Having attended my first AIDS conference in Mexico City in 2008, and now due to give a poster presentation at AIDS 2010, I initially took a sophomoric ‘been there, done that’ approach to the proceedings. However, I quickly discover that I still had much to learn and gain from the dynamic projects and people in attendance.

Under the theme Rights Here, Right now, the conference stressed in no uncertain terms, that any effective response to the AIDS epidemic must include the promotion of human rights at all levels. Working in the community sector, a rights-based approach to HIV prevention has always been a method in which I strongly believe, and I am appreciative of the international exposure it was now getting in this important setting.

Many new developments resonated with me, the first, being a rather old idea now viewed from a difference perspective. Called Treatment as Prevention, it is one of five pillars in a strategic platform known as Treatment 2.0. Essentially, Treatment as Prevention is calling for universal access of HIV treatment for all people who need it, which is nothing new. Previously, however, it had been argued from an ethical and human rights standpoint, whereas today mathematical modelling from researchers has shown that universal access to HIV treatment has a public health benefit, too, it lowers the global viral load, which in turn, should lower the number of new HIV infections globally by up to a third.

G8 Leaders Fund AIDS Now! Broken Promises Kill

Treatment as Prevention could therefore make a massive difference in regions heavily impacted by AIDS like southern Africa, for example, where the epidemic is generalised. Given its high promise to improve dramatically the lives of people infected and affected by HIV, global AIDS agencies have signed up to Treatment 2.0 as the way forward.

The second development to catch my attention was the successful results of the CAPRISA research trial in South Africa. This trial studied the effectiveness of a gel designed to reduce the risk of HIV infection during sex, and known as a microbicide. The study included close to 900 women with highly optimistic results. Risk of HIV infection was reduced by 39% overall, and by 54% for those women who used the gel consistently. That’s good news!

I was particularly happy to hear the results of this trial, as I had been involved in microbicide advocacy for a few years; and this success was a clear breakthrough from a research and a social perspective. From a research standpoint, this was one of the first success stories of a biomedical intervention in the HIV field. The integration of biomedical and social interventions is the future of HIV prevention, in my opinion, and this promising result will spur greater confidence in microbicide research for both vaginal and anal sex and bring us one-step closer to having microbicides in the public domain as an effective HIV prevention option.

From a social point of view, microbicides as an alternative HIV prevention tool will contribute to the empowerment of women, by introducing a product that can be a female controlled alternative to the condom, and thereby provide a viable prevention option to lower the risk of HIV infection for those who are not able to negotiate condom use.

UNIAIDS: Outlook Report 2010

Recognition of the importance of protecting and promoting human rights for vulnerable populations was, for me, perhaps the most important theme raised in the conference. With respects to HIV, some of the most vulnerable groups include men who have sex with men (MSM), injecting drug users (IDU), sex workers, and transgender people. These groups are disproportionately impacted by HIV, and yet, more often than not, their access to treatment and prevention services is hindered and when they do receive these services, they are often of poor quality. This is the result of being socially maligned and excluded, stigmatised and discriminated against by individuals and institutions, and is further compounded by the fact that they are often criminalised by governments around the world. The human rights of vulnerable populations must be protected and promoted so that they too are supported and empowered to make well-informed choices regarding their health and lives.

I currently coordinate a peer education programme in the United Kingdom on sexual health and social well-being for young black African, Caribbean and British MSM, and so the issue of human rights is one close to my heart. I understand the damaging effect that stigma, discrimination and a lack of human rights can have on the sexual health of black MSM. Whether it’s institutionalised stigma from groups within their communities, or the structural discrimination from certain governments in Africa and the Caribbean where homosexuality is criminalised, for example, having supportive and affirming environments in the lives of these men makes all the difference in their sexual health and social well-being.

Protecting the human rights of vulnerable populations not only makes ethical sense, but in terms of HIV prevention, it also makes practical sense. Huge amounts of research have consistently shown the significant effect that needle exchange programmes have on driving down HIV transmission rates amongst injecting drug users. Yet, many governments continue to refuse to fund needle exchange programmes, whilst criminalising illicit drug use amongst IDUs. Police forces continue to harass and abuse this already vulnerable group, driving their drug use further-and-further underground, preventing them from accessing potentially life-saving drug treatment programmes, whilst causing the HIV rates of many Eastern European and Central Asian countries to sky-rocket over the past 10 years.

