Death or life? Pick one. by Morgana Wingard

MONROVIA, LIBERIA- JUNE 15, 201...2015. Photo by Morgana Wingard

MONROVIA, LIBERIA- JUNE 15, 2012: PrincessÂ grew up as a refugee in Ghana during Liberia's civil war. She eventually became very ill, but doctors couldnâ€™t pinpoint the problem. Some said malaria, others said TB, but nothing made her better. When she finally returned to Liberia and visited JFK Hospital, she discovered that she was HIV positive. Thanks to the Global Fund, she was able to immediately begin antiretroviral treatment (ART), which drastically improved her health.

But two years later, she defaulted and quickly deteriorated again. Her mother brought her back to the hospital. During her appointment the nurse grabbed a piece of paper and wrote â€œdeathâ€ and â€œlife.â€

â€œPick one,â€ she commanded. She adhered to the treatment program ever since. Soon thereafter she became pregnant and enrolled in the Prevention of Mother to Child TransmissionÂ (PMTCT) program. Nine months later she gave birth to a healthy, HIV-free baby boy.

Thanks to the Global Fund, 4,800 people like Princess in Liberia receive ART. Access to PMTCT services has improved dramatically in the past few years with government reforms. In 2008, only 28 health facilities offered PMTCT services; over the last 3 years, that number has increased to 156 clinics, health centers and hospitals offering PMTCT services to HIV-positive mothers. With the proposed new national scale up plan, the MOHSW aims to reach 80 percent of pregnant women in 2015. Photo by Morgana Wingard

CHITUNGWIZA, ZIMBABWE: January ...grams. Photo by Morgana Wingard

CHITUNGWIZA, ZIMBABWE: January 14, 2016 - Loyce Maturu, 23, was born with HIV. Before the age of 10, she lost both her parents and her brother. Loyce had a difficult time growing up with HIV and accepting her status: she faced stigma and verbal abuse from some of her relatives, nearly committed suicide, missed school often due to ill health and she found it challenging to obtain money to get to the clinic. She didnâ€™t start receiving ART until she contracted TB when she was 12 years old; during that time Loyce had to manage both TB and HIV treatment for the first time.

In 2004, Loyce joined Africaidâ€™s Zvandiri Programme as a beneficiary where she had the opportunity to meet her peers with the same status. Since 2009, she has been working with Africaid as a peer counsellor and advocacy officer on issues around treatment, care and support including HIV- related stigma and discrimination for children, adolescents and young people living with HIV; their campaigns have been rolled out in schools and communities throughout Zimbabwe.

As a member of the Young Peopleâ€™s Network hosted by the National AIDS Council, Loyce has also contributed to a variety of national policies, guidelines and training curriculum. Loyce is also a member of the Communities Delegation to the Board of the Global Fund and Y+ Network Steering Committee and co-Chair for the Y+ Global Network of Young People Living with HIV.

In Zimbabwe, 15% of the population is living with HIV and mother-to-child transmission accounts for the highest number of HIV infections. The Global Fund has provided HIV financing to Zimbabwe since 2005, almost 70% of its total funding to the country. Currently, of the 1.4 million people living with HIV in Zimbabwe, 670,000 of these people are on ART through Global Fund-financed programs. Photo by Morgana Wingard

OMUTHIYA, NAMIBIA: December 5, ...ikoto. Photo by Morgana Wingard

OMUTHIYA, NAMIBIA: December 5, 2016 â€“ Lempy Ndadena, an HIV-positive patient at Omuthiya District Hospital.Â HIV rates are particularly high, reaching 22.6% in Onandjokwe District. Facing a shortage of nurses to handle the number of HIV patients in Namibia, health officials have had to reach out to retired nurses to come back to work to fill the gap.

HIV is a major factor in maternal and child mortality in Namibia, where it contributes toÂ 59% of maternal deaths in the country, and 14% of infant deaths. AboutÂ 250,000 people live with the virusÂ in Namibia. The country also has theÂ fourth-highest prevalence of tuberculosisÂ in the world, and almost half of those infectedÂ are HIV-positive.Â

This is why integrating HIV services into maternal and child health, family planning, and tuberculosis services is key, and IntraHealth International is working to do just that through the USAID HIV Clinical Services Technical Assistance Project (UTAP).

