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HIV Heroes Photographs by Nell Freeman December 1, 2008 marks the 20th anniversary of World AIDS Day. The impact of HIV on sub-Saharan Africa has been particularly cruel, leaving 12million children orphaned, and making it home to 22million people living with HIV or AIDS. Despite these facts HIV/AIDS is no longer the bewildering catastrophe it once was. Over the past 30 months photojournalist Nell Freeman has worked in Sudan, Senegal, Cote d’Ivoire, Kenya, Uganda, Tanzania, Zambia, Malawi, Morocco, Madagascar, Ghana and the Democratic Republic of Congo, meeting the unknown leaders of this change. She found the stories by working with international NGOs Christian Aid, AMREF, Concern Universal and the International AIDS Alliance, with African hospitals and universities and, asking people impacted by HIV and AIDS if they know someone ‘whose work is making their life better’. This work tells the stories of individuals across Africa caring for those affected by AIDS and ending the spread of HIV. They are true heroes and deserve our celebration. KAMPALA, UGANDA: Zam and Edriss are a discordantly HIV positive couple, meaning one is HIV positive and the other HIV negative. Discordancy places tremendous strain on a relationship, creating fears of infidelity, abandonment and rejection. Unusually, Zam and Edriss have chosen to stay together. Their room is bare apart from the mosquito net issued by the clinic to protect against greater susceptibility to malaria because of HIV infection, and two bottles of ARVs on the bedside table. Zam says "When I learned he wasn't positive I thought he would stop loving me." Edriss replies "But I stayed, of course I did."

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Thanks to the work of almost entirely unrecognised individuals, HIV/AIDS is no longer the automatic death sentence that it formerly represented to many Africans. The number of people dying from AIDS is falling. The number of new HIV infections across Africa is stable or falling. Helvina Phiri is a teacher at Chiwoko Basic School in rural Zambia: ‘As educators we felt it had become necessary to teach our students about HIV - as necessary as mathematics’. In Madagascar, sex workers led by Patricia, their co-operative president, refused to rent rooms unless the hotel manager provided condom disposal bins. The AngloGold Ashanti Goldmine in Geita Tanzania has made HIV prevention, testing and care available not only to all of its miners, but also to the local community. These stories are evidence that the 6,800 new infections per day can be lowered and that anti-retrovirals can be effectively distributed across Africa. Meeting this need would stop AIDS being subSaharan Africa’s biggest killer. In the past 20 years the image of and response to AIDS has changed beyond recognition. While many of these changes are positive, this anniversary offers an opportunity to highlight how much more still needs to be done.

BOLE, GHANA: Samuel T Damamga and Mary Basio, HIV positive activists. "People ask me, why have you sold yourself out? You should have just taken your drugs and stayed quiet. Others say, if I come out about my HIV then yes, I can get my drugs, but soon I will be out of my job and my family will turn against me and I wont be able to pay for the drugs or food anyway. Either way I die. And if I stay quiet and deny myself drugs yes I will die, but I wont die alone. I say, it is the hiding in the room that causes you to die - but after crying, crying, crying, I came out of the room to talk. If I had stayed in the room I would certainly have died. I don’t why people have chosen this sickness to hate. It is just a sickness. I really don't understand.

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NYIMBWA, UGANDA: (L-R) Zubedda, Nakato, Babiryi and Kabwama Dirisa hold the hens they were given so they can sell the eggs and support themselves. The children are orphans whose family is affected by HIV. Kabwama Dirisa says "Five people live in my home. Us and a big lady - my grandmother. I like the chickens but the best thing about them is that I can sell their eggs and get some money. I will not use the money to buy sweets, I will use the money to buy more chickens or maybe even a cow in the future. Eventually I would like to be a businessman and sell cars are all across Uganda. I don't yet know the name of my business but I am thinking about it. After that I will want no more than one wife and three children, but now I must pass my exams and finish primary school."

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KALANGALA ISLAND, UGANDA: Georgie Walakira is an HIV peer educator who has helped co-ordinate the delivery of 3 powerful motorboat engines which can be attached onto wooden fishing boats and used to transport patients needing specialist HIV care from the islands to the mainland. HIV is a particular problem on the islands because a large proportion of the men work as fishermen like the men behind him. Andre Kaggwa, Secretary of 'Te Mpauro Talikabe AIDS Group' explains: "Being fisherman means you are a man with money. On small islands there might not be any population apart from the fishermen and the women who follow. There are many more men than women so they have to compete with their money. Fishermen are nomads. They follow the movement of the fish, and the virus follows along with them."

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ABIDJAN, IVORY COAST: Margaret Doe (R) and 3 women who are sex workers who tested themselves for HIV at the mobile clinic parked outside the 'La Villa Hotel' where the women work. Margaret Doe, 56 years, peer liason worker: "I am the one who goes to the girls. I tell them we are working for a clinic and its free, free, free, free to treat yourself. Come to treat yourself. Don't let it get serious. They will come if you talk to them softly and I know how to talk. I tell them, we have a doctor and all the drugs. And inside is air conditioning. You can sit in the air conditioning and see the doctor and you will not pay anything and they are happy with that. There should be more clinics like this, it is very good. It is better than the hospital because you don’t have to pay. I was born in Accra, but I left my husband because I am a very jealous woman. I was working as diamond trader when someone stole them so that is how I became a sex worker. I stopped being a sex worker 3 years ago because its no good for me I don't like it. After I stopped that I went to work at a market selling second hand clothes. I like this job of peer liason because it is better than being a prostitute, but I want to be a big mama and have lots of money."