I was not the only one among the delegates to applaud as conference officials at AIDS 2010 introduced a resolution entitled The Vienna Declaration. It called for health policies on illicit drug use to be based on scientific evidence, not ideology, and I could not agree more. But when Dr. Chris Beyrer, the esteemed professor from the Centre for Public Health and Human Rights at Johns Hopkins University in USA, took to the stage to give his fascinating presentation, my mind was fixed. Using mathematical modelling, Dr. Beyrer showed that scaling up prevention services to 100% for MSM, and 60% for IDU, in low and middle-income countries would reduce the rates of new HIV infections within these populations, and in the general population, too. This study could be used to boost the human rights argument for providing health services to all vulnerable groups regardless of whether some governments criminalise homosexuality, or injecting drug use.

Demonstrators at the 18th International AIDS Conference in Vienna (July 2010).

The energy and passion of participants raising the profile of issues of concern to them, through demonstrations, marches and protest, was never very far away from my consciousness. The largest such demonstration, The Human Rights and HIV/AIDS March and Rally, brought together thousands of delegates and protesters in Vienna’s city centre to demand that human rights be an integral part of the AIDS response “Now More Than Ever.” Internationally renowned singer and UNAIDS goodwill ambassador, Annie Lennox, delivered a riveting speech calling world leaders to task, demanding that they stand by their commitments to global AIDS funding and human rights, before giving thousands of spectators a free, live musical performance.

Both inside and outside the main conference hall, protesters from a hodgepodge of groups led the Fund Global AIDS demonstration, intent on ensuring that world leaders kept their promises about AIDS funding and support for universal access to HIV treatment, since many countries had already rescinded on agreements made previously, citing current global economic difficulties as a factor in their inability to offer the level of financial support they had promised. The powerful rallying cry “Broken Promises Kill, No Retreat, Fund AIDS” was a constant echo throughout the six-day conference.

As Prime Minister Cameron and his coalition government settle into their new roles, I implore them to keep the UK’s commitment to domestic and global AIDS funding. I would particularly like to see more money for research into new prevention technologies, vaginal and rectal microbicides, as well as vaccines. I would also encourage more support for prevention work, treatment for vulnerable populations, and the protection and promotion of their human rights. Each time we fail to protect the weak and vulnerable in our society, we lose a part of our own humanity.

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1. Brothers on the Down Low
2. Who will protect Kenyan men from themselves?
3. ConDem Government Urged to Invest in Construction

A puzzled look consumed his face as he wondered why I stopped him from reliving his plight. After all, he was just beginning to share the juicy details from which his troubles stemmed. He was about to unwittingly smoke the crack pipe of doom lit by his historical legacy. I, in effect, disappointed him by metaphorically telling him to “step away from the pipe” as I succinctly informed him he was asking the wrong question. Unbeknownst to him at that moment, the session was transforming into a profound turning point in his life.

I repeated my response so that I knew he heard me correctly the first time. You’re asking the wrong question, I emphasized. I compassionately began to explain.

“You find what you’re looking for,” I said. “If you ask about dysfunction, you get answers about dysfunction – and nothing more. You don’t necessarily receive solutions, emancipation, or relief. Instead, you get reasons, data, and sources.” I paused so he could consider the point I was illustrating. In fact, his line of questioning, although well meaning, simply pulled him further down the rabbit hole of the dysfunctional malaise of which he desired to be free.

As he listened, I revealed a potent principle about life. “Nature abhors a vacuum,” I said. “This means that space will be filled from a catalyst. If you spill a glass of water, it will ‘fill the space’ of the area equal to the volume of its content. This is true when it comes to a question as well,” I continued. “A question creates a vacuum – a space for an answer. Depending on the nature of the question – it’s ‘volume’ – you’ll get an ‘answer’ – a response – that equals the nature of the question.”

“If you are asking, ‘Why do I have money troubles?’ or ‘Why are relationships so difficult for me?’ or ‘Why can’t I lose the weight,’ you invite a response commensurate with the nature of the question. In other words, when you ask why ‘bad’ things are happening, you inevitably get a response – an answer – that corresponds and is commensurate with the toxic nature of the question.”

“For example, the question, ‘Why am I always strapped for money?’ invites answers that explain the circumstances indicating why you are strapped for money. Get it? If you ask, ‘Why are relationships difficult?’ You get circumstances that illustrate why relationships are difficult – not because they inherently or fundamentally are difficult, but because that was the nature of your question.”

