The political economy of HIV prevention in Ghana: peer education, queer social reproductive labor, and the global development industry

ABSTRACT

Peer education has become an increasingly popular mode of community-level human immunodeficiency virus (HIV) prevention around the globe. In Ghana, networks of volunteer peer educators are mobilized by non-governmental organizations (NGOs) to conduct sexual health outreach among populations disproportionately affected by HIV, including men who have sex with men (MSM). In development discourse, peer education is typically rationalized in terms of its cost efficiency and “community empowerment” objectives. This article explores whether these initiatives are indeed “empowering” for the working-class men who work as MSM peer educators in the Ghanaian capital, Accra, as well as their broader impact on queer political organizing. Empirically, the article draws on ethnographic research conducted between 2013 and 2014, including participant observation in an HIV/MSM NGO, group and life story interviews with peer educators, and semi-structured interviews with key civil society actors involved in HIV/MSM and wider lesbian, gay, bisexual, trans, and intersex (LGBTI) rights work in Ghana. The article conceptualizes peer education as a form of social reproductive labor that is systematically devalued and frequently invisibilized within the global capitalist economy. It further argues that, contrary to the intervention’s core “empowerment” aims, peer education in Ghana places a disproportionate burden of responsibility on queer working-class men in dealing with the HIV epidemic, increases peer educators’ risk of homophobic violence and abuse, and engenders division between working-class queer communities and the civil society organizations that are supposed to represent them.

KEYWORDS:

• HIV
• social reproduction
• peer education
• LGBTI rights
• Ghana

Introduction

Peer education interventions to prevent the human immunodeficiency virus (HIV) have been implemented extensively across the Global South since the 1990s (Medley et al. 2009). In many contexts, including Africa, they continue to constitute the cornerstone of HIV prevention efforts at the micro level. Peer educators are typically engaged by non-governmental organizations (NGOs) on a voluntary basis to carry out HIV prevention activities and other sexual health outreach work among populations disproportionately affected by HIV, including men who have sex with men (MSM) and female sex workers. The World Health Organization (WHO) defines peer education as a “community empowerment-based intervention” for which “the benefits are high, there are no harms and the required resources are relatively low” (WHO 2012, 21). This article explores whether these initiatives are indeed “empowering” and harmless for the working-class men who work as MSM peer educators in the Ghanaian capital, Accra. It also considers how these interventions impact on the wider terrain of queer political organizing in this context. Theoretically, I do so by reading peer education through the lens of social reproduction theory – that is, as part of the “life-making” activities that are systematically devalued (and frequently invisibilized) within the global capitalist economy (Bhattacharya 2017). Empirically, I draw on ethnographic research conducted in Ghana between 2013 and 2014 – namely, participant observation in an HIV/MSM NGO, group and life story interviews with peer educators, and semi-structured interviews with key civil society actors involved in HIV/MSM and wider lesbian, gay, bisexual, trans, and intersex (LGBTI) rights work in Ghana.

In 2013, a Special Issue of the International Feminist Journal of Politics sought to challenge the assumption that incorporating sexual minorities necessarily offers a “pathway to progressive politics” and to uncover instead how “inclusions can be murderous by shifting the focus from their promise to their violences” (Haritaworn, Kuntsman, and Posocco 2013, 445). Elaborating on the theme of “murderous inclusions,” Andil Gosine examined the integration of MSM into sexual rights advocacy efforts in development, as part of what he termed a “risk-rights” strategy. Using evidence from the Caribbean, he argued that “the particular ways in which MSM have been brought into the fold as targets and clients of development have also come at an enormous cost,” primarily because MSM are framed as a public health risk to heterosexual populations – that is, as “murderous men” (Gosine 2013, 477). Gosine’s article contributed to a corpus of scholarship that examines the politics of MSM interventions and their implications for local queer communities and identities, notably through social anthropological studies of development (Boellstorff 2011; Boyce 2007; khanna 2011). In this context, development’s discourse of MSM “community empowerment” is primarily studied in terms of its (dis)connections from/to local subjectivities and ideas of selfhood and critiqued for its embeddedness in Western individualism, liberal rights frameworks, and biomedical ways of knowing. This scholarship provides rich insights into the opportunities and constraints of conceiving of MSM as a sexual/epidemiological category and as rights bearers in development policy (and what this means across different spatial and temporal contexts). However, it does not typically conceptualize peer education as a form of (queer) labor, nor does it consider the links between neoliberal development processes, relations of social reproduction, and the provision of preventative HIV services for MSM more broadly.¹

