Designing and delivering HIV prevention services for African MSM in the UK is a multifaceted challenge, particularly for migrant populations, because they are embroiled in a network of systems aiming at achieving different and often conflicting purposes. Further, little is known about this vulnerable population notoriously hard to reach.  The situation calls for a system approach to improve the delivery of HIV prevention services with the ultimate goal of reducing the number of new HIV infections in this group.

However legal entry into Britain is not easy and straightforward. When possible, obtaining a work permit, even for low-qualified positions, is challenging. Many migrants are aware of these difficulties and this is where “traffickers” (often family members of relatives, though organised trafficking can’t be ignored or denied) comes in as facilitators. They may act coercively or on the promise of a job in exchange of a sum of money. Once in-country, opportunities are limited because of employment and immigration laws. Sex work often remains the only prospect to make a living.

Perception of the situation of women in the sex industry differs according to different worldviews. For some support organisations, women are victims. For other, choosing to be a sex worker is an expression of free will and in many cases empowering, allowing women to support themselves and their family and sometimes escape difficult situation at home. It certainly isn’t neither/or but many academic research concludes that “women as victims” is a far too simplistic conception.

The legislator under the pressure of some support organisations and the public opinion, often manipulated by the media, has adopted an approach that penalises women’s clients whilst also criminalising the worker.

The police has admitted the limitations of the current legal framework but still carries on with interventions (from which they financially benefit) such as “Pentameter”, which led to few arrests of real traffickers and have limited, if any impact on migration and trafficking. Meanwhile, women are put in a situation where they have to admit being trafficked or sex-worker with the respective consequence of being sent back home or to jail.

The current legal approach to human trafficking and sexual exploitation of women ignores human agency and the complexity of women’s situation and is therefore inefficient. A proper framework for intervention would need systematic and systemic understanding of those that the law allegedly wants to protect.

2010 will be a year to remember for the field of HIV prevention. After decades of interventions with limited results (with the exception of circumcision and the prevention of mother to child HIV transmission), two clinical studies are raising the hope that the HIV epidemic can be tamed.

In July, the CAPRISA team (based in South Africa) reported that a vaginal gel containing the anti HIV drug tenofovir could reduce the risk of HIV infection by 39%. This was the first proof of concept that a microbicide could potentially reduce the risk of HIV infection whilst offering women an HIV prevention tool that they could control.

In November of the same year, the iPrEx study conducted on a population at high-risk of infection showed that taking the anti HIV Drug Truvada reduced the risk of contracting the virus by an average of 44 percent.

Both studies are hailed as a milestone and landmark in the history of HIV prevention and expectations are high that HIV prevention will finally mean more than the ABC of ‘Abstinence, condom and faithfulness’. But despite the hope, neither approach will immediately translate into marketable products as there are a number of questions that needs answering before microbicide and PrEP are available to the public.

Can a pill a day prevent HIV?

The iPrEx study was a large clinical trial, sponsored by the US-National Institutes of Health (NIH) with co-funding from the Bill and Melinda Gates Foundation and drugs donated by Gilead Sciences. Its purpose was to test if taking two anti-HIV drugs on a daily basis could help prevent HIV infection amongst HIV negative people at high risk. The approach called Pre-Exposure Prophylaxis (PrEP) is based on the concept that drugs are taken to prevent infection rather than treat it. This is similar to taking anti-malarial tablets when travelling in areas where the disease is endemic. The study was conducted in the USA, South Africa, Ecuador, Peru, Brazil and Thailand and involved 2,499 sexually active Men who have Sex with Men (MSM). The drug tested, Truvada (a cocktail of two drugs), is commonly used to treat people infected with HIV.

The study, published in the New England Journal of Medicine, showed 44% less HIV infections in the group that was given the drug compared to the group that received a placebo. These results represent a significant development in the field of HIV prevention. However, they cannot easily be translated to other groups ‘at risk’ or to the general population without further studies.

Whilst the PrEP approach raises hope for the prevention of HIV infection, it also presents a number of challenges for scientist, advocates, and crucially for public health systems. Many of these challenges, such as adherence (people taking their pill as prescribed), side effects, potential resistance (existing drugs becoming ineffective against the HIV), and cost effectiveness are best left for discussion by scientists and clinicians as they will require many more clinical studies.