By this point in the discourse, I had my client’s rapt attention. It began to dawn on him that he has been experiencing the consequences of the questions he had been asking. As his mindset became sufficiently clear on the erroneous nature of the questions he’d been posing to himself – and vis-à-vis to the Universe – we began to reset his point of reference. Resetting would position him, in effect, to receive “responses” – circumstances – that would fill his life with his desires rather than his perceived limitations.

We began to ask the right questions! To help him constructively construct appropriate questions, I referred him to a Zen koan (a saying) prominently displayed on my desk. It says, “Show me the face you had before your parents were born.”

My puzzled charge re-read the sentence three times before he could complete it because the statement was non-linear and seemingly nonsensical. “Show me the face you had before your parents were born.” Essentially, this koan means that in the true scheme of things, you were already an idea before you were biologically conceived! As you became “an idea whose time had come,” Intention coordinated and synchronized all the influences and circumstances necessary to produce your birth.

Appreciating the subtle ramifications of this reality is to strip yourself of the gross mis-perception that who you are began – and ends – with the influence of your biology or upbringing which is what causes you to ask the wrong questions! In realizing, rather, that you are the offspring of a grand Intention expressing more of its magnificence in the form of you, you then have the point of reference for asking the appropriate – right – questions so that your life becomes filled with the content of the responses to those right questions.

My client and I then began practicing how to ask the right questions. We started with, “Show me why I’m here.” This question invites the Universe (Cosmos, Life, God – whatever resonates with you in terms of reference) to begin filling your experience with fruitful, bountiful expressions. More precisely, this question creates a vacuum reflective of its nature such that you get “responses” (experiences) indicating all the grand and glorious potentials of your real, purposeful nature. Then we asked (and these questions can, indeed, be rhetorical), “What ways am I to reveal abundance?” and “How am I to express courage?”

At this point, the client and I were on a roll. He chimed in with, “How am I suppose to successfully express my creativity?!” “Absolutely!” I responded and then added, “How am I to reveal love in my life?” The session continued very productively from there.

During this session, the client profoundly shifted into a context of his identity that was not incumbent on his personal history, but rather on his true identity. To be clear, “personal” discovery can indeed serve a purpose. The question becomes, however, “What purpose do you want to satisfy?” Are you interested in collecting evidence of malfeasance for the (pseudo) satisfaction of merely knowing? Or, are you interested in the shortest, most authentic route to true freedom and emancipation from trials that bind you to limiting circumstances?

The choice is yours. For my money, I’m betting that you desire freedom and emancipation. As you begin to ask the right questions, feeding your potential rather than your perceived limitations, then the Universe – always responding in kind – will begin to deliver content that reflects the questions you are posing.

Oh, incidentally, that client, an actor, called me a mere few hours after that session to inform me that he just received a call after a long period of career inactivity for one of the biggest auditions of his career. The Universe indeed responds to whatever is being asked!

Show me the face you had before your parents were born.

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This disturbing pattern is reflected in the UK with a recent survey indicating that almost one in six adults have a neurotic disorder (such as depression, anxiety, phobias, etc.), while one in 250 has suffered from a psychotic illness (such as schizophrenia or delusional disorder).

The figures above will make worrying reading for most people. There is something uniquely disquieting about the notion of mental illness, which means that regardless of greater public awareness around the issue, popular discourse is still steeped in the language of the asylum. To admit to having mental health problems is to confess to being mad, to being a mentalist.

It is the social stigma attached to mental illness that often discourages people from seeking appropriate help early on. As such, it is vital that mental health services do all they can to inspire public confidence – to convince them that they will be treated fairly and can expect some kind of positive outcome from putting their minds in the hands of the professionals.

However, according to a report published by the Sainsbury Centre for Mental Health, the relationship between black communities and mental health services is characterised by fear and mistrust, with black people reluctant to seek help from a service they see as punitive and racist. This is all the more alarming when you consider the large body of research literature suggesting that race has a powerful influence on risk of mental illness, with studies consistently reporting a higher incidence of schizophrenia and psychotic illnesses in black than white populations in the UK.