In partnership with the government of Namibia, IntraHealth is working to:

Enhance health workersâ€™ abilities to deliver high-quality HIV services.
Improve integrated HIV care and treatment services.
Build the capacities of local nongovernmental organizations (NGOs) and public-sector facilities to deliver high-quality integrated HIV services in Namibia.

The Namibia National Strategy aims to reduce new infections and AIDS-related deaths by 50% each by 2017. But the countryâ€™s chronic scarcity of physicians and maldistribution of nurses could prevent it from achieving its goal of an AIDS-free generation.

IntraHealthâ€™s UTAP focuses on regions with the highest HIV prevalence rates: Kavango, Khomas, Ohangwena, Omusati, and Oshikoto.

Photo by Morgana Wingard

BEIRA, MOZAMBIQUE: July 5, 2016 - Aida Samuel, 29, lives in the Mascharinha neighborhood of Beira with her 5 children. A skeleton of an old van decomposes in the yard as her children run around with others from the neighborhood. The old tires, garbage and crumbling cement inside the walled compound serve as a playground. Inside her simple cement house, Aida watches TV with the kids. Their favorites are Brazilian novellas. This is how they pass most of their days -- watching tv and playing in the yard. Then at 5pm Aida heads into town where she looks for work. She hangs around bars with other women looking for men who want to pay for sex.

Aida turned to commercial sex work when she was 23. With three children and no husband she had no way to support her family and send her kids to school. No one was helping. A friend suggested she try it â€” thatâ€™s how many other girls in her neighborhood support themselves.

Clients come from all over. The city is known for having girls so men flock there. It's the beginning and end of the â€œCorridor,â€ a busy trade route used by truckers hauling goods throughout Southern Africa so many of their clients are truck drivers from Malawi, Zimbabwe and other countries in the region.

Once she has a customer they start negotiating the price and discuss condoms. The more time, the more money. It's typically 100 Meticas (1.45 Euro)Â for 5 minutes. She then takes her client to a nearby room that she rents for 20 Meticas. Most of the time she provides her own condoms supplied for free from MSF. Sometimes the men bring their own but they've been known to poke holes in them so she doesn't trust them. Nowadays she only works 3 days a week from 5pm - 8pm.

She used to work 6 days a week, but now she's not feeling as strong as she used to. Last December (2015) she started to feel sick. It started with a fever. She went to the hospital to be tested. At first she came up negative for everything. Eventually they diagnosed her positive for HIV.Â She couldn't believe it at first and refused to take the medicine but after much counseling from an MSF counselor she finally accepted it and started to take her ARVs. "If it wasn't for MSF, I don't think my family would have done anything when I got sick."

Before she got sick she could do everything and made more than enough to support her 5 children and put money in a savings account at the bank. Now, only working 3 days a week, the 400 Meticas a night or 1200 Meticas (17 Euro) a week isn't enough to support her and her children.

"I want to stop but I can't. There is no one to help. If I could start a business or get a job or get some help, I would stop." Photo by Morgana Wingard

BEIRA, MOZAMBIQUE : July 6, 201... HIV.Â Photo by Morgana Wingard

BEIRA, MOZAMBIQUE : July 6, 2016 - Patrica, 31, moved to Mozambique from Zimbabwe in 2007 because times were rough at home in Zimbabwe. The economy wasn't good and it was hard to find work. She started buying and selling second hand clothes when she first arrived in Mozambique.Â In 2008 she started as a commercial sex worker. "Before I had a boyfriend, but we used to fight all the time. And he lied. He said he wasn't married, but I found out later it was. Working on the street is better. You don't make any promises to each other." 80-85% of the time it's easy to convince men to use condoms.Â Sometimes they bring their own, but if not she provides condoms given to her for free by MSF. Most of her customers are businessmen from other provinces in Mozambique. She works Thursday - Saturday night from 9-2am.