In the meantime, the PrEP approach raises more pressing ethical and social concerns for public health.

PrEP can only be used by people who know they are not infected with HIV. Hence, those who want to access PrEP need to take an HIV test, not once, but at regular intervals. How often is not known yet, but every 3 or 6 months seems reasonable. Getting people to test once is not always easy for a number of reasons. Getting people to test regularly will be even more difficult (and costly), but not impossible if testing becomes part of routine health checks (a controversial issue in itself).

However, regular testing will lead to the identification of existing infections that in turn will require immediate treatment (in the US and the UK about half of those testing positive for HIV need to start treatment at the time of the diagnosis). As PrEP is rolled out, more people in need of ARV will be identified, and inevitably there will be a competition for resources between the sick and the healthy.

Providing ARV treatment to those who need it is already putting a huge strain on the health system of many countries in both the developing and developed world. Considering that only a third of those in need of treatment are currently receiving it under the new WHO guideline, prioritizing a potential PrEP roll out would be an inevitable necessity.

Prioritising PrEP?

Could PrEP potentially be a useful option in some circumstances for some people, particularly for those populations called most at risk populations (MARPs)?

MARP is a broad acronym including Men who have Sex with Men (MSM), Sex workers (males and female, commercial or not), injecting drug Users (IDUs), and any population that has more risks of being infected by HIV than the general population. However, the concept of population ‘at risk’ or ‘vulnerable’ is a controversial and contested one. Not all MSM are ‘at-risk’, a large number of them actually use condoms regularly and consistently. Studies have even shown that gay men were often infected by their partner with whom they were in a stable relationship. Likewise, condom use amongst commercial sex workers can be high (for example it is over 90% in brothel-based sex workers in Cambodia), with many patrons using condoms with a sex worker but not with their regular sex partner. Hence it is not ‘Populations’ that need to be identified and reached, but individuals within these populations and this will be a serious problem if PrEP is prioritized.

Besides, the general population cannot be ignored, particularly in Sub Saharan Africa, home of 68% of all people living with HIV. The UNAIDS 2010 AIDS epidemic update observed that data from urban Zambia “suggest that 60% of the people newly infected through heterosexual transmission are infected within marriage or cohabitation , compared with more than half in Swaziland, 35%–62% in Lesotho and an estimated 44% in Kenya”. . A similar proportion of new infections occur among steady, long-term heterosexual partners all over sub-Saharan Africa suggesting that heterosexual and in particular young girls aged 19-24 could be the primary target for PrEP if it has to be prioritised to the most at risk.

In the current context where for every 2 people put on treatment, 5 become infected, suggesting putting millions of healthy people on treatment, some of them potentially at an early age, when so many who are in need of it can’t access it, is surely asking for trouble.

Taking a pill a day to avoid taking a pill a day?

Should PrEP be proposed to at-risk individuals as an HIV prevention option alongside other non medical approaches? There are still a number of clinical studies to conduct before PrEP is made available to the public. But in some cases PrEP could be detrimental to its intended recipients. For sex workers, the introduction of PrEP could mean replacing a highly effective HIV prevention method (condom) by a less effective one. PrEP is also expensive and will not protect against other STIs. It does not have contraceptive property and could put sex workers back under the control of customers who will be able to enforce sex without condom. For IDU, it would be replacing a non-medical approach that we know works: needles-exchange programmes. And when the acceptability of treatment for those sick with HIV is an issue, will healthy individuals even if at risk be willing to take a pill regularly?

Remarkably, most of those who are at higher risk of being infected with HIV are also those that governments are less prepared or likely to invest resources in. Health care for junkies, prostitutes and gay men rarely score high on the political agenda, and electoral pledges centred on the health of these groups wouldn’t attract many of the electorate.

It would be dangerous to ignore or disregard the impact PrEP could have on a national health system with the risk of introducing two tier/two waiting rooms health care. There will be those who can afford PrEP whilst others will still be on waiting list to receive anti-HIV medication (many already are, even in a developed country). The emergence of a black market in anti-retroviral drugs (ARV) and the spectre of counterfeits flooding it, should not be disregarded, particularly in the developing world where the most vulnerable could easily fell prey to ‘ARV drug dealers’.