This article seeks to address this gap and, in so doing, to re-engage with the Special Issue’s concern over the “queer move to inclusion” within the context of LGBTI politics and global development aid. It does so by considering the “cost” of MSM inclusion (Gosine 2013, 477) from a different perspective: by theorizing peer education work as a form of social reproductive labor. Here, the article brings insights from the feminist political economy literature on social reproduction, and specifically women’s empowerment approaches in development, to bear on the experiences of working-class MSM peer educators in Ghana. The article critically advances the existing feminist political economy scholarship on gender and development by centering forms of sexualized reproductive labor among queer men in the Global South (as opposed to the extant literature’s predominant focus on women and gendered forms of labor) and by illuminating how this labor is mobilized and co-opted by the global development industry. This analysis provides valuable new insights into the everyday political economy of the global HIV response, as this is shaped by neoliberal development policies and practices and relations of social reproduction.

The article argues that global HIV initiatives not only rely on queer men’s (unpaid) material and affective contributions to care, but also have a divisive effect on local queer politics and forms of organizing – namely, by (re)producing class hierarchies. This qualifies accounts that identify the emergence of HIV activism (including peer education programs) as a key driver or “catalyst” for LGBTI organizing in the Global South (Roberts 1995) and in West Africa in particular (Armisen 2016; Broqua 2015). Instead, I interpret peer education as a form of social reproductive labor that, contrary to the intervention’s core “empowerment” aims, places a disproportionate burden of responsibility on working-class queer men in dealing with the HIV epidemic, increases participants’ risk of homophobic violence and abuse, and drives a wedge between working-class queer communities and the civil society organizations (CSOs) that are supposed to represent them. Responsibility for these dynamics does not lie with the local NGOs who recruit and co-ordinate networks of peer educators across the Greater Accra region; rather, it reflects the unequal power relations that are (re)produced through global development processes and the political economy of aid, as well as the intersections of race, sexuality, class, and geopolitics that mediate queer lived experience in Ghana.

The article proceeds in four parts. First, I consider feminist political economy work on social reproduction, the “care crisis,” and women’s empowerment approaches in development, and evaluate what insights this offers for the study of HIV prevention initiatives involving MSM. I then briefly set out the overarching political and policy context shaping HIV and LGBTI activism in Ghana and offer an analysis of peer education programs for MSM. The next section uses group and life story interview material to explore how these programs are experienced and understood by MSM peer educators themselves. These findings highlight three key issues that, I argue, undermine claims to “community empowerment” and reveal an unequal and ultimately exploitative set of power relations in peer education: financial and affective costs, recognition, and accountability and representation. Finally, I conclude by considering the implications of these findings for the political economy of HIV prevention, as well as avenues for future study.

Social reproduction: from women’s work to HIV initiatives

Since the 1970s, a wealth of feminist scholarship has sought to render visible the role and value of social reproductive labor within the global capitalist economy (Bakker 2007; Bhattacharya 2017; Dalla Costa and James 1972; Federici 2004; Laslett and Brenner 1989; Vogel 2013 [1983]). At its most basic level, social reproduction is defined as “the maintenance of life on a daily basis and intergenerationally” (Laslett and Brenner 1989, 382–383), with women understood to carry a greater burden of social reproductive labor than men. While early work on social reproduction primarily focused on women’s unpaid contributions to domestic labor and household (re)production, social reproduction scholarship has taken on new theoretical and analytical directions in the neoliberal era. This literature highlights how changing regimes of capital accumulation have led to “increasingly privatised forms of social provisioning and risk” (Bakker 2007, 541), particularly in the Global North, documents the varying relations of social reproduction outside Europe and North America (Arslan 2022; Kunz 2010; Mezzadri, Newman, and Stevano 2022; Naidu and Ossome 2016), and centers social reproduction in discussions of everyday political economy (Elias and Rai 2019; Elias and Roberts 2016). Though far from homogeneous, this scholarship reveals how life-making activities under neoliberalism (and the social relations that organize them) are mediated by shifting regimes of accumulation, dispossession, and exploitation, and by multiple axes of oppression, including gender, race, class, caste, nationality, and citizenship.