Thereâ€™s no romance in her businesses. Clients pay based on the amount of time. â€œI like the customers who pay 100-200 meticas. If they want more than that, they have too many needs. Thereâ€™s no romance. No more than 5 minutes.â€ After meeting a client sheâ€™ll take them to a local lodge or theyâ€™ll go to a car or a hidden place.

â€œThis lifestyle is dangerous, but you are a soldier. You have to be strong.â€ In the mornings, the women typically gather and talk about what happened the night before. So far nothing bad has happened to her, but sheâ€™s known girls who were taken to a house with several men and locked inside to have sex with all of them.

Itâ€™s getting more difficult to get money these days. And, now that she has a child she has to keep a tight budget â€” no extra spending.

The chances of catching HIV for someone in Patricaâ€™s business are high. Patrica knows several family members and friends who have contracted the disease, though not necessarily from CSW. â€œYes, Iâ€™m scared of getting it," she admits.

MSF is testing ways to improve access and adherence to treatment through the â€œCorridorâ€ project. Between locations in Mozambique and Malawi, MSFâ€™s project supports care for over 3,800 sex workers and 4,500 truck drivers (many of whom are their clients). MSF also works with men who have sex with men, an extremely hard-to-reach group due to intense discrimination and criminalization. MSF aims to offer early treatment and ensure adequate care to 200 of them. â€œOur dream is to find a way to ensure continuity of care for these vulnerable and highly mobile groups,â€ explains Marc Biot, MSF coordinator of operations for Southern Africa.

In April, Patrica agreed to be a part of an MSF PreP study. As a member of the study, sheâ€™ll receive pre-exposure prophilaxis to reduce her chances of getting HIV. Every 3 months sheâ€™ll be tested HIV.Â Photo by Morgana Wingard

BEIRA, MOZAMBIQUE : July 6, 201...for syhpillis. Photo by Morgana

BEIRA, MOZAMBIQUE : July 6, 2016 â€“Â MSF peer educator, Constantino, tests a comercial sex worker for HIV, yellow fever and Syphilis while Patti, another MSF peer educator, counsels her inside of the MSF vehicle in her neighborhood. She wasÂ last tested in 2014, but this is the first time she's been tested by MSF. This time she tested negative for HIV and yellow fever, but positive for syhpillis. Photo by Morgana

BEIRA, MOZAMBIQUE : July 8, 201...virus. Photo by Morgana Wingard

BEIRA, MOZAMBIQUE : July 8, 2016 - Pre-Exposure Prophylaxis (PreP) that prevents HIV infection amongst HIV negative women, which is particularly interesting for sex workers who are at high risk of infection and subsequently transmitting the virus. Photo by Morgana Wingard

NAIROBI, KENYA - JANUARY 20, 2....Â PhotoÂ byÂ MorganaÂ Wingard

NAIROBI, KENYA - JANUARY 20, 2011:Â â€œYou are now getting married for the second time,â€ said Dr. Mohamed Osmani, an HIV/AIDS specialist at Mbagathi District Hospital in Nairobi, Kenya to his patient, Harriet. â€œFirst, you married your husband. Now you are marrying your ARVs. Are you ready to make that commitment?â€Â Harriet nods. â€œFor how long?â€ the doctor asks.Â â€œFor the rest of my life,â€ she responds.

Four weeks ago, Harriet found out she was pregnant with her first baby â€“- and that she is HIV positive. She was not surprised, she says. She was shocked. She was also concerned for her husband who tested negative. She is worried she may have infected him. She is frightened for their child. Sheâ€™s also nervous since this is the first day of this â€œsecond marriageâ€ and she has just been told what to expect. Nausea. Yellow eyes. Skin rash. Perhaps some fever.

Sheâ€™s 24 years old and traveled two hours in an overcrowded matatu for her appointment. Her husband found the hospital for her after inquiring with everyone he knew how he could help his wife get treated with ARVs funded through PEPFAR and the Global Fund.