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DAKAR, SENEGAL: JAMRA is a primary school for children whose lives are affected by HIV/AIDS, drugs or poverty. It is a Muslim based education. Bamar Gueye, National General Secretary of JAMRA Islamic School for children affected by HIV and AIDS, says "We run a school of 200 students for children affected by HIV/AIDS either infected themselves or orphaned. We also include other children. We mix the childre n- those that are infected, those that are affected and those that aren't. To us all children are the same. We teach the very youngest that AIDS is a new illness. We show drawings. With the older ones they start to ask questions, but we go very gently as they are young and can be fragile. At the start it was difficult for us Muslims to talk about AIDS, but all religions are the same in that respect. Many in our community said we should not talk about AIDS in the mosque. They said 'This is a place for sanctuary and prayer not AIDS', but I say that we come from the same spiritual perspective of caring for our people. I have a lot of hope for AIDS in Senegal. The students are engaged in the fight against AIDS. The imams can speak in the mosques and relieve some of the stigma for those living with HIV. We have hope for Senegal but it must be a global fight."

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NAIROBI, KENYA: Jane Wamboi, 48, an HIV-resistant sex worker and mother of two, at the Majengo Clinic at Pumwani Hospital. She is part of a 20-year research study of how certain women who are frequently exposed to the HIV virus manage to remain uninfected. Over 3000 of these women have been recruited into the study. Once enrolled, they receive free healthcare and must return every month for a brief medical exam, blood test and vaginal swab. Jane receives around 5 clients a day, at 500 Kenyan Shillings (USD $6.25) each. She has tested negative for HIV since she started with the project 18 years ago. There are genetic marker differences between the women who are HIV resistant. This resistance is sometimes lost if the women stop being frequently exposed to HIV. When they return to sex work, there is an increased likelihood that they will become infected. This has led to the idea that specific antibodies can be produced in the vagina in response to frequent low-level HIV exposure, rather than immunity in the blood. This research is being used to help develop an HIV vaccine. It is an example of the 'return to basics science' called for by Anthony Fauci, head of the National Institute of Infectious Disease, after the complete collapse of two very promising vaccine trials in 2007. More people given the vaccine became HIV positive compared to those given the placebo vaccine. Jane Kamene, nurse at the Majengo Clinic states "People talk about resistant cells, but I know them as women. I see them differently than the scientists in the labs. They know them as sample numbers, but I know them as Editha, Jane and Mary. They are a group of very special women and we have grown together like a family."

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NAIROBI, KENYA: The 'Pumwani Sex Workers Cohort' is a 20-year research study of how certain women who are frequently exposed to the HIV virus manage to remain uninfected. The UNITID lab is where blood and tissue cells are analysed by Kenyan and Canadian researchers from the University of Manitoba. More than 3000 women who are frequently exposed to HIV have been recruited into the study by word of mouth and outreach work. Once enrolled they receive free healthcare and must return every month for a brief medical exam, blood test and vaginal swab. Mary Musya (top-right), one of the study participants, receives around 4-7 clients a day, at 500 Kenyan Shillings (USD $6.25) per visit. She has tested negative for HIV since she started with the project 10 years ago. There are genetic marker differences between the women who are HIV resistant. This resistance is sometimes lost if the women stop being frequently exposed to HIV by stopping sex work. When the women return to sex work, there is an increased likelihood that they will become infected. This has led to the idea that specific antibodies can be produced in the vagina in response to frequent low-level HIV exposure, rather than there is an innate immunity in the blood. This research is being used to help develop an HIV vaccine. It is an example of the 'return to basics science' called for by Anthony Fauci, head of the National Institute of Infectious Disease, after the collapse of two very promising vaccine trials in 2007. More people given the Merck vaccine became HIV positive compared to those given the placebo vaccine.

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LUSAKA, ZAMBIA: Aaron Kaile (R) consults traditional healer Dr. Stephen Mkangala (L), who has agreed to work with the local medical clinic and now refers patients who he believes may be HIV positive to the clinic for testing and treatment if needed. In turn, the clinic refers patients back to him for psychosocial support.

