AFGHANISTAN: UNAMA raps new report by rights watchdog

Photo: Ahmad/IRIN

Rights watchdogs accuse Taliban insurgents of widespread and systematic attacks on civilian people

KABUL, 22 January 2009 (IRIN) – A spokesman of the UN Assistance Mission in Afghanistan (UNAMA) has dismissed recommendations to the UN and other international actors by the Afghanistan Rights Monitor (ARM), a new Kabul-based rights watchdog, as “superficial and deeply uninformed”.

The ARM report criticises the UN and international aid agencies for their alleged inability to reach and assist needy communities, particularly in insecure areas.

“Whilst millions of people desperately needed humanitarian assistance� the UN and other aid agencies were entrenched in diminishing security zones in Kabul and a few other cities,” ARM said.

ARM called on the UN to maintain its neutrality, reach and assist people in volatile areas, and improve accountability and transparency in the disbursement of international funds.

However, Dan McNorton, a UNAMA spokesman, strongly rejected the criticisms of UN agencies.

“The report has overlooked our regional and provincial presence; the thousands of road missions conducted every year; the immunisation programmes for millions of people; the assistance to millions of returnees; the winter pre-positioning of 34,000 tonnes of food; the disaster relief operations; and major work with communities across the country,” he said, adding that the UN had a country-wide footprint.

Civilian deaths underestimated?

The ARM report also said that in 2008 the number of civilians killed or displaced was higher than reported by the media or international organisations.

“About 3,917 civilians were killed, over 6,800 were wounded and around 120,000 were forced out of their homes in 2008,” said the report, The Plight of Afghan Civilians in 2008.

ARM figures on civilian deaths are higher than those from the Afghan Independent Human Rights Commission (AIHRC) and the UN Assistance Mission in Afghanistan (UNAMA), which also track the impact of conflict on civilians.

Insurgents loyal to the Taliban killed over 2,300 civilians, mostly in indiscriminate and disproportionate armed attacks, and over 1,500 civilians were also killed in counter-insurgency operations by Afghan and international forces, the report said.

The AIHRC puts the number of civilian deaths as a result of armed hostilities in 2008 at around 1,800. “About 1,000 civilians were killed by the Taliban and the rest were killed by Afghan and international forces,” AIHRC spokesman Nader Nadery told IRIN on 21 January.

In September UN Secretary-General Ban Ki-moon reported about 1,300 conflict-related civilian deaths between January and the end of July 2008.

ARM accused all sides of “repeated and systematic” violations of international humanitarian law, the Geneva Conventions and Afghanistan’s laws applicable to war situations.

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RWANDA-UGANDA: Joash Runga, “I sleep with my wife and my girlfriend, that’s all”

Photo: IRIN

“On the road, there are so many dangers”

KATUNA, 7 January 2009 (PlusNews) – Joash Runga, 44, a long-distance trucker, is spending the night at the Rwanda-Uganda border town of Katuna. At the end of a hard day’s drive, he likes nothing better than to kick back in one of the local bars and have a cold beer. He talked to IRIN/PlusNews about the dangers of the road and his belief that having one girlfriend instead of many reduced his chances of contracting HIV.

“I will park the truck, book into a lodge, have a shower then come into the bar for a beer and some food. This is not an easy job. This trip I have jet fuel that I am transporting from Kenya to the DRC [Democratic Republic of the Congo].

“On the road, there are so many dangers; we have lost many brothers through accidents, AIDS and other sicknesses. When I have a break, I like to use it to relax and enjoy life – after all, who knows how long I have?

“My wife is back home in Kenya, and I have a girlfriend here in Katuna whom I see when I make the journey. I have been with her since she was young, maybe about 19 years old; now she is almost 30.

“Although I drink, I am careful not to sleep around, because these towns are full of malayas [commercial sex workers] who can give you AIDS. I sleep with my wife and my girlfriend, that’s all.

“My wife gets tested for HIV when she is pregnant, and because she is negative, I believe I am also negative. I have never been tested for HIV, and my girlfriend, as far as I know, has also never tested.

“I hope she is faithful to me, but you can never know, can you? I treat her well, pay her rent and give her money to spend, so I hope she respects me and does not sleep around.