The doctor examines her and feels her baby moving, lets her listen to its heartbeat. For the first time she smiles.Â PhotoÂ byÂ MorganaÂ Wingard

NAIROBI, KENYA - JANUARY 21, 20....Â PhotoÂ byÂ MorganaÂ wingard

NAIROBI, KENYA - JANUARY 21, 2001:Â Although his stature resembles a basketball player, Bethwel, an HIV-positive father of two, depends on antiretroviral (ARV) drugs for survival. Just 10 years ago, Bethwel could not figure out why he could not stay healthy. He kept going back to his doctors suspecting that he had malaria and tuberculosis. But only after his doctors at the Mbagathi Hospital in Nairobi, Kenya prescribed ARV drugs to him did he realize that he had something much worse: HIV/AIDS.Â

But, by the time that was figured out, his doctors doubted he would make it. â€œI had lost from 89kg to 49 kg (196lbs to 108lbs). I was like a walking corpse,â€ he recounts. Thankfully, the hospital was able to provide him with free medication thanks to grants from the Global Fund. In Bethwelâ€™s own words, â€œThe ARVs are working. They gave me back my life. They gave me back my health. They gave me back my fatherhood.â€

His wife, also HIV positive, soon began taking ARVs provided by the Global Fund as well. And thanks to Mbagathiâ€™s prevention of mother-to-child transmission (PMTCT) program, she was able to get pregnant and give birth to a baby boy, Isaac who is now two years old and HIV negative.

The funding for programs like those at Mbagathi District Hospital are in jeopardy as the House and Senate hammer out the FY 2011 budgets. The House has proposed a 43 percent cut, about $450 million, to the Global Fund. If the funding is cut, more than 400,000 mothers and fathers will not receive their antiretroviral medication. And more than 58,000 HIV-positive, pregnant women will not receive treatment to prevent mother-to-child transmission of HIV.

â€œThe only thing that I need to continue living, to continue being a father to my children, is assurance that these drugs will continue to be supplied,â€ said Bethwel.Â PhotoÂ byÂ MorganaÂ wingard

KISUMU, KENYA - JANUARY 18, 201...x.Â PhotoÂ byÂ MorganaÂ Wingard

KISUMU, KENYA - JANUARY 18, 2011:Â Jackline Raganga's job is to do home-based HIV counseling and testing outside Kisumu, Nairobi.Â She is part of a project through the CDC (Center for Disease Control) and funded by PEPFAR (Presidents Emergency Plan for AIDS Relief).Â The program sends workers like Jackline out into villages to walk from house to house testing for HIV and counseling families about having safe sex.Â PhotoÂ byÂ MorganaÂ Wingard

BEIRA, MOZAMBIQUE: July 7, 2016... yet. Photo by Morgana Wingard

BEIRA, MOZAMBIQUE: July 7, 2016 - Zulfa, 32, started working as a commercial sex worker at 18. Three years ago she met Patientia, a peer educator from MSF, who helped to get her viral load tested. She was diagnosed positive for HIV. Patentia then helped her go to the hospital and get a medical card so she can receive her antiretroviral treatment. Later she became pregnant but because of the Prevention of Mother to Child Transmission program her 1-year-old girl is negative for HIV. â€œThey have helped me too much,â€ she says. â€œThey help me if I get sick. They come and do testing, take me to the hospital and give me drugs. Now with two children at the age of 32 she says sheâ€™s too old to go out on the street, but she hasnâ€™t found another job yet. Photo by Morgana Wingard

BEIRA, MOZAMBIQUE: July 7, 2016... cent. Photo by Morgana Wingard

BEIRA, MOZAMBIQUE: July 7, 2016 - A sex workers waits outside a room she rents. Her client, inside, will pay 50 meticas for 5 minutes with her.

MSF launched a â€œkey populationsâ€ project in Beira, Mozambique in late 2014. The project looks at adapting models of care for sex workers, long distance truck drivers and men who have sex with men in order to reduce HIV incidence and increase care amongst those most-at-risk groups. In 2015, it provided testing for HIV and sexually transmitted infections to 967 long-distance truck drivers and 548 sex workers, a particularly vulnerable group with an HIV prevalence of 55 per cent. Photo by Morgana Wingard

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