To clarify how we might conceptualize peer education in this context, Catherine Hoskyns and Shirin Rai’s expanded definition of social reproduction is useful. In this account, social reproduction entails

biological reproduction; unpaid production in the home (both goods and services); social provisioning (by which we mean voluntary work directed at meeting needs in the community); the reproduction of culture and ideology; and the provision of sexual, emotional and affective services. (Hoskyns and Rai 2007, 300)

According to this definition, the unpaid, voluntary labor that undergirds HIV prevention programs can be understood in terms of its social reproductive function, since it encompasses the provisioning of care and affective and emotional services at the community level. This work is neither fully privatized, since it does not take place only within the family or through kinship networks, nor fully socialized, since it is supported by civil society actors who do not cover all of the costs, particularly in terms of labor.

The emergence of a “care crisis” in the Global North is another significant area of discussion within the feminist social reproduction literature (Bakker and Gill 2003; Fraser 2016; Hoskyns and Rai 2007). Broadly speaking, this work suggests that, as provisioning in child, health, and social care has been rolled back, the costs of – and responsibility for – social reproduction have been increasingly transferred from the state back to individuals and households, through a process of “reprivatization” (Bakker 2007; Bakker and Gill 2003). The care crisis is thus rooted in the deep, structural contradictions of maintaining and reproducing life under contemporary modes of financialized capitalism and represents one facet of a broader, multidimensional “crisis of social reproduction” (Fraser 2016). While the salience of the “reprivatization” thesis has been questioned in countries such as Mexico (Kunz 2010), across much of Africa, social reproduction has been characterized by similar patterns of commodification and crisis, albeit in this context through the imposition of structural adjustment programs (SAPs) and other forms of neoliberal restructuring (Ossome 2021).²

In Ghana, the social welfarist policies of the post-independence era gave way to deep public spending cuts and sweeping market-oriented reforms during the 1980s, followed by continued market liberalization in the 1990s (Konadu-Agyemang 2000). In health care, this entailed the systematic introduction of user fees, a so-called “cash-and-carry” system that resulted in widespread health inequalities and poor health outcomes for large swathes of the population (Abukari, Kuyini, and Mohammed 2015). It is in this context that women’s unpaid care work (and the household more broadly) has been understood as a crucial “shock absorber” for the effects of SAPs in countries such as Ghana (Elson 1992). This landscape of limited state provisioning, inadequate health infrastructure, widening inequality, and ongoing crises of social reproduction – which have been exacerbated by the HIV epidemic – is also the context in which queer men have found themselves increasingly caught up in development’s “global health–human rights nexus” (Biruk 2020, 478). This is a complex web of public–private relations that comprises states, international organizations, international financial institutions (IFIs), development agencies, and NGOs.

Feminist scholars of development have long documented how the types of poverty reduction and gender equality interventions that proliferated within development policy in the 1990s impact on social reproduction. One key policy change from the structural adjustment era was an increased role for civil society and a turn toward the language of women’s “empowerment” (Molyneux 2006, 429). However, studies show that, in practice, conditional cash transfer programs and microfinance initiatives serve to advance the commodification of women’s labor power, intensify the unequal division of labor, and reinforce patriarchal gender norms (Chant 2008; Molyneux 2006; Parpart, Rai, and Staudt 2006). Significantly, these programs frequently rely on women’s voluntarism, resulting in what Sylvia Chant (2008, 187) calls the “feminisation of responsibility and/or obligation.” By sourcing women’s productive labor on a voluntary basis (and not addressing their disproportionate responsibility for social reproductive labor), economic empowerment programs paradoxically serve to increase the overall burden of labor on women. These processes are racialized as well as gendered in character; thus, as Kalpana Wilson (2015, 807) explains, the production of “hyper-industrious, altruistic, entrepreneurial female subjects” in neoliberal development discourse is bound up with wider processes of extending and intensifying women’s labor across the Global South, as a central strategy of global capital accumulation.