“I can’t give her up because the alternative is sleeping with prostitutes; I am away from my wife for so long and I have needs. If I get HIV, then that’s my unlucky day.”

kr/ks� source.www.irinnews.org

COLOMBIA: Most vulnerable fall through gaps in health system

Photo: B. Heger/UNHCR

Among the vulnerable groups missing out on HIV prevention and treatment are people like this family displaced by the armed conflict

BOGOTA, 12 January 2009 (PlusNews) – When Martin Alonso Hernandez, an AIDS activist in Bogota, Colombia’s capital, learned that his partner of six years was HIV positive, he waited another five years before getting himself tested for the virus.

“I was out of the social security system,” he explained. “It was very expensive to test otherwise.”

Hernandez’s partner did have health insurance through his job, but was fired when his status was discovered. He lost his health benefits and fell into a deep depression, Hernandez told IRIN/PlusNews, eventually dying in 1999.

By the time Hernandez accessed Colombia’s state-regulated health insurance system and tested for HIV in 2001, he had a number of AIDS-related symptoms and weighed just 32kg. “I was quite sure of the result,” he said. “I just wanted the piece of paper so I could access treatment.”

Colombia introduced its national health insurance system in 1997, with the goal of achieving universal coverage by 2000. But about 14 percent of the population remain uninsured and according to a 2008 grant proposal submitted by the Colombian government to the Global Fund to Fight AIDS, Tuberculosis and Malaria, a disproportionate number come from among the “vulnerable, excluded and impoverished”.

In theory, those not covered by the health insurance system – mostly the very poor and those who lack identification documents – should be able to access health services directly from the state. But Dr Ricardo Luque, an advisor to the Public Health Directorate on sexual and reproductive health issues, noted that Colombia’s decentralised system of government means that each of the country’s 32 regional departments determines its own spending priorities. “There’s competition for resources and they’re spent based on demand,” he said.

The Global Fund proposal confirms that some departments have not prioritised the health needs of their most impoverished populations who are most likely to be uninsured.

Treatment refused

The health insurance system functions by requiring those who are employed to pay into a state-administered fund which is used to pay private health companies to deliver services. An additional, smaller salary deduction helps pay for a social security fund that subsidises health services for the unemployed.

The private health companies are mandated to provide essential services, including all those related to HIV and AIDS treatment, care and prevention. But according to Ricardo Garcia, UNAIDS country coordinator, people living with HIV, especially those covered by the subsidised health system, have often been refused such services and had to resort to the courts to force the health companies to meet their obligations.

Garcia added that while access to ARV treatment had improved in recent years, with 80 percent of people in need of the drugs now getting them according to government figures, the quality and consistency of provision was still patchy. “We’ve had complaints of people receiving the ARVs for three or four months and then, because of a shortage of drugs resulting from bad supply management, they have to interrupt treatment.”

UNAIDS estimates that 170,000 people are living with HIV in Colombia, of which 18,000 are currently accessing treatment according to Luque of the Public Health Directorate. He explained that the figure of 80 percent coverage for ARVs was based on reported cases rather than prevalence estimates – the basis for most countries’ treatment coverage figures. “Only 25,000 people have tested positive and found to be in need of treatment,” Luque said. “Access to treatment is one thing; the gap in diagnosis is another.”

Vulnerable groups miss out on prevention

Critics of Colombia’s health system argue that there is little incentive for the private health companies to promote HIV testing and that regional health authorities have also under spent on either promoting testing or training health personnel to provide it.

The private health companies receive money from the government to do HIV prevention, but they’re not using it to actually do interventions

HIV prevalence among Colombia’s general population has stayed below 1 percent, but the limited data available suggests that concentrated epidemics are occurring among certain high-risk groups such as men who have sex with men (MSM) and sex workers. People displaced by the country’s armed conflict are also thought to be at greater risk of HIV infection.

Currently, Colombia has no national strategy or budget for HIV prevention programmes targeted at these vulnerable groups. Prevention and awareness-raising is left to the private health companies, the local departments and non-governmental organisations.

“The private health companies receive money from the government to do HIV prevention, but they’re not using it to actually do interventions,” said Garcia of UNAIDS.

“Some of the health companies are fulfilling their mandate to do prevention, others not,” conceded Luque. “We do need more resources for a national strategy of prevention, that’s why we’re applying to the Global Fund.”

