VCT counselor from Marie Stopes Kenya talking to clinic patients about HIV/AIDS testing and family planning options. (Amanda Cary/PHR)

This is the third post in the Health Action AIDS Campaign’s March weekly blog series focused on integration of family planning and HIV/AIDS services.  

In our last blog post, we explored how service integration is critical for protecting and promoting the health of women and turning the tide on the feminization of the AIDS epidemic. However, there are other, profound benefits to integrating HIV/AIDS and family planning services. For the right to health to be realized, health systems must be be available, accessible, acceptable and of good quality. Service integration is one strategy that can be employed to build health systems responsive to this framework. Even with limited resources such as infrastructure, health workers, supplies and financing, service integration can have a deep impact on human rights.

Take, for example, the success at the small health dispensary in Kenya’s Eastern Province. On a bright, hot Tuesday morning, an outreach team from Marie Stopes Kenya (MSK) has come to provide a full range of family planning services. MSK is known across the country, and when the outreach team arrives, women come from the surrounding areas to speak with health workers, learn and make decisions about their family planning options. When rural women and men are actively seeking information and counseling, MSK takes the opportunity to provide them with the option of testing for HIV.

Access to health services in Kenya is a major challenge, as it is for many other countries. Service integration is one way to eliminate simple barriers, such as time-consuming and costly travel. 80% of the Kenyan population lives in rural areas. Integrated services help to reach those who are the most vulnerable, leveling the playing field when it comes to accessing quality health services. According to Cyprian Awiti, Country Director of MSK,

The end product is the poor woman, who cannot travel a long time, or several times, to come to the facility. [With integrated services] people can access services at one visit, at one place and under one roof.

There are, however, other barriers to health services access. Structural inequalities and stigma prevent people from seeking out health services. It may be hard to imagine methods of overcoming these barriers, but when we see service integration in action, possibilities become clearer.

As the day wears on at the health dispensary, the lines seem to slowly dwindle. Women who have received information, counseling and family planning services spread out across the lawn in front of the facility, or say their goodbyes and walk out of the dispensary gate. The nurse with the MSK outreach team who is administering VCT stands in the doorway of the private counseling room and asks if there are any others who would wish to be tested. The women sit quietly, momentarily pausing in their low conversation. With no reply, the nurse turns around and begins to pack up his supplies.

And then a small woman quietly slips in and shuts the door.

This is the reality in Kenya, as in many other countries. For rural women, for poor women, for women who are sick it is not easy to find the time, or the money, or the means to get to a health facility. It is not easy to overcome the many barriers to get tested for HIV and AIDS, including the fear of stigma and discrimination. And when they do—when that door opens—we must work to make sure that the health system takes advantage of the opportunity, and lets just one more slip in.

Integrating services is an approach that protects and promotes women’s rights and fosters the development of a rights-based health system.

Read here to find out how integration promotes the right to health by contributing to better availability, accessibility, acceptability and quality of health services.

Additional Resources

• Halting the Feminization of AIDS: Lessons from Kenya (slideshow)

A new documentary on Zimbabwe's cholera epidemic quotes a former UN humanitarian official as saying:

The United Nations deliberately downplayed the crisis to avoid confrontation with President Mugabe and his ZANU-PF regime.

The Geneva-based International Council of Voluntary Agencies goes further and calls for the UN to sack the current UN humanitarian coordinator in Zimbabwe, Augostino Zacharias, because he's too closely tied to Mugabe and won't speak out against him. This blame-and-shame approach does make enticing news copy, but unfortunately does not address the real issue.

That the UN engages in quiet diplomacy with the host government should come as no surprise. It was this type of closed-door dialogue that ultimately persuaded Mugabe to allow humanitarian organizations to resume operations after a four-month mandatory hiatus in 2008.

So what are the real issues? Let's start with Mugabe's 2005 nationalization of municipal water services for political gain and profit. After the government took control, it abrogated its most fundamental responsibility toward its citizenry by

• dumping contaminated waste into the water reservoir
• failing to maintain the reticulated water system
• neglecting to procure enough aluminum sulfate for water treatment
• shutting off water to selected communities
• abandoning municipal waste collection
• ignoring sewerage repairs

It's Mugabe's malfeasance that directly caused the eight-month-old and ongoing cholera epidemic. So if there's anyone to blame, it's the octagenarian with all the power.

Resources

• PHR's Zimbabwe report, videos and advocacy opportunities

Without Peter's work, there would be no PEPFAR.

This was how Ambassador Mark Dybul (PDF), former U.S. Global AIDS Coordinator, introduced Uganda's Peter Mugyenyi, MD, before remarks at Georgetown University yesterday.