This evidence draws attention to the increasingly powerful role of transnational governance actors such as the World Bank and the International Monetary Fund in re-structuring the organization of social reproduction across parts of the Global South. It also illuminates the political economic logics and imperatives that underpin development interventions on women’s empowerment, particularly when contextualized within the World Bank’s “gender equality as smart economics” framework (Roberts and Soederberg 2012) and broader trends of upscaling civil society and downscaling state provisioning (Ruckert 2010). Of particular relevance to this study is how empowerment approaches premised on voluntarism have contradictory and/or negative impacts on existing gender power relations and the distribution of (re)productive labor and how this works to reinforce patriarchal norms. To date, however, scant attention has been paid to these dynamics in the context of development interventions on HIV and peer education work among MSM, with “gender” still largely operating as a synonym for “women” in much of this literature (and the underlying theoretical framework centering patriarchy rather than heteronormativity).

This is not to suggest that queer sexualities have been entirely ignored by scholars of (the political economy of) development; there is an established body of scholarship that seeks to “queer development” and, in particular, to highlight how global governance and development processes discipline and regulate queer intimate relations (Budhiraja, Fried, and Teixeira 2010; Jolly 2000, 2007; Lind 2009, 2010). One key area of critique pertains to development policy’s enduring investment in heteronormative household models (Drucker 2009; Jolly 2011), which promote a heterosexual “two-partner model of love and labour” (Bedford 2005, 301) and exclude other non-normative household arrangements (Bergeron 2010). This literature has usefully begun to disentangle how development discourses, structures, and policies reinforce relations of heteronormativity and homonormativity under neoliberalism (Lind 2010; Rao 2015). However, it has largely focused at a discursive, policy, and macro or meso level, such as by examining the practices and policies of IFIs (Bedford 2005, 2009; Gosine 2013, 2018; Rao 2015) or by looking at how development discourse constructs queer subjectivities and sexualities (Jolly 2011), including MSM (Gosine 2013, 2018). One key exception to this trend is Shana Ye’s (2021) study of social reproduction and the HIV/AIDS (acquired immunodeficiency syndrome) industry in China. Ye argues that China’s emerging HIV/AIDS economy relies on “queer intimate labour,” primarily among tongzhi (a Chinese word meaning “comrades” that is used to refer to queer men). She links this economy to transnational labor regimes that (re)produce workers’ precarity, which she argues are structurally sexualized in character, as part of the “homonormative division of labour” (Ye 2021, 1788). While this article shares Ye’s concern for the micro-level impacts of HIV interventions and their social reproductive dynamics, I explore this using an alternative approach – namely, by examining MSM peer education in relation to development discourse on “empowerment,” forms of gendered and racialized labor, and the crises of social reproduction associated with neoliberal economic restructuring. Finally, then, the article builds on studies of community health workers and the everyday political economy of global health emergencies, as this is characterized by neoliberal privatization and dynamics of social reproductive depletion (Nunes 2020; Sekalala 2021). It does so by looking at unpaid community peer educators in the context of the global HIV response.

