TASO Summary

I came to TASO to learn about HIV and it socio-economic impact on developing 3rd world countries. I really wasn’t sure what I’d be exposed to or how involved I would be in treating HIV patients. My college funds internships like this one with the expectation that students tackle a major global or social justice issue. HIV prevalence and a lack of volunteers are two major global issues deemed important by the World Health Organization so TASO seemed like a good place to work and to increase my understanding as to why HIV is so prevalent in East Africa. I imagined that I was going to physically assess patients and interact with them to learn about their lifestyles and ways they could live healthier lives. At the end of my internship, I can say I accomplished most of what I set out to do, but have learned much more about the factors promoting HIV prevalence than I anticipated I would.

Upon my arrival, I was placed initially in the medical lab to assist with collection and analysis of blood samples. I was annoyed that I was placed in the lab, because I could have easily found a lab to work at in the US. Having traveled all this way to Uganda, I wanted to be able to interact with patients. Thankfully, a brief meeting with the medical coordinator resulted in designing a schedule, in which I would move around to different departments each day, and interact with and assist a counselor. As a result, I was able to gain a better understanding of various activities at TASO.

I typically worked in the clinic Mondays and Fridays, where I would collect blood samples from patients for CD4 counts and test for other communicable diseases (e.g. malaria, tuberculosis, syphilis). The activities on Tuesdays and Thursdays varied greatly; I spent some days in the adolescent clinic, where kids and young teenagers were rounded up and asked about any difficulties in adhering to their medicine(s), how school was going, how to eat healthier, and how to live in sanitary conditions. While these lectures were given to a general audience, adolescents then met with counselors one on one to discuss any private issues. Another clinic that was held on Tuesdays was the Prevention of Mother to Child Transmission. This clinic was specifically for mothers, and like the adolescent clinic, consisted of a group lecture followed by individual meetings. HIV positive mothers were given the necessary instructions to keep their babies HIV negative (taking anti-retroviral medicines while breastfeeding, visiting TASO to test their babies for HIV, etc) before meeting individually with counselors.

On Tuesdays and Thursdays, I participated in Community Drug Distribution Point trips, called CDDPs. TASO has set up meeting places in surrounding villages where they visit every six months to re-bleed patients for CD4 samples and to administer medications. People in a village travel to a central point and within a few hours, everyone can be treated. On these trips, I was responsible for managing clients’ files and assisting with blood drawings. We would sometimes visit multiple points, with each site containing 10-50 clients, so those days were always exhausting. Wednesdays were by far the quietest day of the week. TASO tries not to schedule appointments on Wednesdays, so there aren’t too many patients to attend to. The day is usually spent analyzing samples from the clinic or CDDPs, and recording hard and soft copies of patient results. It is imperative to run samples and record quickly because samples will just backup if they are not analyzed. TASO has a few other programs that offer mentoring sessions to other health clinics. In short, I primarily assisted physicians in clinics and helped counselors in counseling sessions.

Despite being exposed to the various departments, there were some difficulties I personally experienced that I wish I had more support for. When I first began working in the clinic, I was thrown into pricking and drawing blood from patients without any real training. Maybe people assumed since I was white and from the US that I had already learned basic medical techniques. I really struggled with the first few patients I had; it wasn’t until I had to desperately ask for help that someone corrected my technique. It would have been more helpful to me (and less painful to the patients) if someone had sat me down, and taught me the proper technique for bleeding. Lesson learned – speak up when I don’t know something! Another problem I had was the language barrier. Few clients knew English, but Luganda and Lusoga were the most common local languages used at TASO. I usually was paired with a counselor who was bilingual, but we moved at a rapid pace as there were a fair number of clients who needed to be counseled. I understand I could have spoken up about having someone translate a conversation for me, but I still didn’t appreciate the promise from the medical coordinator that never materialized. If there is one regret about my experience, it is not being able to talk in greater detail with the clients. The stories I heard from the English speaking clients were very thought provoking, and I could only imagine what other stories I may have missed.