To date, having failed to achieve the sustained change in behaviour required to reduce the number of new HIV infections at the population level, making little progress in getting rid of discriminative laws that stigmatise and cast out those most vulnerable (76 countries have state-sponsored homophobic laws), and facing the challenge of achieving universal access to HIV treatment by 2015 (MDG 6) should we now embark on this controversial approach to HIV Prevention?

The iPrEx Team deserves praise for the quality of their work and should be commended for providing the first proof that daily oral use of an anti-HIV drug can reduce the risk of HIV infection This is an important breakthrough for HIV prevention. It has been a long road pockmarked with ambushes and difficulties. But now, Pandora’s Box is open at a time when his holiness Benedict XVI is opening even ever so slightly the  door to condom use, at a time when the World Health Report 2010 confirms that one billion people cannot afford healthcare and at a time when the latest UNAIDS AIDS 2010 epidemic update shows that the rate of new HIV infection is stabilising at around 2.6 million new infections a year.

No matter how one looks at it, the iPrEx study has opened the door to the medicalisation of sex, and in the current state of research and prevention, that amounts to taking a pill a day to avoid having to take a pill a day.

The views expressed in this article are the author’s and do not necessarily reflect the views of his employer or of the organisations he works for.

Originally published by openDemocracy on 25 November 2010

This is the narrative I wrote when nominated for the 2006 UN Online Volunteer of the Year Award. I did not get the award but another volunteer from Nabuur was one of the 10 volunteers to receive the award.
In 2005 I decided to take a break from the hectic London life and to move to Thailand for a year. I arrived in Bangkok in February 2006 and after a couple of months holidaying around, I decided to devote some of my free time to voluntary work.

I have often been involved in voluntary work. I believe volunteering is a civic duty which origin goes far back in time when small communities were helping each other in difficult times or hostile surroundings. With nation building, social progress and technological developments, helping each other has become less of a necessity in people’s mind; society is here to provide. But everyday life shows us that this is not the case and that we still need to help each other on a voluntary basis.

Whilst in London I was volunteering for The Food Chain, a registered charity whose mission is to improve the health and well being of London’s population living with HIV by alleviating hunger and malnutrition. I started as a navigator, helping a driver delivering meal on Sunday. I quickly became involved in the management of the organisation. Between 2004 and 2006 I chaired the Fundraising Subcommittee contributing to the organisation of fundraising events and managing other volunteers. Previously I volunteered as a tutor helping young French student in difficulty at school and was also a supporter of Survival International.

In Thailand, because English is not the first language, online volunteering was the best option for me. I can do it from home and have no problem contributing everyday if needed. After much research on the internet, I found the United Nations Online Volunteering website and my attention was caught by a Nabuur advert seeking online community facilitators. I checked the organisation website and decided it was something I could contribute to and joined in April 2006.

Nabuur is the first online organisation I volunteer with. Its mission is to give communities in developing countries access to their global Neighbours via the Internet and through these neighbours to the huge reservoir of resources (knowledge, solutions, energy, creativity) that is available elsewhere. I choose this organisation for several reasons.

Nabuur is an online community and Nabuur’s assignments involve communicating with other volunteers. Our activities as volunteers are not performed in isolation (such as other volunteering opportunities of translation or researching information). This fundamental feature of the organisation allows for a lot of interactivity between volunteers and makes volunteering very attractive and motivating.

Nabuur offers a direct contact between the people who help and those who are helped. There is no red tape and working for Nabuur is working directly with the people in need. There is an ongoing dialogue between the online community and the real community.

Nabuur works from bottom to top. It is the real community that comes with a problem that the online volunteers will try to solve, not the volunteers that tell the community what it needs. In all project, the community leads.

Nabuur offers work opportunities related to all kind of issues such as community development (agriculture, education, income generation…), health (Water sanitation, HIV/AIDS, nutrition…) and social issues (Gender, Youth…). The volunteers join a particular “village” because they feel close to its location or because they have a strong feeling for the issue at stake. As a volunteer I am both facilitator in one village and members of other villages, increasing the possibility for me to expand the field of my knowledge.