Peer education as “community empowerment”

Empowerment is a nebulous, “elastic” concept in development discourse (Cornwall 2016, 342). While it has a long history in feminist activism and social movements (Batliwala 2007; Cornwall 2016), the concept has become increasingly disconnected from its more radical roots as a result of its incorporation into mainstream development policy and practice. The fuzziness surrounding empowerment is reflected in the peer education literature, where the underlying theoretical rationale for the approach has not always been consistent or well defined (Turner and Shepherd 1999). Typically, peer education has been associated with concepts of credibility, empowerment, reinforcement, role modeling, and cost effectiveness (Turner and Shepherd 1999), and has been grounded in behavioral change theory (UNAIDS 1999). More recently, the empowerment dimension of peer education has taken on greater prominence in the health policy literature, where peer education approaches are specifically rationalized as models of “community empowerment” (see for example Campbell and Mzaidume 2001; Kerrigan and Weiss 2000; UNAIDS 1999; WHO 2012). The WHO’s (2012, 21) assertion that there are “no harms” associated with peer education is understandable if assessment is based exclusively on health-related metrics among target populations (though the evidence base for this is at best patchy³). However, given the significant challenges that many MSM peer educators face across the Global South (and parts of the Global North), which include criminalization, stigmatization, and elevated levels of anti-queer violence, this seems like a problematically partial assessment. It also highlights the extent to which the impacts of peer education approaches on peer educators themselves – that is, as a discrete group of individuals (and workers) – have not been routinely or systematically evaluated in the African context.

What does emerge clearly from the health policy literature – and documents such as the WHO guidelines – is that, in addition to empowerment, a key reason for the popularity of peer education approaches is their perceived cost effectiveness, primarily because they do not use fully qualified or trained health care personnel (Hutton, Wyss, and N’Diékhor 2003; UNAIDS 1999; WHO 2012). In this sense, they are again consistent with the neoliberal development imperatives of downscaled public service provision and upscaled reliance on civil society actors.

A number of these assumptions can be discerned in Ghanaian HIV policy and practice. The Ghana AIDS Commission (GAC) National Strategic Plan identifies the protection of the social, economic, and human rights of key populations (KPs) as part of its core strategies, which is to be achieved through a range of activities, including offering support for community advocacy by providing “technical assistance and material support” to “CSOs and PLHIV [people living with HIV] associations’ advocacy on promoting and protecting the rights of KPs” (GAC 2016, 94–95). While the protection and promotion of rights for KPs is undoubtedly a laudable commitment, this has been hampered in reality in Ghana by the ongoing prohibition of same-sex relations, stigmatization, and entrenched forms of political homophobia, including among key national stakeholders. These barriers and constraints also mean that, in practice, it is the biomedical and individual-level aspects of behavioral change – such as partner reduction and condom usage – that predominate in HIV prevention interventions among MSM in the country (rather than the rights-based, “community empowerment” aspects). In the following section, I examine in more detail how HIV policies for MSM play out at the micro level in Ghana, with a particular focus on the role of MSM peer educators.

Peer education interventions in Ghana

Overview

Since the late 1990s, a small number of NGOs have been working on HIV/MSM rights in Ghana, both in Accra and in other large cities such as Takoradi and Kumasi. Some of these organizations have also incorporated a focus on LGBTI rights, though their advocacy activities have been constrained by the hostile legal, political, and cultural forces that govern minoritized sexualities in the country. Under Ghana’s “unnatural carnal knowledge” law (first imposed by the British during the colonial era), sexual relations between men are criminalized. At the time of writing, an “anti-LGBTI” bill (formally called the Promotion of Proper Human Sexual Rights and Ghanaian Family Values Bill) is being debated within the Ghanaian parliament, which would significantly strengthen and expand the law’s existing anti-LGBTI provisions. This bill reflects the growth of politicized homophobia in Ghana over the last two decades, which has been fueled by anti-gay religious, political, and media elites (Mohammed 2019) and represents, in part, a backlash against burgeoning activist demands for LGBTI rights.

At the same time, Ghana has developed one of the most comprehensive HIV policies on the African continent (Gyamerah 2017; Makofane et al. 2013). Notably, this has entailed the recognition of male same-sex transmission and the prioritization of MSM as part of the country’s strategic response to the HIV epidemic, led by the GAC. Shifts in Ghanaian policy have both contributed to and been shaped by the steady evolution of national governmental responses to HIV across Africa. This reflects improved understanding of the socio-demographic and geographic distribution of HIV, how this distribution is shaped by structural factors – such as poverty, gender inequality, homophobia, and discrimination – as well as behavioral and clinical ones, and the development of appropriate and targeted interventions for those most at risk.

