Morocco

Morocco was my first international travel experience so I read this chapter with interest. As a 16 year old I lived in Morocco for a month baby-sitting my two younger cousins. I came away with several lasting impressions from the trip: Poverty...we lived in a nice residential compound but the second we stepped outside the gate there were hundreds of families camped outside, begging, digging through dumpsters, and just staring blankly at us as we drove by in our shiny volvo. Second impression: women weren't allowed in certain areas, certain cafes, and I never saw a woman's legs. Coming from America in the height of the mini-skirt craze this was shocking to me. The third thing I remember is our tour guide stopping in the middle of our tour, pulling down his pants and relieving himself two feet from me on the castle wall....Two of the three were indirectly addressed by D'Adesky in this chapter.

In her portrait of Morocco, D'Adesky makes a case for treatment that I hadn't really considered before. An Islamic country, the topic of HIV is often a taboo subject in Morocco due to its connection with homosexuality, bisexuality at promiscuity. As such, prevention measures have minimal and the leadership largely mute on this topic. Until now. While the epidemic is still relatively tiny in Morocco (according to UNAIDS, as of 2005 there are an estimated 19,000 people living with HIV), the Moroccan health officials hope to launch a bold experiment.

They hope that by initiating a national treatment plan for HIV, they can can not only bridge HIV prevention efforts, but actually serve as a prevention tool. By combining treatment with expanded HIV counseling services, advocates argue that it will spur those who are now afraid to get tested, as well as help doctors identify patients at earlier stages of infection. Health officials will then be able to target prevention efforts to stem potential outbreaks.

Some argue that Islam's ban on homosexuality and extramarital affairs has helped curb the rates of HIV in the Islamic world. While this may have contributed to the slow development of the disease in Morocco, it may have devastating effects once HIV reaches the broader community. The ban on homosexuality typically causes men to live secret double lives as they often give in to societal pressures and get married. Islamic law also permits men to have more than one wife which could also lead to rapid spread of the disease. As we learned from Helen Epstein's lecture, long-term concurrent sexual relationships have been a primary driver behind the epidemic's rapid spread. The low status of women in much of Moroccan society leaves them virtually powerless to make demands, or refuse their husbands. This makes women particularly susceptible to the virus.

One main theme of the course is the importance of cultural sensitivity when developing HIV programs. I think the Moroccan case study is an interesting example of how to deal with such a culturally sensitive issue. According to D'Adesky, the National government has steered clear of national media campaigns, instead targeting cities and commercial sex workers (who actually make up only a small percentage of women that are infected) because of the stigma associated with AIDS. Media is subject to censorship by state and religious groups, and references to sexuality are often forbidden. By focusing on treatment, the government is able to sidestep the issue of sexuality.

According to Professor Hakima Himmich, "stigma can change with access. The minute a mortal disease becomes a chronic one that you can treat, this is where you will see the change happen. It's clear you can't have an effective prevention strategy without access to care for affected people."

It will be interesting to see if this treatment model works. Because it was initiated while HIV was still relatively contained in Morocco, it may have a better chance of succeeding, yet it will be difficult to replicate in countries where the epidemic has all ready spread. I still remain skeptical of relying entirely on treatment measures to contain the epidemic. While it may help reduce the stigma associated with the disease, I think treating HIV like a chronic disease is dangerous. People feel healthy, and will not take as many measures to protect themselves, and HIV will continue to spread. As I mentioned earlier, it is only a matter of time before the virus mutates into another treatable form.

D'Adesky still hasn't sold me on the treatment model...