For these negative experiences with TASO, there were many positives that served as a counterbalance. My time at TASO has shown and taught me a lot about HIV prevalence and healthcare outside of the US. I learned patient communication skills and lab techniques that I will likely encounter or use in a medical setting. I learned how to maintain composure if a patient proved to be difficult or uncooperative. I learned how counseling programs and trips to the field demonstrate both encouragement and support to patients who are doing their best to break free from the grasp of poverty. I learned that HIV prevalence isn’t really a medical issue at all; there are so many political, economical, and social factors that President Museveni and his party can tackle which would result in empowered, educated people. I would not have learned any of these things if I was working by myself. There was never a day that I worked alone. Whether I was in the lab, or in the field, I always had a supervisor with me. The staff at TASO helped me refine techniques when dealing with patients, but also shared their insights regarding the larger problems Ugandans faced. Being able to talk with sensible, educated workers really helped broaden my understanding of a country that most Americans know nothing about. My interactions with the staff have definitely been the highlight of the trip, and I’m very grateful that they were willing to have such delicate conversations with me. TASO does great work. As long as it has dedicated staff, TASO will continue to make its vision of an HIV-free Uganda more of a reality.

Sketchy Business

Hello, I hope you all are surviving the summer heat well. For being extremely close to the equator, Jinja is not as hot as you may think it should be. It gets to about mid 80s during the day, without any humidity, making outdoor activities somewhat manageable.

There are two interactions that I want to detail in this blog post that don’t directly pertain to TASO (or work). Last weekend, I ventured to Kampala to meet up with a colleague. Getting to Kampala was stressful in of itself. Most towns have ‘taxi parks’ which are giant parking lots filled with taxis and buses to different areas of the country. I took a coaster, a smaller bus that can fit about 30 passengers, which travels a little slower thus making for a safer ride. The bumpy drive took roughly two and a half hours; the coaster itself was hot, and the windows were only cracked open, maintaining a delicate balance between air exchange and blockage of dust kicked up from passing cars. Kampala is broken up into seven hills, kind of like the five boroughs of New York City. I was headed to Namirembe, which is the Manhattan of Kampala, but I had no clue as to where it was located. I told the conductor where I was headed, but was not sure if he remembered, as there were all the other passengers he had to worry about. To make matters worse, people were talking in Luganda to the conductor and were using a hand signaling system to signal when to get off. I have never felt more out of the loop or lost in my life than I did for those 30 minutes driving around Kampala, until all remaining passengers had to disembark at the last stop. Fortunately for me, that last stop was in Namirembe, and a short boda-boda ride to the mall I planned to meet my acquaintance. Being outside in Kampala reminded me a lot of New Delhi; sidewalks were packed with people, and car fumes, honking and anarchy ruled the streets. In a ten-foot radius of my boda-boda were another ten boda-bodas, all inching their way forward whenever space became available. The phrase “every man for himself” could not have described the scene better. I saw on the news a few days ago that there is talk of putting bike lanes in Kampala to reduce congestion. That is a good joke.

I met with Justin Kibira in a small food court. Justin is a pharmacist by training, but works with HEPS Uganda, an organization that advocates for increased access to affordable medicines for the poor. Justin specifically works to oversee drug distribution to public health facilities. Public health facilities tend to be out of stock often because of a lack of funding. Private health facilities are able to restock medical supplies much more efficiently, as they have funds from donors and other parties. Our discussion revolved around ways healthcare can be improved and HIV prevalence can be decreased. While Justin agreed with me that Museveni has had his fair share of time as president, he mentioned that illiteracy and a lack of civil duty and empowerment are the biggest issues Uganda faces. Statistics by Tulane University lists that 56.5% of women and 30.7% of males are literate, a sign that fuels the need for improving education. Justin champions that a literate population will be motivated to work, live in sanitary conditions and will be informed about politics and global issues. He even went as far to theorize that Museveni does not put in enough money for education so that his voters and supporters, a large majority of which are rural farmers and illiterate, vote for him based on popularity in the upcoming election(s?). We both chuckled after that statement, but it makes you wonder.