If the grant proposal is approved, it will be used to target vulnerable groups such as MSM, sex workers, young displaced people, and prisoners. In the meantime, there are no programmes to even distribute free condoms to these groups. Local departments have limited budgets for HIV prevention, some of which they can choose to spend on condoms while the private health companies receive only enough condoms from the health ministry to give to people already living with HIV and those with other sexually transmitted infections.

“It’s insufficient, but it’s a lack of resources,” said Luque. “Most condoms have to be paid for out of people’s pockets.”

Unfortunately, it is the most high risk groups for HIV who are often least likely to be able to afford condoms. Eduardo Pastrana of the local NGO, Amigos Positivos which runs HIV/AIDS awareness programmes aimed at displaced people living on Colombia’s northern coast, said most of the people he works with have very low incomes: “They would rather buy food than condoms.”

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BY JEFF OTIENO

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Prime Minister Raila Odinga has been condemned strongly by Karachuonyo Professionals and Keen Political analysts for humiliated their MP Eng. James Rege.

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During last weekend�s burial of mother to Marie Stopes Country Director Cyprian Awiti in Mawego, the MP in his brief address appealed to the PM to come to the rescue of his constituents who are currently entrenched in hunger and also Marooned in poor dilapidated state of roads for decades.

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When he took the podium, the apparently enraged Prime Minister thundered to the legislator that his approach to problems bedeviling his people were not worth tackling the way Eng. Rege did.

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�We have various ministries in charge of such issues why don�t you approach the ministers� Raila said to the chagrin of Karachuonyo voters.

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Opinion is however divided in the region with one group of thought saying that the PM had a point but another is of the strong view that the PMs onslaught was unjustified, arrogant and manifested a leader who was now living in an ivory tower.

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�Even if he has something personal with Rege why embarrass him in a forum of such magnitude� quipped some former MPs from Luo Nyanza.

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An estimated crowd of about 20 thousand ever seen in the recent passed was in the funeral.

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Raila was accompanied by public service Minister Dalmas Otieno, Lands Minister James Orengo and Immigration Minister Otieno Kajwang�. Also present were Mumias Sugar Managing Director Evans Kidero, Top Civil Servant Sam Wakiaga and a Nairobi based businessman Onyango Koyoo.

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For starters Karachuonyo is one of the poorest constituencies according to the recent poverty index released by the government. Dilapidated state of roads, lack of water and abuse of girl child is the hall of mark of everything.

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END

INDONESIA: Extremely low condom use in hardest hit region

Photo: Obinna Anyadike/IRIN

“It’s not a good choice, but there is no other choice”

JAYAPURA, 20 January 2009 (PlusNews) – At night, Imbi Park, in the Indonesian city of Jayapura, buzzes with a furtive, sleazy energy – this is where, beneath a statue of US World War II hero General Douglas MacArthur, Jayapurians shop for sex.

Knots of sex workers sit and wait among the “Ojek” – the motorbike-taxi drivers – the cheapest way to get around in Indonesia. These street walkers are at the lowest rung of the sex industry in the Melanesian island of Papua, Indonesia’s easternmost province.

Some are extremely young. Marcella, 14, told IRIN/PlusNews she had been working around Imbi Park since she was aged 10. Her father was a soldier posted to the next-door province of West Papua, who remarried after her mother died. Marcella did not get on with her stepmother and ran away from home. She knows of six other children from similarly broken homes selling sex.

Marcella shares a room with three women, all divorced, two of whom have children to support. With only limited education in a region where formal job opportunities are scarce, prostitution is one of their few options.

“It’s not a good choice, but there is no other choice,” said Vanda Kirihio, the director of Yayasan Harapan Ibu, an NGO working with sex workers in Jayapura. “They don’t think about the future, only about their survival.”

Nearly all the sex workers IRIN/PlusNews spoke to at Imbi Park had a packet of condoms. They were aware of HIV, as were most of their clients, they said, but all admitted they had sex without protection if a customer insisted.

“Men have egos, they want to see themselves as strong and macho, so they don’t want to wear condoms,” said Kirihio. “They say they are not afraid, and infection or no infection, they are going to die sometime.”

Condom use is extremely low across the two provinces of Papua and West Papua, collectively known as Tanah Papua (the land of Papua). According to a 2006 behaviour study, just 2.8 percent of people used a condom in their last sexual encounter. When sex was paid for, the figure was slightly higher than 14 percent.

