SAN SALVADOR, El Salvador — Carla, in her late 40s, is a big-boned woman who feels trapped in her male body. In the deeply homophobic culture of El Salvador, the confusion over her sexual identity nearly got her killed.
It takes courage to be gay in Latin America, and especially in El Salvador, where a sizeable portion of the country is controlled by gun-toting street gangs with a concept of masculinity that does not allow for much nuance.
Being a professional sex worker at night didn’t help. An enraged potential male client shot Carla nine times. Released from the hospital, she was shot again.
In 2001, she was thrown in jail and tested positive for HIV/AIDS.
“I didn’t want to believe it,” Carla recalled. “I didn’t know what to do.”
Prison saved her life. After doctors detected the disease, she was able to start taking anti-retroviral treatment. Today she's a dynamic activist in the city’s transvestite community.
The anti-retroviral treatment would not have been available, and Carla would probably be dead by now, if it had not been for the Global Fund, an innovative, relatively new actor on the international development scene.
The fund provides a revolutionary model by investing in carefully structured projects proposed by governments or nongovernmental organizations (NGOs). To avoid corruption, the aid money is not simply handed over. Enough money is granted to get a project started, but before additional funds are released, the project must achieve clearly identified benchmarks that are independently audited.
If the project is not working, the funding is suspended.
“We offer an 85 percent to 90 percent success rate on investment, said Jon Liden, the Global Fund’s head of communications in Geneva. “That is unique.”
The fund — whose full title is the Global Fund to Fight AIDS, Malaria and Tuberculosis — is loosely tied to the United Nations. G8 countries provide roughly 80 percent of the funding, with the United States responsible for about 30 percent. Norway, which kicks in $4 million, has the highest per capita contribution.
El Salvador now has one of the lowest HIV/AIDS rates in Central America, less than 1 percent of the population. But that could change quickly, especially since an estimated 50 percent of cases go unreported. The rate of HIV/AIDS among men having sex with men is nearly 18 percent, the highest in the region. HIV/AIDS among sex workers ranges from 3 percent to 16 percent depending on the area of the country.
The solution, analysts say, is a combination of education, free testing and affordable treatment with retrovirals. Social change and a respect for sexual identity are also key elements.
“I didn’t even know that I was gay,” said Kassie, a friend of Carla’s. “I didn’t know that I was a homosexual. Little by little, I learned about sexual orientations.”
The actual relationship between the Global Fund and cases like Carla's is indirect but effective. The government of El Salvador handles 85 percent of the cost of HIV/AIDS, but it would not have been able to afford the retrovirals needed to save Carla without the financial boost from the fund.
A strong point in the fund’s philosophy is that the initiative for dealing with the problem needs to come from the country itself, rather than being imposed from the outside.
“Demand is a concrete thing,” Liden said. “It is need distilled into investable action.”
Additionally, the fund provides a platform for members of local NGOs and civil society to be in regular contact with officials in their own government. The byproduct is a dialogue that gives the government better insights into public issues and gives the NGOs a chance to improve communications with the government.
The fact that the fund holds the purse strings also frees other international development organizations to act as mentors. In El Salvador, the United Nations Development Program (UNDP) is training local NGOs to write effective grant requests, and to structure projects that work. It’s a development version of the classic good cop-bad cop approach (with the fund playing the role of bad cop).
Traditionally, NGOs raise money on an individual basis either from private donors or from large organizations, such as the U.S. Agency for International Development. The groups then have to report back to donors on what they actually accomplished.
Now organizations like the UNDP can present themselves as mentors, helping governments and others meet the standards set up by the Global Fund. If those standards aren't met, it's the Global Fund that cuts off the funding, not the organizations. The process insulates organizations from pressure to relax their standards.
Today, Carla works as a coordinator for a local aid group, called Rainbow, which advocates for transvestite rights. The problems Rainbow deals with can be as basic as trying to decide whether you are a man or a woman on a health insurance form.
Transvestites are only one element in El Salvador's fight against HIV/AIDS. Grants through the Global Fund are also helping orphanages for children whose parents died from HIV/AIDS. The cost of running an orphanage may be less than $1,000 a month, but even that would not be possible without the boost provided by the fund.
“Before we didn’t have enough money to buy supplies. Now we do. We couldn’t afford the level of training. Now we are being challenged to maintain higher standards," said Cecilia Quintamiglia, director of the Fondacion Esperanza y Allegra, one of the several orphanages for children with HIV/AIDS.
El Salvador’s prison system is another focus. Esperanza, the main prison for men in San Salvador, was designed for 800 inmates. Today, it houses 4,000, including violent gang members.
The threat from HIV/AIDS has provided an opportunity to bring warring factions together in a struggle for mutual survival.
“I told them God will decide when you die, but it is not going to be now,” said Anna Parada Estrella, a doctor working inside the prison system.
For some women, prison has provided an opportunity for crucial education about the disease. Maritza was arrested for smuggling marijuana to help her husband, a gang member. She contracted HIV/AIDS after sleeping with him, despite knowing he was infected. Why did she do it?
“I loved him,” she explains softly.
From the fund’s point of view, the goal is to equip people to make the right choice before it is too late.
“We are doing much more than saving individual lives,” Liden said. “We are enabling people to establish human rights for every citizen in their country.”