Justin went on to further explain that the biggest issue Ugandans face is acquiring a sense of civil duty and respect towards one another. This issue applies to people who have failed to obtain a degree from a University (and it most certainly excludes people at HIV/AIDS clinics like TASO, where the staff constantly serves the community). Justin gave the example of just trying to move around town. Cars and boda-bodas will zoom by if there is open road ahead, even if there are pedestrians waiting to cross. You either have to continue waiting, or run the risk of getting smashed. I thought while it would be nice to have cars wait for you, there are plenty of other cities where these kinds of problems occur; this is a rather poor example of citizens acting accordingly. Justin then showed me a video a friend sent him. It was of a man being publicly beaten by a few others with a crowd of bystanders watching a few feet back. After being beaten to a pulp, the man was then burned alive. I had to refrain from eating my lunch in order not to gag, but this was sickening. While I didn’t know the background of the events leading up to the beating, they didn’t matter. It was disgusting to witness so many people just watching someone without the proper authority to treat another human that way. I was even more disheartened by the fact that no police arrived to clear the incident; this implied that no one out of all the witnesses even bothered to inform the authorities. The whole video is disturbing, but is a good example of the barbarism that lies within Ugandans and how some unexplainable behaviors are the norms. I’m not going to include the link because it is too graphic, but Google searches work well for the curious.

The days following my trip to Kampala have been less stressful and gut wrenching, but still thought provoking. On Wednesday, I was in the lab waiting to help analyze some sputum samples from TB patients, when one of the nurses struck up a conversation with me. She was interested to know how I was managing with the local foods and the kinds of meats and starches that were available in the US. One thing led to another, and soon we got on the topic of health facilities making cuts to their faculty. When I mentioned that Museveni’s signing of the anti-gay bill will hurt HIV/AIDS organizations, the nurse lit up. She expressed her support for the law, and made it known to me that she was anti-homosexual. I had initially assumed a lot of Ugandans were anti-gay simply because they thought it was someone’s choice to be gay; since most Ugandans are Christians, this choice conflicts with a lot of their religious beliefs, and they look down upon people who choose to behave otherwise. She asked me about my views, and I retorted that I support LGBT rights, because sexuality has been proven to not fully be a choice. The exact mechanisms that determine whether someone is homosexual or heterosexual have not been elucidated, but the current understanding is that part of identifying one’s sexuality originates from both genetics and personal choices. Since a person’s genetics are beyond their control, how can you accuse them for behaving a certain way? These were my points that I explained to her, in which she responded with a curveball. The nurse really didn’t comment on my thoughts but went on to explain that children and other youths are bribed to be gay by NGOs, which strive to spread the support of LGBT rights, since most African countries are conservative. She went on to claim organizations have come to Africa with the sole purpose of trying to normalize homosexuality. Students or young adults are the targets of these companies as they are in need of money for food or school tuition; they are told to act gay and inform others that it is ‘cool’ to be gay. This was not the first time I heard this; a counselor told me the same thing a few weeks ago, but I had brushed it aside since that sounded silly and unreasonable. My host family later confirmed that they had heard of organizations bribing people to be gay, with the Walter Reed Project being the most prominent example. Granted this is the opinion/belief of a few educated Ugandans, but if it was true, did other countries (the US, Sweden, Norway, countries that have suspended funds to Uganda) know about this?

After digging around the Internet for information and case examples, I can conclude that the Anti-Homosexuality Act has been very loosely written, and has resulted in many misunderstandings about how gays are treated. Earlier this month, after Western countries passed sanctions, the Ugandan government released a statement saying the intention of the Anti-Homosexuality Act was to “stop promotion and exhibition of homosexual practices.” The statement also noted that the government is “committed to the protection of rights of all individuals” and “committed to guarantee full access to social services, including health and HIV/AIDS services” for every Ugandan. While this statement carries the objective to illustrate a ‘common misconception’ that Westerners have interpreted the law harshly, and that Ugandans don’t discriminate against gays, there are two pieces of evidence that contradict the statement. The first is that Museveni led an Anti-Gay rally in Kampala soon after the bill’s signing. He publicly championed the law, and said things like homosexuality creates grave health problems in addition to being criminal and cruel.  Since Museveni said these comments at a public event, I have a hard time believing he supports the rights of gays, as mentioned in the statement. The second piece of information is that Sexual Minorities Uganda (SMUG) an advocacy group for LGBT rights, has reported a ten-fold increase in Anti-LGBT attacks; since the signing of the bill, there have been 162 reported incidents (and potentially more that have not been reported) of attacks, which compared to the 19 incidents in 2012 is a staggering jump. Yet, the police are not the ones behind a lot of the attacks. Non-state actors play a large role in initiating these incidents and are free to do as they please since the police force is so crappy at maintaining jurisdiction. I though there was a line in the statement released to guarantee equal treatment for all persons in Uganda. That is another good joke.