Nabuur presents the community it helps with professional solutions not just quick fixes. It is important to provide communities with real solutions otherwise they would be disappointed by the organisation and the volunteers too would be frustrated. If the project is successful, it will translate into a working solution that can be implemented by the local community. The volunteer get the satisfaction to see their project taking shape with regular update, stories and pictures from the community and witness the direct results of their work and involvement.

After joining the organization, I chose the assignment of creating an awareness and training campaign on safe use of drinking water for a community in Uganda. This project offers me the possibility to use my professional skills of coordinator in the role of online facilitator and it also contribute to my personal development as I knew little about water sanitation and Uganda before that.

As a Nabuur volunteer I contribute in four different areas of the Nabuur organization: administrating my village, contributing to other villages, supporting and training other facilitators, and contributing to the development of the organization.

Initially I joined Nabuur as a village facilitator which is a role similar to that of project manager. In this position I am at the junction between the online volunteers and the representative of a local community in Uganda which has asked Nabuur for help. My role is to ensure that the project is on track, that tasks are assigned to volunteers and that regular progresses are made. I also act as a filter between the online virtual community and the local representative of the community. It is important to protect the local representative from to many questions as (s)he and the communities already have enough on their plate. As a facilitator I am also a forum moderator, seeing that the online discussions are focused on solving the problem, and a web host, welcoming new volunteer, introducing them to each other and to the issue and developing a “homy feeling”. I also report regularly on the progresses of the project to the online volunteer and to the local representative.

Soon after I joined two other online villages dealing with a similar issue. This facilitates and enhances the cooperation between villages tackling the same problems and avoid redundancy of work. It also offers an opportunity to share our resources easily.

We quickly found out that the problem of our community in Uganda was going beyond awareness of safe use of drinking water but that the community was lacking of clean water and did not have the skills or knowledge to produce it. But after only a few months, the 25 volunteers of my villages have achieved quite a lot. We have identifying several methods of water sanitation, we have surveyed the skills and assets of the community, and we have surveyed the various sources of water available as well as the general quality of the water. We are now in the process of selecting the best and most relevant water sanitation methods for the community and we also started work on the awareness campaign.

Besides working for real communities in need, I also contribute to the online community by providing other facilitators with management and coordination skills and help training them. As a professional coordinator, I share my experience with other facilitators who may come from very different way of life. Recently I ran a technical tutorial on producing newsletters, an essential tool for the communication between the facilitator and its volunteers but also to share the achievements of the project with the online community and the local representative. I will soon run another tutorial on using a Wiki tool for collaborative writing and project management. I also provided other facilitators with sample letters for inviting new volunteers and welcoming new members and I have designed an online survey for improving the contribution of the volunteers.

Finally, I am contributing to the future development of the Nabuur concept and of the Nabuur project. As members we are welcome to contribute to the organisation of Nabuur and I have made several suggestions and proposals to improve the management of the volunteers and the administration of the organisation.

Because I am involved in several aspects of Nabuur, I spend a fair amount of time volunteering online. Most days, I spend two hour online but it does happen that I spend a full day working online. It is a well invested time as I have met some very interesting people who I hope will become long time friends.

I believe that overall I am a driving force for Nabuur. By sharing my knowledge and helping with the training of other facilitators I believe I contribute to improve the performance of the organisations. I am not directly involved in solving all the problems of the 100 and more communities supported by Nabuur but I provide tools, methods, and strategies that will help achieving results. I also hope to be a motivating force for those facilitators who have sometimes to deal with low level of contribution in their village. Most importantly I would like to believe that I am contributing to the creation of a community spirit between all the Nabuur volunteers. Such spirit is fundamental for the success of the various projects currently in progress.

