIV interventions. The sheer magnitude of the funds--$15 billion over five years--was unheard of for HIV/AIDS intervention. Bush could be commended for his funding commitment, but the billions of dollars could have been spent more effectively and have actually had numerous negative consequences. The funds were earmarked to specific activities, and many conditions were imposed on their use. For example, Bush reinstated the gag rule cutting off funding for all organizations offering abortions or abortion counseling; PEPFAR stipulated that at least 66 percent of prevention funds be used for abstinence-only programs, and that more than 55 percent of funds be spent on treatment. PEPFAR funds completely sidestepped local governments, and a majority of the funds were distributed to American international NGOs. These types of stipulations greatly limited and dictated the type of HIV/AIDS interventions that could be pursued, regardless of their effectiveness or consequences.

Obama overturned the gag rule within days of taking office, and made other changes in PEPFAR, including a commitment to collaboration and community partnerships with local governments. On paper many of the new ideologies sound great, but it will be interesting to see how they are implemented and if they make any actual improvements. In my experience there is often a large disconnect and lag time between the implementation and creation of policy. The Obama administration policy did not change many of the key provisions of the original PEPFAR, such as continuing to require at least half of all prevention funds for abstinence-only programs. I believe such changes to be fundamental in creating constructive and effective prevention programs.

QA: How is our policy flawed and what should we be doing instead?

MH: My biggest criticism of our policy is the dominance of biomedical interventions. Biomedical models are inherently individualistic and decontexualised, and dominate public health and infectious disease policies and programs. These types of programs remove the spread of HIV from the local context and essentially deny the social, political, and economical inequalities that shape individual behavior. Behavioral change programs that focus on education as a means of achieving behavior change, I believe, will always fail in the current economic situation of East Africa. This is not to say that education programs are not necessary, but they are not sufficient on their own to create behavior change. Biomedical intervention on its own will never be able to curb the HIV epidemic because there will be no examination of the larger structural barriers that fueled and continue to perpetuate the HIV epidemic.

I think we need to move beyond looking at the HIV/AIDS epidemic as a separate issue from the concurrent social, political, and economic issues. Instead of having narrow programs addressing one issue at a time, there need to be larger, more comprehensive interventions. Instead of preaching monogamy to women who have multiple concurrent partners as a survival strategy to feed their children, programs could provide schooling, vocational training, and job placement. Yet even for these interventions to work, there needs to be an expansion of markets in Sub-Saharan Africa to support this type of growth. Policy needs to work towards addressing these larger issues in order to promote effective HIV/AIDS prevention.