But the deception does not end there. In the beginning of April, the Walter Reed Project at Makere University in Kampala was raided by Ugandan police. The project, which is funded by the U.S. military, was established in 2002 with the objective of developing an HIV vaccine. The project also offers additional educational and treatment opportunities including youth-focused and most at risk programs, SMC and PMTCT. The Ugandan police allegedly sent two cops undercover to the project to investigate the various programs. The officers claimed that other citizens or trainees were shown homosexual videos, encouraged to bring along other male partners, and given money for transportation as well as condoms and lubricants. The officers arrested one of the lead facilitators, but later released him, as the chief of police had not cleared the whole infiltration scheme. Even though the description provided by the cops seems to make the Walter Reed Project look like a recruitment firm, (which definitely would oppose the Anti-Homosexuality Act), it is hard to really know the truth without a testimony from any of the facilitators. A lot of the acts that were taking place happen in most other HIV/AIDS facilities. It is possible that since the project is funded by the US, gays may have felt more comfortable and safe going there for help or being educated about healthy living styles. Thus, it makes sense as to why same-sex videos were shown, or trainees were encouraged to bring their partners (so both of them could be educated together). Most clinics distribute condoms and lubricants to patients, so I don’t really view that as a form of recruitment. Unfortunately, we don’t really have conformation as to whether my points or the undercover cops’ are valid. But what is important to understand is that most Ugandan media has portrayed the Walter Reed Project as a recruiter for gays. As a result, most Ugandans believe that the Walter Reed Project and other organizations are terrible and trying to impose social codes to follow, without knowledge of the whole situation.

Before researching some of these cases, I thought maybe Ugandans are upset at Westerners for trying to promote human rights by bribing people, and that the law is really to stop influencing minors about their sexuality; maybe the US and other countries have misinterpreted the law and what it entails. I now see that this mode of thinking is incorrect. Simply put, most Ugandans hate homosexuals, homosexuality, and any organization that tries to promote equal rights for LGBT. I also believe the government made a half-hearted attempt to try and fool Western countries that the law is to prevent influence with their statement in July; Museveni’s open stance, the increase in anti-LGBT attakcs, and the raid on the Walter Reed Project all clearly show Ugandans do not guarantee the equal treatment of all people. I have pity towards Museveni and the people who believe there are people recruiting gays; no one is recruiting anybody. All the people and organizations are trying to do is promote equal rights and fair treatments of gays and HIV patients. But the government and Ugandans are just currently too stubborn to realize that there isn’t sufficient evidence to claim these organizations are recruiting. Members of the LGBT community are beginning to flee the country, and some have even asked to seek asylum in the US; it is sad to see that some people are so afraid of their own safety and government that they believe the only option for themselves is to leave the country.

Risky Business

This past week and a half has been another quiet week at TASO. Friday provided the most excitement as I interacted with patients the whole day. I was stationed in the doctor’s office, where patients came with forms identifying the specific tests needing to be done on them. I spent the whole day pricking and squeezing ring fingers for small droplets of blood for malaria strips and sticking needles into clients’ arms for blood samples. I must say that my technique has drastically improved and I did not need to be relieved of duty. As promised, here is a picture! 

Taking a blood sample for CD4 analysis

I am happy that I was able to help out more efficiently than last time. There was only one other hired staff and me working to attend to 50 patients. I collected the samples while my colleague ran the tests on them. We worked efficiently and were able to call it a day at 4:30, but if one of us hadn’t been there, the workload easily could have dragged on for another two hours. And in a few weeks, my colleague may have to stay that late if someone doesn’t fill my shoes.

The weekend was pretty relaxing, as I hung around town. A big fair came to Jinja at the beginning of last week. The event is known as, “The Source of the Nile National Agriculture and Trade Fair” also known as the “Shop.” The shop is nationally and internationally accredited; Yoweri Museveni usually attends one of the days. Vendors from Kenya, Rwanda, Tanzania, and of course Uganda, came to campout and sell their crafts, agricultural products, and even farm animals. People from all around Uganda and surrounding countries make the journey to Jinja to peruse and buy anything striking their fancy. The Shop is literally open 24/7; it doesn’t close at night, only at the end of the week. I visited various craft stores with my host mother who was helping me decipher the authentic items from the cheap. Some vendors were sneaky and claimed to be from certain cities, even though their products indicated otherwise; the quality or make/design of the product gave clues as to the product’s origins and could not fool a local Ugandan, but only white people like me. Most items did not have fixed prices, so people bargained to come to a deal. I had been warned that vendors give white people “muzungo prices”; they jack up their initial offer by 100-150% when a white person is buying something, as they think they can get more money out of them. Once again, my host mother came to the rescue and helped negotiate some reasonable prices for authentic Kenyan crafts.