Amb. Dybul called Dr. Mugyenyi a true hero, whose successful pioneering efforts to bring antiretroviral treatment to sub-Saharan Africa had been key to the Bush Administration's decision to go forward with the massive AIDS relief initiative in 2003.

Dr. Mugyenyi, who leads Uganda's Joint Clinical Research Centre, is an advisor to PHR and is in DC this week for a series of meetings and speaking engagements to raise awareness about funding shortages that are severely limiting access to HIV treatments in Uganda.

In his own remarks, Dr. Mugyenyi acknowledged Amb. Duybal's work leading (PEPFAR), stating that history would record his tremendous contribution to the African continent.

Dr. Mugyenyi also highlighted the tremendous HIV burden among the young women of Africa and urged the integration of HIV prevention and care everywhere that they seek care and social services, including family planning clinics. In response to a question about the still high rates of transmission from women to their babies, he noted that most programs aimed at preventing these transmissions are located in towns and urban areas, far away from rural women who need access to the programs.

Dr. Peter Mugyenyi, Executive Director of the Joint Clinical Research Centre in Uganda and PHR advisor, speaks with Congressman Payne from New Jersey

Dr. Mugyenyi's remarks came in the middle of another day of meetings on Capitol Hill, including a meeting with Representative Donald Payne (D-NJ), who serves as Chair of the Subcommittee on Africa and Global Health for the Committee on Foreign Affairs. Dr. Mugyenyi explained the challenges that Uganda and other countries in sub-Saharan Africa are facing due to the budget uncertainty surrounding global AIDS funding. Payne, who was unaware of the challenges on the ground, committed to further investigating the issue after hearing Dr. Mugyenyi's concerns.Today and tomorrow it's back to Capitol Hill and then to the White House for a meeting with representatives of the Obama Administration.

It is a very busy schedule and in the midst of all of the running around, it is sometimes easy to forget all that Dr. Mugyenyi has seen and accomplished over the past two decades. Whenever we ask if he wants to take a break or slow down, he reminds us of the emergency his patients are facing on the ground. He is willing to go wherever he needs and meet with whomever he can to carry that message.

Dr. Peter Mugyenyi told a full house at the Center for Strategic and International Studies that funding constraints are forcing health clinics in Uganda to stop enrolling any new patients in antiretroviral treatment.

 

Peter Mugyenyi, MD, at the Center for Strategic and International Studies

At his first event in Washington, the pioneering Ugandan AIDS doctor Peter Mugyenyi painted a harrowing picture of what lies ahead in Uganda without increased support from PEPFAR.

After urging people to get tested and enter care, we now have to tell them there is no treatment available when they need it. We created hope and now we are returning to the days when one member of a family can get treatment and the others cannot.It is a recipe for chaos as patients start to share doses or skip treatment altogether. I fear that we will soon start to see more drug-resistant strains of HIV and rising death rates.

Though Congress authorized significant increases when it reauthorized PEPFAR last year, those increases did not make it into budget this year. Funding stayed flat. Without new funds, clinics are now being forced to cap their patients.

Later, Dr. Mugyenyi told us of his euphoria when President Bush signed the new PEPFAR legislation; Dr. Mugyenyi was actually at the White House for the bill signing last year. Now that no additional funds are flowing, that euphoria has faded.

Dr. Mugyenyi spoke of the extreme sense of urgency among those, like his own Joint Clinical Research Centre, which built large, treatment programs with high success rates. Those clinics are now being forced to turn away patients. "We cannot return to the days when funerals defined our existence. This situation is untenable."

Next it's on to Capitol Hill, where Dr. Mugyenyi will carry his urgent message to key lawmakers who are about to begin considering next year's budget.Watch for more updates later this week.

Cholera is a preventable disease, yet there’s an epidemic raging in Zimbabwe. At least 4,000 are dead, and some 90,000 infected. PHR's Richard Sollom tells Foreign Correspondent: “Such outbreaks happen in wartime. The last cholera epidemic on this scale was in Rwanda after the genocide.”

Watch or Listen Now »

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Source: ABC News Foreign Correspondent

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One of the pioneers and leaders of AIDS treatment in Africa, Dr. Peter Mugyenyi, is on Capitol Hill this week to share stories about the impact of the President's Emergency Plan for AIDS Relief (PEPFAR) in Uganda and throughout sub-Saharan Africa.

PHR and its members played a key role in the passage of an expanded and improved PEPFAR last year, and we're hosting Dr. Mugyenyi in DC as part of ongoing efforts to raise awareness about the need for more funding.