It is against this complex and contradictory political and policy background that key national stakeholders have rolled out peer education programs targeting KPs in Ghana. For the purposes of this research, in 2013 and 2014 I interviewed 30 peer educators who had either previously worked or were currently working for Accra’s longest-running HIV/MSM NGO. All of my research participants were men (or assigned male at birth), aged between 18 and 45, and identified as MSM (or more typically saso, a Ghanaian word used to refer to queer men). I also undertook extensive participant observation within the HIV/MSM organization, and conducted five group interviews with peer educators and ten semi-structured interviews with civil society workers involved in the field of HIV/MSM and LGBTI activism. In the interests of confidentiality and identity protection, research participants have been given pseudonyms.

This study raised complex ethical issues, especially in terms of the power relations shaping the research process and my positionality as a white, queer British researcher. Beneath a veneer of commonality produced by shared experiences of queerness, the relationship between myself and my research participants was deeply marked by class relations, geopolitical and racialized hierarchies, patterns of uneven development, and colonial legacies. I sought to navigate these asymmetrical power relations by drawing on feminist postcolonial epistemologies and methodological approaches, which foreground questions of power, knowledge, and positionality in the research process.⁴

Understanding the role of a peer educator

According to the GAC’s Standard Operating Procedures (SOPs), MSM peer educators in Ghana are responsible for “day-to-day community outreach activities; providing information, education, and services to their peers in project sites; compiling weekly narrative reports; and mobilising KPs for prevention, care, and/or treatment educational programs” (GAC 2014, 63). As this short description suggests, peer educators play a central role in HIV prevention and sexual health outreach work among KPs. Indeed, the SOPs go on to specify an extensive range of duties that peer educators are expected to carry out. This comprises over 20 separate activities, many of which are linked to specific metrics, such as the provision of one-on-one and small-group sessions on HIV prevention, condom and lubricant demonstration and sales, the referral of peers for sexually transmitted infection (STI) services, and the referral of peers for testing and counseling services (GAC 2014, 63). The level of detail in this job description, for what is essentially a voluntary role, is striking. Moreover, as Akua Gyamerah (2017, 241) documents, when these job responsibilities are cross-referenced with the minimum package of services set out in the SOPs, peer educators are given “the most responsibilities in carrying out the minimum package of services in MSM HIV/AIDS efforts” across all service providers and implementing partners.

As part of their employment, peer educators receive a stipend, known locally as an “allowance.” At the time of my research, this was approximately 240 Ghana cedis per month (then equivalent to around 40 British pounds). The stipend is intended to cover travel expenses, as well as any other costs arising from the work. While the GAC’s more recent SOPs state that peer educators “can be engaged on a stipend or as fully paid staff members depending on the financial capacity of the implementing partner” (GAC 2018, 17, emphasis added), all of the MSM peer educators I interviewed were in unpaid voluntary roles and I encountered no fully paid peer educator staff members during my fieldwork. Thus, though peer educators are paid a monthly allowance, I classify this work as “voluntary,” since the allowance is only supposed to cover expenses arising from the work (and structurally peer educators occupy a different position to paid NGO staff). Nonetheless, it is important to recognize that, in the absence or scarcity of alternative forms of paid work, whether formal or informal, many men use their volunteer allowance as a kind of wage. Frequently, this forms part of a wider portfolio of informal income generation activities through which they attempt to make ends meet.

In terms of monitoring and evaluation, peer educators are expected to fulfill certain weekly and/or monthly quotas, which are set and agreed upon by implementing partners, in light of the overall targets and objectives specified by the funders for each intervention. These quotas pertain to indicators such as the number of new peers reached, the number of condoms distributed, the number of peers accompanied to an STI clinic for testing, and the number of peers referred for HIV testing and counseling (GAC 2014). Each peer educator’s performance is then monitored and evaluated against these metrics through various mechanisms – namely, field observations, monthly review meetings, and the submission of weekly reports.