Men have egos, they want to see themselves as strong and macho, so they don’t want to use condoms. They say they are not afraid, and infection or no infection, they are going to die sometime

Tanah Papua has an HIV prevalence rate of 2.4 percent among people aged 15 to 49, the worst in Indonesia. Its hard-to-reach lowland and highland regions limit the delivery of health and education services, but do not inhibit the mobility of those looking for seasonal work or trading, who are familiar with the footpaths that crisscross the heavily forested terrain. This has allowed the virus to penetrate some of the remotest parts of the island.

Multiple sexual partners are common in Tanah Papua, alcohol abuse and sexual violence are high, over one-third of Papuans have never attended school, and male circumcision, unlike in the rest of Indonesia, is rare; the multiplicity of languages and cultures – roughly 250 – complicates advocacy campaigns.

Under the statue of MacArthur, staring out across the sea to the Philippines, Papuan sex workers make a difficult living among local ethnic Melanesians and working-class migrants from the rest of Indonesia, settled here by the government in the 1970s and ’80s in response to a separatist movement opposed to Indonesian control.

Upmarket STIs

At the top end of the sex industry are the karaoke bars and brothels like Asiefa, a 20-minute drive from Jayapura on the shore of Lake Sentani, one of the more picturesque locations for a house of disrepute.

With dyed jet black hair, sadly only drawing attention to his advancing years, high-waist trousers, and ring glinting on pinky finger, Hassan Haryanto looks every inch a brothel manager. He ushered the IRIN/PlusNews reporter into his office to show off a declaration signed by, among others the chief of police, proclaiming the complex was committed to “100 percent condom use”.

“Those who don’t use we can reject,” he said firmly. But the injunction has loopholes, judging by the level of sexually transmitted infections (STIs) treated at the brothel’s clinic.

The clinic, supported by the international NGO, Family Health International (FHI), treated 328 STI cases in October 2008. “From the examination results they have STIs, so if they’re saying they always use condoms with their clients, that’s impossible,” said the clinic’s Dr Hesti Purikasari.

Voluntary HIV testing of 300 women working in the complex in 2006 found 22 were HIV positive. Three of them have since died, but the rest might still be working, said Dr Purikasari. She did not know whether any of them were receiving antiretroviral drugs, as treatment and case management were handled by a hospital in town.

None of the sex workers in Asiefa are Papuan; most of them are from Java, Indonesia’s most populous island, lured by the money that can be made from the soldiers and civil servants that are the typical customers of the establishment.

Three women IRIN/PlusNews spoke to in the afternoon lull before business got going, said the many months they had spent in Asiefa were worth it. Despite the monthly deductions for basic services like water and electricity, a kickback to a man who provided “security”, and a fee to Hassan, they said money could be made, which was sent home to the parents looking after their children.

They insisted they were HIV-aware, but in an impromptu quiz all assumed the virus could be transmitted by kissing, and one believed it could be caught from a toilet seat. And while they maintained condoms were a must with customers, none used them with their boyfriends.

“We love and believe our boyfriends, and they don’t want to use them,” said Dika, curled up on a bed with her two colleagues.

Gus Sutakertya, the head of FHI in Tanah Papua, believes a lot more needs to be done at all levels of society, and without delay. “There are not enough programmes on HIV/AIDS; government and cultural leaders don’t talk about AIDS,” he told IRIN/PlusNews.

“I’m very worried; if we don’t do something now, the future is bleak for Papuans, and Indonesians as a whole.”

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KENYA: Food shortages threaten ARV adherence

Photo: Julius Mwelu/IRIN

Mbula Waema still takes her ARVs every day

MAKUENI, 23 January 2009 (PlusNews) – Makueni District Hospital in eastern Kenya has recorded a significant drop in the weight of several of its HIV-positive patients in the past three months, which nutritionists ascribe to severe food shortages across much of the country.

“We have a large number of patients with a BMI [body mass index, a measure of nutritional status] below the healthy cut-off of 18.5,” Fransiscah Yula, a nutritionist at the hospital, told IRIN/PlusNews.

An estimated 10 million Kenyans are battling a food crisis as a result of crop failure due to poor rains and drought, high food prices, and the effects of post-election violence in early 2008 that disrupted farming activities in Rift Valley Province, the country’s breadbasket.

Yula said she counselled HIV-positive patients to eat a healthy, balanced diet, but the advice was somewhat ironic under the circumstances. “Most of the patients we see tell us they have one meal per day; some take drugs on empty stomachs,” she said.

