How do we address the HIV prevention needs of transgender women?

This is a live blog from the Global Fund Concept note writing process. I am wondering, when considering how to include transgender women (TG) in the proposal for funding. As we know, transgender women also comprise of adolescent trans girls and young trans women. In this vein, there is reason to cover them under the priority group known as adolescent girls and young women. Yet they are also a key population, and the Global Fund Modular Framework Handbook, they are part of key populations. Herein lies the rub – in which group to include them. And this is not a mere existential question. It has to do with access to funding, including access to the new catalytic funds for the priority population.

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Fantastic time

A party for the LGBT+ community is a rare occasion in Windhoek and tonight’s party, which is still kicking, was refreshing for me.

I am grateful to OutRight Namibia for Organising it. I look forward to the Church service tomorrow morning, at Holtel Pension Alexander at 10h00.

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Brief reflection on health seeking

Indeed, one of the healthcare workers I know came to see me. All I have is a strep throat and she told me which medications to get for that. I detected it early, which is great. Afterwards, she ended up chatting with another healthcare worker, who happened to be in the vicinity.

State health care may not be as bad as we believe it is. She said that in public health care facilities they have certain preparation of clorhexidine mouthwash that, according to her, is more effective than the brand name mouthwash from the pharmacy. Then she share about her own experience "My daughter was diagnosed with a specific condition [omitted here] at the state, after seeing many private doctors".
The problem, according to her, and the healthcare worker who saw me was the immense wastage of health care materials. Nurses, according to her, do not use the materials sparingly. In contrast, in the private sector everything is charged for, from the cotton swab needed to disinfect the skin, the needle for a drip and of course, the drip itself. For this reason, she commented that "in the private sector, you are sometimes scared to put on gloves to touch a patient’s blood".

They both concluded that healthcare workers appreciate the state a great deal, because use of products is not billed to the nurse, in the event a patient is not billed for it.
Yet they acknowledged that the health care services are overburdened: "imagine 90% of the population sees the state [health care facilities]".

Clearly, the state health care facilities are struggling both with patient volumes and prudent – rational – use of materials.

Pancho Mulongeni,MPH

University of Cape Town (2016)

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Brief reflection on health seeking

Despite not having a medical aid, I am extensively connected to healthcare workers that I can seek care outside of the state health system. But what about those who cannot afford to do so? I wonder how many other people use their social capital to seek health care in Namibia.

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Rest in peace George Michael and Jacobus Witbooi

Today I had the rare privilege of actually going to one of the main attractions of Windhoek – the place they call the okapana market. With three other friends in the LGBT community, one of them a local singer and friend, we shared the delectable grilled pieces of beef, cut in pieces that are neither strips nor chunks – something in-between – in memory of George Michael. We also reflected on all those we lost this year, I said this as a sort of benediction before our meal. George Michael passed on Chiristmas. And our friend, someone we know, Jacobus Witbooi – an activist for our community – passed on Nov 24th from Malaria.
And I wonder. Should I aim to remain in the only city of Namibia, Windhoek, where I can continue to build community. Or do I aim to work in the rural outpost of the Zambezi, where an international team aims to find new ways of detecting the disease and stemming its spread?

Too many thoughts for one night. I am just grateful for the day.
Earlier in the day, I went to Catholic mass. I prayed.
Let me continue doing so.
By the way, I graduated from UCT. I have the Master of Public Health.

Good night

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Namibian University of Science and Technology Undergraduate Research Symposium

I want to briefly jot down my reflections surrounding the day:

The day began relatively late, as is expected in Namibia. It is rare for programs to start on time, even when the “08h00 for 08h30” rule applies. That worked in my favour, because I had enough time to show up.

As I arrived a student spoke about a mathematical model of food and mouth disease. As I entered, he was speaking about the basic reproductive number – R nought. I did not see the start of his talk, where he elaborated on the states and structure. Yet I understood his model was rather complex as his R naught was a function of the transmission probability -Beta, divided by several other parameters. If you consult a basic mathematical modelling textbook, you will find that R naught there is defined as Beta over Alpha. Beta is a quantity modelers use to estimate the force of infection in these Susceptible Infectious Removed models. The force of infection – the average rate at which susceptible individuals acquire the infection – is proportional to this Beta. Alpha is now the average rate at which infected individuals move to the removed state. I think Wikipedia and other blogs will help clarify this. I did point out his definition of R naught must state that it is the expected number of new infections that happen when the population is totally free of infected individuals and one of these arrives.

What I asked him at the end of the talk was an eye opener for me. I posed the following question : Your talk is rather mathematically intense, so how do you propose to communicate the importance of modelling to our policy makers,. some of whom only have basic education?  His reply was really something else. Basically, he said he as a mathematician. He told me that he would work with epidemiologists and they would then explain it to the policy makers! Is that not a worthy response for an undergraduate? Did he just sum up my whole search for meaning in public health? I guess epidemiology is the career choice for me then. For many people in the audience, this might have been the first time they heard the word “epidemiologist”. By fashioning the meaning of epidemiologist as a person who communicates the usefulness of an infectious disease model to policy makers, what meaning does epidemiology take on? How does it relate to the large, global, profession of epidemiology in academia and the development agency world?

The other talk I really enjoyed was a review of the Demographic Health Survey data of 2013 in Namibia. I am glad the student who presented accurately described the goal of her survey to understand socio-economic determinants of HIV infection. She also explained the logistic regression technique well, though she could have explained what a covariate was. Most of us in the audience though were taken aback with her humor. For example, she found that relative to single people, widowed and separated people “had a higher risk of HIV infection”. She then added “yes we don’t know why those people are widowed” with a slight laugh. I am not sure if this was inappropriate, but she could have gone further to point out this was a survey. Hence, the implication that being widowed leads to HIV infection is not the most plausible one – rather that widowed individuals lost their partners, in all likelihood, to AIDS. In this talk, widowed referred to people of either gender. However women had significantly greater HIV prevalence.

I did wish to ask her several questions – such as who does she think the survey left out? In particular, did the survey manage to identify transgender people who have the largest likelihood of being HIV positive of any at risk population known? But I did not, for the simple reason that her talk was replete with misguided interpretations. For instance, people who use condoms are at higher risk, according to her, of HIV infection. This was one of the findings. But this could have been avoided with the mere use of the term “likelihood of HIV infection” instead of risk. I let her know after the talk. One lady in the audience though correctly pointed out that “condom use” by itself is meaningless, unless it is consistent and correct condom use. I was thinking of the simpler possibility that condom users knew they were HIV positive and purposefully wished to protect their partners from infection.  But of course, I wonder which explanation is more popular in the literature.

Time to go to Mass.

And then I have to finish my mini-dissertation corrections!



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I will survive

I am in a transitory period as you may know.

Not a student anymore, but not graduated.

Not unemployed, as I am doing freelance health communication work, but still working.

Not applying for a PhD formally, but I have big ideas.

Yet I am grateful for it all. I know I am in very creative space. Just today, reading the news paper add, a medical aid fund stated it would be "rewarding"its loyal members aged 65 and above with reduced premiums. It seems reasonable to give the elderly a break. But not all elderly members will qualify, only those who have been with the fund for at least 20 years. That is the long time and in our new country of 26 years of democracy and non-institutionalized racism, that means a great deal. People aged 65 years and above today survived the South African apartheid project, that without saying, determined social position then and so ability to have been a medical member just in the first decade after independence.

That’s as much as I am writing.

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