The Shop reminded me of a local fair back home, except it was more crowded and dusty. It took about two hours to walk around the entire campus, talking to different vendors about their products and stopping to admire agricultural products or animals. A small zoo-like section was set up on the edge of the fair, and displayed a leopard, lion, python, ostrich and a Crested crane, the national bird. But the animals that stood out the most were the 8ft long, 1500 pound boars sprawled out in their pens. I had never seen one so big before, and there were 6 of them! I didn’t even know boars could grow to that size in real life. I immediately equated these boars to the large devilish boar in Princess Mononoke; except these boars looked like they could hardly hold themselves up to walk. It was truly a sight that highlighted a fun and cultural morning.

The past weekend was the finals of the World Cup, and Ugandans could not have been more excited. In preparation for the games, news stations were constantly broad-casting stories about sports bars ramping up security and warning viewers to remain safe if they choose to watch the games in public. These frequent and rather excessive warnings were prompted by the 2010 World Cup Finals. The Ugandan 9/11 is only 2 digits too much; “7/11” as most Ugandans call it, refers to a bombing of a sports bar during the Spain vs Netherlands finale. 76 soccer patrons were killed and many more were injured. The attack was traced back to al-Shabaab, a faction of al-Qaeda located predominantly in Eastern Africa, and those directly responsible were caught. al-Shabaab has terrorized Eastern Africa, especially the coast of Kenya, in recent months; there have also been threats of attacks in Uganda. Just within the past week, the international airport in Entebbe (my way home) was threatened to be bombed. Additionally, my host mother informed me that four al-Shabaab members were caught trying to sneak into the Shop, trying to enter with bombs attached to themselves (they were apprehended before they could enter). As the games drew closer, a lot of Ugandans reminisced about that horrible day and their contempt towards the faction; most people remember exactly what they were doing when they heard about the bombing, signifying how much of an impact the event had on them.

In 3^rd grade, I had just been let out from school on a sunny Tuesday afternoon, when I was surprised to see my mom picking me up. The immediate excitement turned to confusion once she told me the Twin Towers had gone down. There is a look out point, Washington Rock, in my old town where it is possible to see the New York Skyline. My dad, brother and I tried to drive there to see the city, but it was too crowded to find parking. We were forced to the confines of our TV, where news stations replayed the planes crashing, the towers falling, and small flecks of people jumping to their deaths. At the time, I was scared and upset. I didn’t understand why there could be so much hatred by a group of people towards another. How could someone want to kill or be happy that 3000 people had died in one day, and hundreds more were injured? Even today, I still don’t understand. I could empathize with the Ugandans about the sorrow they felt, but a small part of me was pissed off. Any bombing resulting in the death of a group of people is horrible. But I have a hard time comparing the events when viewing them from a numbers perspective. The bombing in Kampala four years ago resulted in the deaths of less than a 100 people and a wrecked sports bar. 9/11 resulted in the death of 30 times the number of citizens and the destruction and damage of businesses and federal buildings. Both events are terrible, but I have a hard time accepting the way Ugandans feel about their 7/11, when they haven’t experienced the full wrath of al-Qaeda. They make it out to be the worst thing that has ever happened. I’m not saying they should feel any different, or that someone should exhibit a certain level of sadness or mourning depending on the number of deaths in an incident. Maybe it’s my American pride coming out, but Ugandans haven’t faced the level of terror and sorrow in their 7/11 as Americans did during 9/11. The events are comparable, but I believe they are so different. Fortunately, no major attacks occurred this past weekend, so everyone was able to enjoy the Dutch and German victories.

I would like to write another post soon about information on Busoga culture and information about Ugandan healthcare and the distribution of medicine at the end of this week, but it may be posted in the middle of next week, pending delays. Until then, stay safe.

Update at TASO

Hello, hope all you guys had an enjoyable 4^th. Most Ugandans had no idea it was America’s Independence Day last week, so I had to report to work. There were three conversations I had throughout the week that I found to be pertinent to HIV prevalence.