“It would help if the distribution of relief food was accompanied by the distribution of nutritious complements like tinned meat, vegetables and fruit to help provide these people with a nutritional balance – the food they eat at home is not nutrient-dense at all.”

Poor nutrition weakens the body’s defences against the virus, hastens progress from HIV to AIDS, and makes it difficult to take antiretroviral (ARV) drugs, which can increase appetite. Enough food can help reduce some side effects of ARVs and promote adherence to drug regimens.

The food shortages in Makueni are evidenced by farmland lying fallow, long queues of people patiently waiting for maize-meal donations at a local political party’s headquarters, and river beds so dry that people have to dig a hole to find water.

Health workers say local residents have begun to resort to dangerous practices to put food on the table. “In December we got reports that men were sending their wives out to sleep with other men in exchange for food,” said Albanus Mutiso, the district HIV/AIDS and sexually transmitted infections coordinator for Makueni district. “You know the situation is desperate if people are going to that extent to find food.”

He said rations for HIV-positive people were often insufficient because they were intended for one person but were used to feed entire families. “A mother will almost always feed her children before herself, so she remains undernourished,” he noted. “Recently we saw a pregnant HIV-positive woman who weighed just 35 kilos – unless the government moves in swiftly, people will die.”

Makueni has an HIV prevalence of seven percent in a population of about 290,000, slightly lower than the national prevalence of 7.4 percent; 73 percent of the people live below the poverty line, and just 26 percent earn a wage, leaving the rest to depend mainly on subsistence farming to make a living.

Harder to adhere

“I weigh 48 kilos now – I sometimes go one month without drinking milk and three months without eating meat,” said Mbula Waema, an HIV-positive widow who is caring for a family of ten.

I feel weak, nauseous and dizzy – my stomach burns when I don’t eat well and take the medicine. It’s difficult to farm when I’m this weak, but I have to

Her obvious malnutrition deeply concerns Millicent Ondigo, who coordinates ‘Zingatia Maisha’, a HIV drug-adherence support programme run by the African Medical and Research Foundation (AMREF), which has its headquarters in Nairobi, the Kenyan capital. “I have never seen Mbula like this; I’m very worried about what would happen if she got sick now.”

Despite the fact that Waema eats one meal a day – usually a cup of porridge – she has continued to take her life-prolonging ARV medication because she knows that interrupting her regimen could mean death, but taking the drugs on an empty stomach is hard.

“I feel weak, nauseous and dizzy – my stomach burns when I don’t eat well and take the medicine,” she said. “It’s difficult to farm when I’m this weak, but I have to … When I feel too dizzy I sit under a tree and rest.” Waema farms sisal plants, from which she weaves ropes for sale in the local market, otherwise her family will starve.

Marietta Nzula, 38, is more fortunate; she lives at her family’s homestead near the town of Kathonzweni in Makueni. “My family makes sure I get treatment when I’m sick, and even now, when times are tough, at least I get some of the children’s uji [porridge] so I can have something in my stomach to take my medication,” she said. “My brother’s wife reminds me to take my drugs every morning – they are very good to me.”

Nzula says she wishes she was able to do her part to keep the family afloat; she feels that especially in hard times such as these, she is a burden her family could do without.

Support networks under pressure

Although the traditional community support systems still exist, they are stretched to breaking point said Onesmus Mutungi, who heads two local HIV support groups.

“I eat two or three meals a day, which makes me better off than most, so I share with those who have less,” he told IRIN/PlusNews. “But now, even in my home, things are tight, and sharing my food means that I eat less, so I feel weak when I take my medication.”

Mutungi said it was getting harder to persuade support group members to stay on their medication when they did not have enough food. “None of them have stopped taking their ARVs, but many are tempted to do so,” he said.

“We can’t hold additional support meetings because transport costs are too high – many people aren’t even coming to the meetings because they can’t afford the matatu [minibus-taxi] fare.”

AMREF’s Ondigo said Zingatia Maisha was working with local NGOs and the government to try to provide the HIV support groups with food supplements so they would be less likely to interrupt their treatment regimens.

President Mwai Kibaki has declared Kenya’s food crisis a national disaster and the government has appealed for 37 billion Kenya Shillings (US$400 million) to meet the needs of the food-insecure.

kr/kn/he
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