Experiences of MSM peer educators in Ghana

Financial and affective costs

All of the peer educators I interviewed in Ghana stated that the money offered to them by the organizations engaged in peer education is insufficient, not only in comparison to a proper wage that would cover living costs, but also to meet the basic expenses arising from the work, such as travel, condom distribution, and testing and counseling. As indicated in the SOPs, for example, rather than providing condoms and lubricant for free, peer educators are expected to sell these items to their peers, since it is envisaged that the financial investment, however small, will act as an incentive for the men to use them. To do this, peer educators buy the condoms beforehand from the NGO, which, along with other expenses such as travel, significantly eats into their stipend. These micro-level practices are reflective of what Alan Ingram (2013, 438) calls “entrepreneurial rationalities” in the global HIV response – that is, the ways in which market logics are operationalized and rationalized through a neoliberal “discourse of scarcity.” In the Ghanaian context, these logics are both embedded in and reproductive of the material conditions in which peer education programs are implemented. As Adam, a former peer educator and community activist, noted, for example, often MSM peers do not have any money to pay for condoms or for the STI or HIV testing services that they are encouraged to use. In these situations, many peer educators end up paying for these items and services out of their own pockets: “For those with HIV, they are not living. So I talk to them, I counsel them, I pay their hospital folders,⁵ even consultation fees to see doctors. I pay it with my own money.”

This suggests that, in practice, some of the key micro-level costs of peer education work are being borne by volunteer peer educators. There are also what could be termed “affective costs” as well as financial ones. Both during his time as a peer educator and since leaving his role, Adam has sought to provide material and emotional support to queer men who are affected by HIV and other STIs. In a seemingly intentional reversal of the preferred public health term “person living with HIV,” he described these men’s lives as bereft of vitality (alive but not alive) – a situation that he seeks to counter by giving money toward medical fees and by offering counseling and support. In the context of widespread health inequalities, stigmatization, and discrimination, this support role takes its own emotional toll on peer educators such as Adam.

As well as financial and affective costs, research participants also noted that they are often required to work longer hours than officially recognized, as their responsibilities are considerably more time consuming than accounted for. It is notable that the SOPs do not stipulate an exact number of hours that peer educators are expected to work; in practice, this depends on how quickly and effectively they fulfill their quotas. Peer educators’ extensive official (and unofficial) responsibilities, combined with the lack of adequate financial remuneration, have prompted a number of research participants to leave peer education. As in Adam’s case, this was not because they intended to stop community outreach work altogether, but a reflection of growing anger over the terms and conditions of their involvement in peer education and with national and international development organizations. The fact that many of these men continue with community activism, which is in itself both voluntary and unpaid, suggests that the issue is not exclusively or essentially about financial reward, but a question of compensation, recognition, and “who benefits.”

Recognition

Even among the most long-standing peer educators I interviewed, issues of financial compensation engender a great deal of anger and resentment. Research participants emphasized that they carry out some of the most difficult, dangerous, and time-consuming aspects of development organizations’ work on MSM rights in Ghana, while at the same time failing to benefit from or be appropriately recognized for their contributions. Marcus, a former peer educator who was involved in some of the earliest outreach initiatives among MSM in Ghana, explained that peer education is challenging and skilled, requires dedication, and is fundamentally different to the “office work” of NGOs:

As for MSM interventions, it’s not theory. It’s not just theory, you sit there in your office and write reports. No, it’s pure practical work. You have to talk to a person and you will know, it’s very difficult. You have to always be there.

Marcus’ comment “You have to always be there” parallels Adam’s description of the support that he offers to queer men in his community and sheds further light on the demanding, time-consuming, and affective character of peer education in general.