In return, Nabuur helped me realize that the Internet can be a helpful and powerful tool for solving people’s problem. Except for its role as a knowledge base and information source, I used to think that the Internet was a big waste of time and space where people were endlessly arguing on meaningless issue in futile forum. But the Nabuur concept demonstrates that it is possible to organise constructive actions when people of good will are brought together. I am lucky to be in a position where I can give a lot of time to online volunteering but in return, I am learning a lot, discovering new opportunities and broadening my horizon. It probably sounds a bit cliché, but despite living in a global village, bad or poor communication is still the main obstacle to peace and prosperity. Volunteering online gave me a little bit more hope that one day we will be able to really and sincerely help each another, even if we come from different backgrounds and have very different stories because all these differences are invisible online and therefore are not an obstacle to working together.

In conclusion, to someone thinking about volunteering online I would say that it is a very rewarding experience but that (s)he must be prepared to be committed. Unlike conventional volunteering, the Internet does put a bigger virtual distance between the people who need help and those who can provide it. But this does not mean that the needs of far away people are not as important as those of your next door neighbours. Organizations working online are particularly dependent on their volunteers and on their commitment. So join an organization, get involved at your level, give a reasonable amount of your time, it will pay back.

Note: I ended my collaboration with Nabuur in 2007. I remain a strong believer in the Nabuur concept as defined by Siegfried Woldhek, but believe that, as an organisation, Nabuur has not chosen a path that cannot deliver suitable and relevant assistance to communities where it is needed and in a timely fashion.

Both messages were embodied in Bill Gates’s keynote speech:

“We need to put the power to prevent HIV in the hands of women. This is true whether the woman is a faithful married mother of small children or a sex worker trying to scrape out a living in a slum. No matter where she lives or what she does, a woman should never need her partner’s permission to save her own life.”

An Eldis report notes that “a decade ago women seemed to be on the periphery of the epidemic, today they are at the epicentre”. Of the 38.6 million people living with HIV at the end of 2005, nearly half of them, 17.3 million, were women (Unaids, 2006 Report on the Global Aids Epidemic). And of the 16,000 new infections that occur every day, up to sixty percent are now amongst women (ILO).

Empowering women was a central policy goal of both the International Conference on Population and Development (ICPD) in Cairo in 1994 and the Fourth World Conference on Women (FWCW) in Beijing in 1995. Women’s empowerment was emphasised in agreements at the World Summit for Children in 1990, the World Conference on Human Rights in 1993, the World Summit for Social Development in 1995, the World Food Summit in 1996, Habitat II in 1996, and the fifth-year review of ICPD implementation (ICPD+5) in 1999.

That, ten years later, women’s empowerment is back on the agenda in the fight against HIV/Aids suggests that it has somehow failed to fulfil its objectives. One explanation for the relative achievements of empowerment strategies might be the failure to recognise that empowering women without disempowering men is like giving a moneybox to the poor in the hope that they will get rich.

Obesity is no longer exclusive to the developed world

The reality is a very different. Obesity and its associated diseases – diabetes, hypertension and kidney diseases – respect neither wealth nor class and strike instead into the heart of every society where there is easy access to convenience food, low physical activity and ubiquitous advertisements for sugar-fat-salt-rich food.

Heart disease, stroke, cancer and other chronic diseases associated with poor diet and low exercise have now made serious inroads into the lives of people in poor and middle-income nations. In total, these accounted for 80% (28 million) of the cases of chronic illness in 2005, according to the World Health Organisation (WHO), which fears that a further 388 million people will die from such illnesses over the next ten years.

Photo by Malias

Across South East Asia, cases of chronic disease are also high, accounting for 54% of all deaths during 2005. The situation in Thailand is particularly serious, says the WHO, which estimates that the number of obese 5-to-12 year olds increased from 12.2% to 15.6% in just two years. Obesity is generally associated with older age groups, but has yet to permeate into poorer areas where the price of convenience food associated with the epidemic is prohibitive.

China, too, has an emerging epidemic with one or two pockets of high incidence. Overall, obesity levels range from under 5% to almost 20% in some areas, according to regional surveys conducted during 2003. Most concerning, however, is high prevalence among the young. In Wuhan Province 8.9% of 10-12 year-olds were classified as obese by the study. Some areas, such as Beijing, also suggest that there is a gender perspective to the epidemic. In the capital more than 10% of 10-12 year old boys were obese – more than three times the rate for girls in the same study.

Responsibilities are divided

The existence of a genetic predisposition to obesity would provide a straight-forward explanation for the world’s growing stock of rotund individuals, but the precise causes of obesity are multiple.

