The battle against Aids in Africa: Behind the pain, there's hope

When actress Ashley Judd, a global ambassador for YouthAIDS, visited Madagascar, her diary recorded how she discovered an extraordinary spirit of optimism - as well as heartache
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For some reason I am very emotional today. Maybe it was the message I woke up to from Dario [Franchitti, husband and racing driver] who called as he watched a nearly full moon rise that made him think of me. And maybe it's because I saw a man holding a young child while he supervised from the street as his wife, a commercial sex worker, had sex with a client in a nearby rice tent. What separates Dario and me, another married couple, from the grave misfortune of Madagascar that I see all around me? However, I also feel serene, having created a protected, peaceful space in our room. And, more importantly, I have made an altar on which I put my incense for harmony and love, powerful spiritual iconography, Nelson Mandela's autobiography, and other items. Moyra, Kate and I blessed the space (and ourselves) with a yoga practice this afternoon, concluding with a long prayer which I dedicated to our teachers. The easy stuff, the hard stuff, the eternal stuff. But it is possible I am confusing serenity with depression.

Today I have begun to see beyond Madagascar's physical beauty and into its extraordinary poverty. The land is lush, but 88 per cent of Madagascar's rural population do not have clean water, and they suffer the consequences of that with the usual tragedies.

All of these things are preventable, including an unacceptably high maternal and child mortality rate.

The land produces fruit, but earns the population no money as 60 per cent of it rots before it can be exported - farmers cannot afford to transport it. And that lovely thing about there being no litter is because there is nothing to throw away, and if people do have something it is creatively recycled and too valuable.

Only half the children have any vaccinations, and the same number are malnourished and stunted. The rural infrastructure is extremely minimal, and our mission of delivering life-saving messages and goods, such as clean water treatment, insecticide treated mosquito nets, maternal and child health education products and, of course, HIV/Aids prevention, is confronted with a whole new galaxy of challenging puzzles. Fortunately, we do have some good funding here from both USAID and The Global Fund. It's money I am seeing in action today both in terms of ideas, programmes and the motivated, dynamic personnel who implement these positive health impact changes for the people of Madagascar.

The HIV/Aids story is that the proportion of the population infected is still fairly low - 1.1 per cent - but the epidemic is accelerating and stigma is extreme. I have spent a good deal of my time here trying to find HIV sufferers who will admit they are infected, which is a frightening but necessary step towards reconciling a fearful and subsequently cruel society with the compassion necessary to embrace prevention. The woman I am waiting to see now is afraid her family will reject her bones upon her death and that she'll not be buried with her ancestors, the importance of which we can barely understand in the West. Another woman is an otherwise empowered, poised, modern mother who founded the first and only HIV support group in the country, which meets secretly in her home every week. She will not step out in a public forum. The layers of cultural beliefs and practices, stigma and religion are huge obstacles to educating and protecting public health. But if people can't talk about it, how can they be educated against it?

These women illustrate the female vulnerability to transmission and demonstrate why we are so passionate about saturating the country with messages, not just to the classic high risk groups. The first woman had multiple partners, which is typical in Madagascar, and was infected by one while her boyfriend was away studying. The latter was infected by her husband, with whom upon marriage she had tested negative. Her husband contracted HIV during their marriage through an outside partner, and she learned of her condition when she was seven months pregnant with twins. The first woman has already buried one of her children due to HIV/Aids.

We walked a narrow, red dusty street lined with tiny shops selling small goods. The shops are smaller than ice cream stands and the space behind the rough wood counter is barely big enough for a person.

On a café patio I met with Annie: a tiny, lovely looking woman, terribly frail and missing some teeth but quick to smile and giggle. She explained that she has a message for her people and it is to be wise. Aids is here, and it is not something made up as a reason to spend money - which is one of the rumours here. It will infect and kill you if you don't protect yourself.

She will not say this openly, only to me. She believes she'll be dead in a year and her entire outlook is geared toward that. I told her that in the name of Jesus I rebuked that fear, and she smiled - we have in common that our favourite thing is to pray.

I asked how she does it, conversationally or with recitations, and she said she gets on her knees and talks to God, which made me remember how once I was taught to remember we are small but God is big. She liked that, too.

She had a glass of cow's milk and told me her husband is also infected. They don't know who was infected first. Her children are 11 and 14, and her mother is the only other person she has confided in. She was on medication, but became too malnourished to swallow the pills.

Moyra suggested we take a nice picture so that she could leave it to her children, and also that Annie might write something for them. Annie is literate, so that is a possibility. We told her about the secret meeting for HIV sufferers and she was keen to go, although she won't tell her husband - even though he has HIV too. We're sending a car to pick her up from a remote spot so no one in her neighbourhood will see her leave. That is consistent with her palpable fear of being found out, as we'd had a lot of drama finding a place to meet with her. Our first choice was another café but one of her relatives works there and she panicked until we found a different spot.

Madagascar has one of the highest rates of sexually transmitted infections (STIs) in the world. There is a 20 per cent rate of male sterility due to diseases such as syphilis and gonorrhea. STIs are such a part of the life that they are considered rites of passage, and thought of as something you could pick up riding your bicycle. But if we can explain the medically accurate reproductive health we teach to even some of the younger population, it will soon be relevant in their lives and help empower them to prevent a huge variety of health problems for themselves and their partners. Given the reality of STIs and HIV, it is possible that it may even save their lives.

Our next activity was a good example of how we make education and prevention interesting and fun, and a classic Youth-AIDS moment of fulfiling our mission of upbeat and positive HIV prevention amongst young people.

We drove along a road made of clay that is dug up to make rough bricks. The resulting surface is a rugged, pocked stretch that curls between rice fields, out to a lovely, but high malaria risk, field.

We were near a rural village where one of our mobile video units was set up to entertain and help educate 300 villagers. Our DJ was working the microphone with fun music and chat, and everyone was shouting and partying, only there was no misogyny or violence in these videos. The messages were about abstinence, staying in school, being faithful to one partner, and correct and consistent condom use. The shining faces were joyous, and even remembering them is making me cry. So sweet, so dear, so terribly excited. Fewer than 6 per cent of the population have television, and only 16 per cent make it through high school, so the media and anything that needs to be read are not effective tools of information dissemination. Such an evening is a huge thrill for these people. It's like a drive-in movie arriving in the field next to your house, when you've never seen a movie in your entire life. The young adults randomly selected to come up to play games and take pop quizzes handled themselves with such poise, and shyly danced with me after they answered questions, bouncing up and down in their fashion of dancing.

I went to to play with the children, one of whom looked at me plaintively with her arms raised, wanting to be held. Many bounced up and down.

Ashley Judd went to Madagascar with YouthAIDS, The Global Fund and VH1