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Intimate Interventions: Book Shows How Countries Were—and Weren’t—Ready for HIV

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Rachel Robinson (right) with Ore Ojo, a senior program manager from White Ribbon Alliance Nigeria.

The AIDS outbreak was so cataclysmic, activists and policymakers often treated it like an isolated chapter in modern times. And the resources needed to combat it were, in many ways, unique and unprecedented. Yet in her new book, American University associate professor Rachel Sullivan Robinson went searching for historical context. She found that family planning programs—those already in place well before the deadly epidemic engulfed millions—were critical to how some African countries responded to HIV/AIDS.

Even when marshalling national and international support, health workers had to address behavior that is quite personal. “I really wanted to show the connection between family planning and HIV intervention. Both are fundamentally about changing the ways that people have sex,” says Robinson, whose book is titled Intimate Interventions in Global Health: Family Planning and HIV Prevention in Sub-Saharan Africa.

In her book, “intimate interventions” are programs, policies, and organizational actions to change sexual behavior, including promotion of condom use. African countries that had a family planning organization that predated the HIV/AIDS epidemic, she argues, experienced greater declines in HIV prevalence.

“I do really attribute that to having an organization on the ground that had experience talking about sex, talking about sensitive topics, and had connections to external organizations and funding streams,” says Robinson, who teaches in AU’s School of International Service.

Malawi, Nigeria, and Senegal

Intimate Interventions in Global Health includes case studies of three Sub-Saharan African countries: Malawi, Nigeria, and Senegal. Robinson visited these countries and interviewed roughly 140 officials with local and international NGOs, donor organizations, governments and health ministries, and universities.

Malawi had a relatively poor record in preventing the spread of HIV. That nation was always going to struggle in this area, she says, because it’s centrally located at the heart of the AIDS epidemic, and it has low rates of male circumcision (a protective factor). Still, the country was too reactive under the authoritarian rule of Hastings Kamuzu Banda, who viewed contraception as Western and anti-Malawian. “In no way was he going to admit that he had a public health crisis on his hands,” Robinson says.

Banda expelled intellectuals and potential technocrats, and the family planning programs didn’t pick up steam until after he left office in 1994. She credits the family planning organization Banja la Mtsogolo for eventually providing HIV testing and treatment.

Nigeria had family planning programs in the 1980s, partly because of pressure from the World Bank to adopt a population policy. The large nation also benefited from the dynamic technocratic leadership of Minister of Health Olikoye Ransome-Kuti. Yet internal strife impeded some of Nigeria’s progress.

She writes that “the political upheaval during the 1990s that distracted the government, limited the reach of civil society, and led to loss of donor funding ultimately produced relatively unremarkable HIV prevention efforts.”

Many health officials declared Senegal a success story, as HIV prevalence never exceeded 1 percent there. Senegal had natural advantages—unlike Malawi, it’s located far from Africa’s HIV epicenter and almost all men are circumcised. Yet Senegal also had some renowned HIV researchers who got plugged into the global circuit of health scholars. It’s a country that looks outward, placing a premium on strong relations with the international community. After UNAIDS was formed in the 1990s, health officials desperately needed a model country to exalt, she says.

“They sort of anointed Senegal as a success story. And Senegal loved that—who wouldn’t? But the country really took to that, and worked hard to keep it up,” Robinson explains. “Senegal has a strong civil society. It is a democracy. It is relatively tolerant. It’s a unique little place.”

Treatment and Prevention

While transitioning to democracy in 1999, Nigeria encountered a new landscape for HIV-wracked African countries. Generic drugs were much more widely available, and officials were now putting more energy into treatment. “The emergence of generic treatments made possible two of the biggest funding mechanisms, which is PEPFAR, the U.S. President’s Emergency Plan for AIDS Relief, and then the Global Fund to Fight AIDS, Tuberculosis, and Malaria,” Robinson explains.

Today, she says, HIV/AIDS work in Africa is heavily skewed toward treatment. That’s logical given the huge numbers of people who are HIV positive, she says, but it shouldn’t supplant the invaluable work of prevention. “It’s partly because treating people seems easier. It’s much more of a game of getting drugs to people, and less about this game of, ‘We really think that you should have sex in a different way,’” she notes.

Yet the focus on treatment is tricky, since—as in the United States—many people in Africa are unaware that they’re HIV positive. “The irony, of course, is that with all that money going towards the drugs, there are still so many people who need them but aren’t getting them.”

Honoring Resilience

Robinson has long been intrigued by how governments handle thorny issues like sex education and reproductive health. She wrote her undergraduate senior thesis on population policy in China, India, and Romania. “I truly have been interested in why and when governments are willing to intervene in these really intimate areas of their citizens’ lives,” she says.

She combined this with her knack for math and statistics, becoming a demographer and sociologist. 

Through her Africa excursions, she’s developed a profound respect for the continent and its people. “I remain so amazed by the resilience of people who have been through so much, in terms of everything from colonialism to massive global injustice,” she says.

In Intimate Interventions in Global Health's opening dedication, she thanked workers on the front lines “who strive to make pregnancy wanted and HIV obsolete.” And on a recent trip back to Nigeria, she personally expressed her gratitude and handed out copies of her new book.