Dr Kwame McKenzie of London’s Institute of Psychiatry sees racism as aetiologically important in the development of mental illness. Writing in a January 2003 edition of the British Medical Journal, he identified racial discrimination as a major public health issue. Indeed, a 2002 survey of Caribbean, African and Asian people found that those who had experienced a racist attack in the preceding year were nearly 3 times more likely to be suffering from depression and 5 times more likely to be suffering from psychosis.

Both race and ethnicity are associated with differential levels of social deprivation, leading some to interpret reported differences in rates of mental disorder as the result of socio-economic inequality rather than racism per se. However, in a post-Macpherson world, where the notion of ‘institutional racism’ is finally acknowledged, it is surely obvious that racism and social inequality are indivisible – they feed off one another creating a web of social exclusion that seems to put black people at greater risk of mental illness than their white counterparts.

Or does it? The vast majority of research into race, ethnicity and mental illness has been based on contact with treatment services, reflecting behaviour when ill, rather than illness itself. In 2000, the Survey of Ethnic Minority Psychiatric Illness Rates (EMPIRIC) – a community-based epidemiological study – reported a much smaller inequality than traditionally found. Though the rate of psychosis in the black Caribbean group in the study was twice that of the white group, the difference was not statistically significant. They concluded: “Since the concepts of ‘Western psychiatry’ are common to all research approaches, this suggests that even if Black Caribbean people are more vulnerable to psychotic illness, they are also treated differently in the UK.”

It is this differential treatment of black patients by mental health services that is of concern to the staff at the Sainsbury Centre for Mental Health, and that informs their 2002 publication Breaking the Circles of Fear. David Robertson, one of the authors of the report, says: “It has to do with the way in which risk is assessed, and the way in which black people with mental health problems are judged…people aren’t able to get the care they require before they go into crisis.”

Risk assessment is now an integral part of the job of psychiatrists and psychologists, a job made harder by hysterical media coverage of the rare – but dreadful – instances when mentally ill patients commit serious violent crimes. It is under such conditions that mental health professionals are prone to overestimate the dangerousness of black patients, perhaps influenced by the stereotype of the ‘Big, Black and Dangerous’ individual who they fear might walk out of the hospital or doctor’s surgery and commit a serious – and high profile – offence. Studies comparing black and white patients have shown that black patients are perceived to be more dangerous, despite lower ratings of psychopathology.

This misperception of the risk of violence posed by black people is thought to underlie the over- representation of African Caribbeans in psychiatric services. Moreover, it seems to underpin the large body of research indicating an experience of mental health services for black people in the UK that is frequently negative, inadequate and overwhelmingly coercive.

There is evidence stretching back over 3 decades showing that black Britons are more likely to be admitted to hospital with a first diagnosis of schizophrenia, more likely to be subject to police involvement in hospital admission, more likely to be detained in locked psychiatric wards, and their treatment more likely to be over-reliant on high doses of psychotropic medication and physical measures such as electro-convulsive therapy (ECT). Conversely, they are less likely to receive psychotherapy, psychological treatments and counselling.

Jacqui Sealy is an advocacy worker with the Mental Health Shop and works with African and Caribbean people in the Leicester area: “Men generally, and possibly African Caribbean men in particular, may not come for help early for fear of being stigmatised. More importantly, many may already have experienced poor services in the past.”

Thus, black people suffering from mental health problems find themselves in a classic Catch-22 situation. They are reluctant to approach psychiatric services for fear that they will be labelled, medicated and incarcerated – some may feel compelled to ‘self-medicate’ using illegal drugs or alcohol. Inevitably, their condition deteriorates and they ultimately reach crisis point, provoking the very coercive responses from services that they fear. This is the downward spiral – the Circle of Fear – that David Robertson and his colleagues at the Sainsbury Centre have been trying to break.

While a lack of funding and of effective communication are perennial problems, attempts are being made to address the system’s failings on a local and national level. In June 1997, five leading UK mental health charities combined to issue a joint policy statement on race and mental health, while the government has published a National Service Framework for Mental Health pledging to ensure a ‘culturally appropriate’ service .

However, Robertson feels that this is not the correct approach: “It is not about people’s culture – it is about inequality. Culture debates give rise to stereotyping, and a very static way of thinking about culture. There is too much emphasis on cultural differences rather than cultural similarities – you don’t need cultural awareness to treat someone with dignity and respect.”

The Sainsbury Centre report surveyed over 200 black service users, carers, professionals and police, and made 15 key recommendations aimed at reintegrating black service users, promoting mental health in the black community, supporting users and carers, and enhancing the infrastructure of the black community generally, to enable it to become more self-supportive.