Dr. Mugyenyi leads one of the largest PEPFAR-funded treatment programs in Africa and calls the program "the greatest mission of compassion in recent history." While in DC, Dr. Mugyenyi will talk with lawmakers and opinion leaders about the urgent need to keep up the momentum with increased resources and support.

His first event will be a speech today at a major foreign policy think tank, the Center for Strategic and International Studies. On Wednesday he speaks at Georgetown University, where he'll be introduced by Ambassador Mark Dybul (PDF), former director of the Office of the Global AIDS Coordinator (OGAC).

Throughout the week, he'll meet with key Congressional offices about PEPFAR funding and operations. He's also slated to participate in a Congressional briefing on strengthening the health care work force in Africa–a key issue in making sure that HIV treatment programs can successful in the years ahead.

It's going to be a very busy week, but in conversations with Dr. Mugyenyi last week, we know he is greatly concerned about treatment programs' reaching capacity and is ready to dive right in to everything we have planned. He's used to it. Back in 2003, Dr. Mugyenyi was summoned to Washington on a day's notice to help the White House draft the framework for PEPFAR. After the work was over, he was seated next to the First Lady for the announcement of the new program during the State of the Union address.

From his past experience, Dr. Mugyenyi knows a good deal about how Washington works, but he offers a compelling perspective that few others can match. Check back for updates on Tuesday and Thursday and we'll let you know what issues come up in his talks and meetings. When the week's over, Dr. Mugyenyi will share his thoughts about his experience and what he hopes he's accomplished.

If you'd like to read more about Dr. Mugyenyi's work in Uganda, check out his new book, Genocide by Denial: How Profiteering from HIV/AIDS Killed Millions. It's reviewed here.

Mark Danner, an attorney and journalist, revealed in yesterday's New York Review of Books never-before-seen sections of a confidential International Committee of the Red Cross (ICRC) report detailing the treatment of detainees held at the CIA "black site" interrogation facilities. Among the many disturbing facts in Danner's article, the ICRC report contains critical new information about health professionals, described by the detainees interviewed for the report as "doctors," closely monitoring the torture of individuals in CIA custody.

Abu Zubaydah, allegedly the first detainee held at the black sites, states the following:

Cold water from a bottle that had been kept in a fridge was then poured onto the cloth by one of the guards so that I could not breathe…. The cloth was then removed and the bed was put into a vertical position. The whole process was then repeated during about one hour. Injuries to my ankles and wrists also occurred during the water-boarding as I struggled in the panic of not being able to breath. Female interrogators were also present…and a doctor was always present, standing out of sight behind the head of [the] bed, but I saw him when he came to fix a clip to my finger which was connected to a machine. I think it was to measure my pulse and oxygen content in my blood. So they could take me to [the] breaking point.

Health professional supervision of torture is one of the gravest affronts to medical ethics and is illegal under both domestic and international anti-torture law. Danner's disclosure of the ICRC report on detainee treatment in CIA custody is shocking but not suprising. For years evidence has been mounting through news articles, government investigations, and even the statements of Bush Administration officials that health professionals were centrally complicit in the breaking of bodies and minds at the black sites, Abu Ghraib, Guantanamo and elsewhere.

Now, as pressure mounts on Capitol Hill for a commission of inquiry into detainee abuses, the work of PHR's Campaign Against Torture is more relevant and critical than ever. PHR is leading the charge to ensure that violations of medical ethics, such as those documented by Danner, are fully investigated and perpetrators are held to account.

Scott Allen, MD, is Medical Advisor for Physicians for Human Rights

A mother and daughter at Emma's clinic (Amanda Cary/PHR)

This is the second post in the Health Action AIDS Campaign’s March weekly blog series highlighting the need to integrate family planning and HIV/AIDS services.

In our last blog post, we talked about the idea of a one-stop shop where people can come to one health facility and receive multiple services during the same visit. In many places around the world, including Kenya, this is much more than a matter of convenience. Accessing services in a one stop shop could mean the difference receiving or not receiving life-saving health interventions. In the context of the AIDS epidemic, particularly in sub-Saharan Africa, service integration has never been more important.

Emma is a nurse who works at a small health centre in the heart of Nairobi, Kenya. Emma pioneered the integration of HIV counseling and testing into family planning services for women who visited her facility, matching up the services she offered with her own, holistic view of the clients who came.

Emma’s capacity to provide VCT with family planning services for her clients demonstrates how integration can protect women in the fight against AIDS. By offering both family planning services and counseling and testing for HIV to every client, Emma contributes to efforts to decrease the number of unintended or high risk pregnancies; improve access to vitally important HIV prevention and educational programs; allow for early detection of HIV and referral to care and treatment; and, if required, ease entry to prevention of mother-to-child transmission (PMTCT) services for HIV+ mothers.