Last week was a fairly quiet week at TASO. Monday consisted of lab work and some filing. Tuesday was more adventurous as the day was spent in the field. We went to two sites, both of which were relatively small, only 12 patients at each site. Since there wasn’t an overload of patients, I assisted in documentation and preparation of supplies for the nurses to draw blood. The car-ride back to TASO was filled with discussion about why HIV is so prevalent. While SMC and safe sex practices were listed as ways of reducing the prevalence, they don’t target the root of the problem, which a lot of TASO’s staff believes to be behavior and the will to better one’s self in all aspects of life. This conversation carried over into Friday’s workday. I was stationed with Lawrence, a counselor who is congenial enough to talk to even the most rugged of patients. In between counseling sessions, after Lawrence explained to me what had been said, we began discussing what might affect behavioral issues. Lawrence informed me that the conception of a family in Eastern Africa is very different, almost deranged from the point-of-view of a Westerner. A man may have multiple ‘wives’ whom he will have children with all of them. From what I gathered, having children is like a badge of honor; the more children a man has, the more respect he commands from his peers. Children are the currency for popularity. This is pre-empted by the Busoga culture, which covers the domains of Jinja and some of the surrounding area. More importantly, there is no family planning involved when having children (in most cases). Darwinian tendencies come into play, as those clever enough to fend for themselves survive, while the weak fail to adapt and perish. While this method of child rearing may yield stronger and robust future generations, it allows HIV and reckless behavior to endure.

Friday also provided me the opportunity to talk to/counsel a mother who could speak English! She was the mother of four children, with the three eldest in boarding school. The youngest accompanied her mother, and was a year away from entering primary school. Her husband had ‘separated’ from her, but they were still technically married; no one else knew about their split up, primarily out of fear that her peers would chastise the mother for not being a better wife/mother. Her financial burdens are many; as a seamstress, she spends her time making clothing, and is always traveling in order to sell her creations. She has to make sure there is enough food for both her and her daughter, and that she has enough money to pay for her daughter’s upcoming schooling. Her husband provides no financial support, as he refuses to pay for his daughter’s education. I learned from her that life as a single parent with multiple children can be very tough, but also that uneducated Ugandan men will do as they please. I am still baffled that the father will not pay for his daughter’s education. He knows he can get away without paying, as his wife is too timid to speak up against him or consult additional help. This behavior sickens me, as it is irresponsible and cowardly. Unfortunately, it is typical of a lot of uneducated Ugandan husbands to act this way, and to leave their wives to fend for themselves and their families. Maybe this stems from Busoga culture, but I’d have to conduct more research before making that claim.

Following my time with this client, I resumed my conversation with Lawrence as we began discussing President Museveni and the anti-gay laws. The consensus we arrived at is that Museveni has shot himself in the foot. Museveni toured the country when the bill was still in discussion in Parliament, championing the bill. After it was signed into law, he publicly celebrated it’s passing. The law could be viewed as the foundation for his platform in the upcoming 2016 presidential election, as it confirms that Museveni has been an active in trying to ‘improve social issues’ amongst Ugandans. Unfortunately for him, he did not expect the US and other nations to boycott the law by cutting funding. HIV/AIDS organizations everywhere are beginning to hurt. TASO, for example, is already planning to make cuts to their faculty. Originally, there were 18 counselors for all the patients TASO receives, but now there are only 11. TASO needs to reduce that number to six in the coming months, meaning the workload for one counselor will triple on average. This is due to a lack of funding; the CDC is TASO’s biggest donor and without them, TASO can’t afford to keep as many workers around to attend to a growing clientele. This downward spiral, coupled with increasing HIV positive patients is a script for disaster. Museveni most likely will not raze the anti-gay laws, as doing so would be hypocritical, severely harming his chances at re-election. Simultaneously, HIV prevalence is going to become much worse in the next couple of years without funding, a consequence that could harm his popularity. Museveni is in a jam.

These conversations concluded what was otherwise a hushed week. This week, I will be a part of more counseling sessions in addition to some excursions to nearby clinics, to assist them. I also plan to learn more about Busoga culture. If patriarchal arrogance is a notion instilled by the culture, then is it possible that getting rid of the culture, or amending it, will reduce HIV prevalence? Is that even an ethical thing to say? Is it even ethical for a Westerner to try to impart his own culture on a society that has followed a certain model of life, even if he believes his ways will improve gender equality and reduce HIV prevalence?