Changing diets have clearly contributed to the development of the pandemic, driven by the move towards food processing that relies heavily on high injections of sugar and salt. Recent research by The Thai Health Promotion Foundation, for example, found that more than 90% of its sample of 700 pre-packed foods to contain excessive levels of sugar, fat and salt – a cocktail that can lead to diabetes and hypertension as well as obesity.

Choice, of course, enables informed individuals to avoid (or moderate their consumption of) foods that are known to have damaging health effects, but bad labeling, the study suggests, does not help in the decision-making process. Just one third of the sample in Thailand, for example, managed to provide adequate nutritional information on their packaging or list ingredients. Where available, say researchers, labels also tended to use small fonts and present information in a way that is difficult to understand. At least part of the blame, therefore, lies with the food industry itself.

Photo by Malingering

Children are most at risk

For now, young Thais have refrained from overindulgence in burgers and chips on account of taste. But tastes are changing and so is the food industry. Pizza Hut (aka Pizza Company in Thailand) has already rewritten its menu to include a Tum Yum Kung (spicy prawn soup) variety. Western convenience food, which contains 3 or 4 times more fat, sugar and salt than healthier local Thai snacks, is now thought to pose one of the greatest dangers to a country of “snackers.”

Catering to oriental taste in order to boost market share is only one dimension of the corporate weaponry. Intensive marketing activity now mostly targets children and changing cultural values now mean that a visit to see Ronald McDonald has become a symbol of growing affluence and status. The price of a Big Mac in Bangkok (the equivalent of USD 1.5 or Baht 60) may cover the food costs of one meal for a family of four, but younger Thais are prepared to splash out on junk-food if it means impressing friends – especially girlfriends. Similar trends are noted throughout many of China’s larger central and eastern metropolises. Shopping malls in Cambodia also house fashionable western eateries that only the privileged can afford.

Obesity ought not to be a problem affecting children, but cases as young as 3 are not exceptional. And for those that then become obese adults the risks (particularly in developing countries) have alarming potential – an increasing susceptibility to illness coupled with reliance on fragile health care systems that may not be able to offer or afford treatment. In China, there is only a very basic social safety net and hospitals are run like profit-making concerns: Only those that can afford treatment receive treatment

Child obesity is expected to soar worldwide according to the International journal of Pediatric obesity, and could start to erode health gains in many countries. Both morbidity and cases of premature death are expected to rise over the next decade costing the economies of China, India and Russian billion of dollars according to the WHO. China alone will lose $558 billion over the next 10 years of its national income due to heart disease, stroke and diabetes. And other important Asian economies – Thailand, Malaysia, Indonesia and others – are fast reaching western levels of development and consumption.

Photo by Robad0b

Political will and increased public awareness will decide whether obesity is here to stay or go, according to Prof. Philip James, the chair of the London-based International Obesity Task Force (IOTF).

“It is noticeable,” he says, “that the public and Ministers readily accept the problem of obesity in adults…..then often and very conveniently blame the individual for their predicament rather than questioning whether their obesity reflects the impact of deliberate policy and industrial developments over the last few decades.”

While the political elite ponder their next move a coalition of five international non-governmental organisations (NGOs) – known as the Global Prevention Alliance – has already pledged new action worldwide to combat obesity-driven chronic diseases. Obesity, the alliance says, ranks alongside HIV/AIDS in terms of importance and impact.

“Cutting death rates alone will not be enough,” according to Prof. James, adding that “No health system or economy can afford the cost of spiraling cases of chronic disease. The only way to address this is to recognize the need to revolutionise our approach to delivering healthier diets and reducing consumption of the foods high in fats, sugar and salt.”

Obesity is a new challenge for countries like China, which suffered a major famine in 1961, suffered routine food shortages until the mid-70s and received food aid from the World Food Programme until 2005. But a solution is not out of reach. As many as 80% of the cases of premature heart disease, stroke and type-2 diabetes could be prevented by a healthy diet according to the WHO. Missing only is the political will to legislate, educate and take on the powerful Food Industry.

© Roger Tatoud.

Published online by Chinadialogue