“We have set up an implementation team focusing on 6 areas – leadership, workforce development, capacity building, supporting service users, families and carers, research and evaluation.” The research and evaluation aspects are particularly important, says Robertson. “We don’t want this to be another report that just sits on the shelf – we are looking to go out into the community and follow up on the work we have done.”

By encouraging closer links between mental health services and the black community through gateway agencies and black voluntary organisations, the team behind Breaking The Circles Of Fear have been trying to open lines of communication that have long been disrupted by mistrust and misunderstanding. And by involving service users and carers in their work, they have allowed them to feel that they are more than mere bystanders, waiting for the powers that be to decide their fate.

For many people such developments will come too late – people who have already found themselves at the sharp end of a mental health system that, despite good intentions, has often ended up mirroring the stereotypes, and compounding the pressures, which impact on the mental health of black Britons in wider society every day. Our public bodies have a responsibility to lead the way, to be brave enough to ask themselves if they are failing their clients and, if so, why? While the black community work to address their own fears and assumptions about mental illness and psychiatric services, it is high time for our mental health practitioners to indulge in a little self-reflection.

For further details, contact the Sainsbury Centre for Mental Health.

1. Are Black Women Destined to be Single?
2. Brothers on the Down Low
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“Hey Matt.”
“Morning Andrew,” I said. How was your weekend?”
“Ah, all I can say is God bless German women.”
“I beg your pardon?”
“God bless German sluts,” he said. “I spent Friday night with three friends and a German woman, and after four bottles of vodka; we all took turns doing her. Last night, it was just her and me, and another bottle of vodka. Let your imagine do the rest.”

No thanks. I hardly know Andrew. What I do know is that he is cocky. He works on safer sex programmes. He is a Catholic, and he loves to talk about sex. I’m no prude, but I do believe that discretion is a virtue. If a guy back home were to tell me the same story as Andrew, I would suggest that he was masking personal insecurity or trying to prove something. With Andrew, I would say that it is roughly the same issue: he wants to prove himself to me, a relative stranger and a foreigner, with examples of his prowess with women. He is perpetuating the myth of the hyper-masculine African man, playing to stereotypes.

But Andrew’s story – reeking of ego as it does – underlines a concerning factor in the fight against AIDS in Kenya (all the more ironic considering Andrew’s daily job on HIV prevention): that culturally sanctioned hyper-masculinity contributes to sexual violence, which is being recognized as a key nexus between sexual and reproductive health and HIV/AIDS.

The feminization of the HIV/AIDS epidemic in Africa – where young women are four times more likely to be infected than men – is being driven by violence against women and girls. Sexual violence is now one of the most reported crimes in Kenya. Reporting figures would likely be higher were it not for the hidden perpetrators: husbands who rape their wives (marital rape is not a criminal offence in Kenya). The problem becomes bleaker with the emerging figure that more than ten per cent of pregnant women are HIV positive, and seven per cent of men and women in monogamous unions (marriage or cohabitation) in Kenya are also HIV positive. With these figures in mind, it is hard not to conclude that the key issue – gaining increasing attention from development agencies and donors alike – is the vulnerability of women and girls.

Importantly, this vulnerability needs to be understood in the context of hyper-masculinity: not only in terms of what men are socialised to expect from women, but also in terms of what Kenya’s patriarchal society expects of men in terms of sexual behaviour, demonstration of prowess and power and how high levels of sexual activity is an indicator of manliness. It is unhelpful to demonise men in this analysis, but it is vital to understand the culture that consents to or even endorses treating women as objects. One may even find reasons for the aggressive assertion of manliness: the uncertainties of modernisation that are leading to more women seeking gainful employment, accompanied by decreasing material dependency on men; straw-clutching to reinforce “traditional” ways of life, many of which are fading with modern city lifestyles and rural-urban migration; or simply for fun, because they can.

Of course, homophobia plays a role too—men proving that they are men—all the more complex when the majority of men who have sex with men are married to women, further increasing vulnerabilities for all. In this context, it is a wonder that protection programmes of non-governmental organisations and the UN focus almost exclusively on women. Just as “gender” should not refer solely to women, “protection to reduce vulnerabilities” is not only a female realm. Who will protect Kenyan men from themselves?

1. Now More Than Ever, AIDS 2010