This is why Mary comes to Emma’s health center instead of her own, closer health facility. When Mary arrives here with her infant daughter Beatrice, she can get a full package of care. Mary has her reproductive health needs met, and she can feel confident that her other needs, such as HIV counseling and testing, will also be met.

Anne, another client at Emma’s health center, feels the same way. Anne tells other women to come to the health center because after getting HIV counseling and testing “they can be free, just as I am free.” Both Mary and Anne, through regular visits for family planning, have been counseled and receive regular HIV tests.

Now, they both want to bring their husbands to be tested at the facility. This type of comprehensive care has ripple effects. By skipping a small stone across the pond, the waves have eventually reached the farthest shores, bringing men and women together to ensure family health.

An integrated response that addresses both HIV infection risk and reproductive health for women is a practical, efficient and effective way to improve women’s access to health services. For example, by integrating family planning and HIV/AIDS VCT services, women have more opportunities to learn about ways to protect themselves from HIV infection and unintended pregnancies.

Emma’s clients, through regular visits for family planning, have been counseled and receive regular HIV tests. Women have even started to bring their husbands to be tested at the facility as well. Creating a one-stop shop doesn’t just make accessing health care easier, it can also make services better and the prevention stronger and can begin to turn the tide on the feminization of AIDS.

Check out our resource library for more information on how integrated services fights AIDS (PDF) by:

• Contributing to the prevention of new infections
• Increasing access to health services
• Easing the strain on the health systems by streamlining resources
• Decreasing stigma and discrimination and increasing uptake of counseling and testing for women

Australian Foreign Minister Stephen Smith just announced that his government will provide Zimbabwe with another $6.5 million in aid to help the so-called unity government restore urgent access to safe water, adequate sanitation and health services.

What's so controversial? He's betting that historically corrupt ZANU-PF government officials won't again abscond with these aid dollars the way they have in the past. (Remember last November when reserve bank governor Gideon Gono stole $7.3 million from the Global Fund ?)

At least Australia has done its homework. In May 2005, the Mugabe regime nationalized MDC-run municipal water services for political gain and profit. Within three years under ZANU-PF control, the national water authority had collapsed due to malfeasance, which directly led to the current cholera outbreak. 4,000 dead and 90,000 infected – and all from an entirely preventable and easily treatable disease. If there's any good news with the new unity government, it's that water services are now back under municipal control. And that's why Australia is donating half of the new aid to municipal authorities for the provision of water treatment chemicals.

And what of Zimbabwe's other major donors? Both the US government and UK government have placed their bets on ZANU-PF not changing its stripes any time soon. The United States and United Kingdom have both stated their respective intents to wait until the unity government has made tangible progress toward improving the human rights situation before they renew substantive development aid to Zimbabwe.

Unfortunately, this modest increase in humanitarian aid from the benevolent Aussies will not address the underlying causes of the current outbreaks in disease and collapse of the health system. For that Zimbabwe needs billions in development aid that will only pour in once the Americans and Brits are satisfied.

2008-09 humanitarian aid to Zimbabwe (USD):

• United States        $220 million
• United Kingdom    $65 million
• European Union    $45 million
• Australia              $24 million

President Obama’s recent executive order mandating the closure of the detention center at Guantánamo Bay mandated a review of the conditions of confinement there. That review has concluded that treatment of detainees is humane and in keeping with the Geneva Conventions standard. Despite the findings by Navy Admiral Patrick M. Walsh (PDF), the Department of Defense (DoD) policies in force at Gitmo still violate medical ethics by allowing military psychologists and psychiatrists to participate in interrogations as Behavioral Science Consultants (BSCs).

The use of health professionals to advise on conditions of confinement designed to enhance the interrogation process is unethical. The report by Admiral Walsh highlights the fact that BSCs do not provide clinical health care. But this distinction is beside the point, since it is unethical for health professionals to have any direct participation in interrogation.

In addition, the DoD’s inhumane policy and practice of force-feeding detainees engaged in hunger strikes remain in place. This policy requires medical professionals to abandon the ethical guidelines promulgated by the World Medical Association and adopted by the American Medical Association, which prohibit force-feeding a competent and informed patient. This policy, which continues to harm the physical and mental health of detainees and compromise medical ethics, highlights the need for a comprehensive investigation into the role of medical professionals in detainee abuse and the DoD’s exploitation of medical professionals in such abuse. The report joins a series of DoD internal reviews that self-servingly justify existing policy and lack the independence and perspective necessary to restore the integrity of military medical ethics.

Physicians for Human Rights continues to support an independent, nonpartisan commission to undertake such an investigation and continues to encourage the DoD to bring its policies in line with established principles of medical ethics.