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Top left & top right: JUBA, SOUTHERN SUDAN: Prisoners at the Sudan People's Liberation Army prison at Old Custom's Yard Juba receive training on how to use condoms. This information was new to many of the prisoners, partly because of the strong stigma against using them, and also the inaccessibility of condoms in most areas of the country. SPLA soldier and Counsellor Majok Ding inserts a wooden prosthetic penis into his trousers to demonstrate condom use to make it as realistic a demonstration as possible. The training sessions are co-ordinated by the SPLA HIV Secretariat, whose head is Lieutenant Colonel John Woja. The secretariat was created in 2005, although there was intial little activity as soldier were still returning from the front lines. Lieutenant Woja has been in charge since the department's creation. They are trained and supported largely by NGOs rather than the government. Lieutant Colonel Woja states "We are diverse as military, but wherever we are, there is always HIV/AIDS. The enemy is big. It has already entered our territory in Southern Sudan. In such a battle you cannot fight alone. That is the only way we can win the war. We need to contain the enemy. That is very, very important. I hope if all of us work together, we will contain the enemy and stop it advancing any further. If not? Then it will be a disaster."

JUBA, SOUTHERN SUDAN: A prisoner at the Sudan People's Liberation Army prison at Old Custom's Yard Juba receives voluntary HIV tests. Counsellor Majok Ding (L) tests a prisoner's blood with HIV-1 ELISA reagent and they wait for his result to appear. In this case, the prisoner's test was inconclusive and he will have to be re-tested. Majok and his colleague Alfred have set up a temporary testing clinic in the office of the prison governor.

JUBA, SOUTHERN SUDAN: A prisoner at the Sudan People's Liberation Army prison at Old Custom's Yard Juba receives voluntary HIV tests. This man demonstrates that he has been tested before.

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MANJI, GHANA: Salii Ibrahim gives a condom demonstration. Behind her, her uncle conducts his Friday prayers. Salii was asked by the district imam leaders to become a peer educators. She had to leave school at 17 when she became pregnant. "The chief chose me to be a peer educator because I had been to school and am educated. I was happy he chose me. I wanted to learn more about HIV. At first we didn't even know how to use a condom. We thought they were useless and that they can come off and get stuck inside you. Buying condoms here is ok. Anyone can get them they are cheap, cheap, cheap. I tell people if you go to a man and he doesn't want to use a condom go somewhere else. He is not the only man around."

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GEITA, TANZANIA: AngloGold Ashanti Goldmine. Mines are normally areas of high HIV levels, spreading to the surrounding community, but prevalence at Geita goldmine is 2%. At a nearby mine it is over 20% and in Tanzania is 8%. Christine Mkambula, nurse and counsellor at the mine's healthcare clinic, explains, "Keeping people healthy is business for the mine. They need healthy workers to make them their money so it makes sense to increase our HIV programme. We have condoms all over the site in every open space, and there is no longer any family who has remained untouched by AIDS. People are getting tested because before it was just about living on hope but now it is about ARVs. I can see it physically, that our HIV prevalence is low. We display condoms everywhere here. If someone wants more we don't ask, we just give. It is pretty clear why someone wants condoms! The town clinic is a good idea. Here at the mine clinic people can feel that everyone will know their business, but in town there is more anonymity. But in the town the women are also more vulnerable. They think all the men from the mine have a lot of money. The women at the mine will know which of the men is a good one and which is one who is proud of his money who feels he can then do anything with his body. They have more information. In the town the women don't know. We need to empower the women in town with knowledge for them to do business instead of depending on their bodies. There is a lot of migration to this area with men for the mines and with women from Rwanda and Burundi and all over for work as hostesses and guest houses. Without the constant pressure of the programme we have we could be in a really terrible situation."

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BICHEM, GHANA: Members of the Love and Understanding Women's Group. Asana Tankeo, 42, is the co-ordinator of group, which meets following the Friday afternoon mosque prayers. "There was no group for women here so I led the process. We needed it for solidarity. There is more power from a group then in going solo. Today we talked about faithfulness and how to avoid HIV both for ourselves and our husbands. We should share experiences and help our husbands with any problems. Abstinence is the best way to avoid and being very faithful to your husband. Our biggest achievement is the group itself. We are aware of our reproductive health and bodies and we also advise each other on marriages, names for the children and things like that. We also save. We have millions in the account now (USD $1 = Old Ghana Cedis 12,000) and use it to support each other with our small businesses for short term loans. Do I fear for HIV? Yes. I fear for every member of my family for HIV. I take good care of the children and tell them that if they need anything at a family level they can turn to me. I tell them how to abstain from sex and to support their friends in this. I talk to them about condoms, but for me, I am married and feel we are faithful so we don't need to. If I found my daughter had condoms I would talk to her about protection. I would tell her protection is ok but abstinence is better."

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ABIDJAN, IVORY COAST: Dao Korotoum, a 19-year-old sex worker, stands in the door way of her work room. On the wall outside is a credit system devised by the women where clients who have brought a gift such as clothes or toiletries will receive a credit for a certain number of visits dependent on the value of the gift. Dao had just received her latest HIV result which said she was negative. She regularly gets herself tested for HIV.

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Contacts

Getty Images London 116 Bayham Street London, NW1 0BA United Kingdom Steve Blogg steve.blogg@gettyimages.com +44 (0) 20 7424 8036 Patrick Di Nola patrick.dinola@gettyimages.com +44 (0) 20 7428 5256 The full set of 96 images is available via your local Getty Images office.

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HIV Heroes