The contrast that Marcus drew between the office and report-writing activities of NGOs and the “pure practical work” of peer education illustrates the powerful sense of difference that exists between peer educators and NGO-based staff. Given the myriad duties, metrics, and monitoring and evaluation procedures that are imposed on MSM peer educators, this is perhaps not surprising. Yet anger over the symbolic and material status of NGO staff among peer educators also illustrates how inequalities are (re)produced through neoliberal development processes and funding regimes. These processes and practices prioritize an NGO-ized “professional technocratic approach” over a more political, grassroots one (Tsikata 2009, 186). They also work to co-opt some (professional) civil society actors into the structures of neoliberal global governance, while excluding and/or marginalizing other, potentially more radical, actors. This co-optation can be understood as part of the broader processes through which neoliberal development interventions facilitate the exploitation of certain forms of gendered and racialized labor across the Global South (Wilson 2015) – in this context, the “sexualized” social reproductive labor of working-class queer men.

According to a number of research participants, it is not only the scale and scope of their involvement in peer education, and the dedication that this requires, that makes the work so difficult. By engaging in very visible forms of outreach – which often extend beyond the original remit of HIV and sexual health rights education – peer educators also find themselves at increased risk of homophobic violence and stigmatization. Gabriel and Adam explained:

Gabriel: Sometimes we, the peer educators, go [to the community] and they beat us.

Adam: Yes they will beat us. They don’t understand us. They say you are teaching people how to do MSM.

Here, Gabriel and Adam described being physically attacked by community members who suspect that they are seeking to “promote” homosexuality through their peer education activities. These dangers were further highlighted by Kobby, one of the youngest activists I met, who shared the experience of a peer educator who committed suicide following a homophobic attack:

May his soul rest in perfect peace … He went for outreach and he was doing education and then this group of guys just barged into the room and started beating him, saying “Gay.” They could see the penis model, condom, everything.

Kobby caveated this story by explaining that the peer educator had already “been through so much.” In Kobby’s view, it was the cumulative effect of his colleague’s experiences of violence and homophobia that led him to take his own life. Nonetheless, as this story demonstrates so heartbreakingly, peer education work entails a great deal of personal risk for the men involved, not least because of the visibility that it brings to them and to the groups of queer men they gather together in the community. This illuminates the very material, violent, and occasionally tragic consequences of politicized homophobia for working-class queer men engaged in sexual health rights work in this context. It also undermines the WHO (2012) claim that peer education is high benefit and harmless.

Finally, many research participants noted that carrying penis models, condoms, and lubricant – the mobile toolkit of a peer educator – is risky and attracts attention, as does wearing the branded T-shirts supplied by funders to identify them as peer educators. Some explained that they had explicitly requested not to wear branded T-shirts on the grounds of safety. However, their requests were refused by NGO staff, who told them that this is a key criterion of the funding and therefore the project’s implementation. This response again reflects the technocratic managerialist logic that accompanies NGO-ization in Ghana; that is, it is symptomatic of the top-down and at times hierarchical management practices adopted by some local NGOs. It also demonstrates the extent to which smaller NGOs – which are operating in the context of stringent funding conditions – fear losing donor monies or patronage for not following the “rules of the game,” even when this puts their intended beneficiaries at risk of physical harm. These dynamics indicate that development funding regimes premised on fixed, quantifiable targets and outcomes and upward-facing reporting and accountability mechanisms are insensitive to the contexts in which activists are working. Moreover, they serve to reinforce rather than unsettle existing divides and power asymmetries, in this context, between the more middle-class sphere of Ghanaian civil society and working-class community networks (and in some instances make them worse, by increasing queer individuals’ risk of homophobic violence or abuse). The divisive impacts of peer education programs in Ghana and the extent of disillusionment and frustration among those engaged by NGOs to carry out this work challenge the credibility of these interventions’ claims to “community empowerment.”

Accountability and representation

Another related source of contention among research participants was the discrepancy between the salaries of NGO workers and peer educators’ volunteer allowances. This feeling of inequality was compounded both by the sense that working-class queer men are undertaking the most difficult aspects of this work and are not being sufficiently compensated for their efforts, as described above, and by the lack of representation from queer individuals within the organizations themselves. Almost all of the peer educators and community activists I interviewed were critical of the lack of representation from and accountability toward working-class queer communities within the NGOs engaged in MSM/HIV and LGBTI rights work in Ghana. Nii, another former peer educator, explained:

In Ghana, LGBTI organizations are not accountable to the LGBTI communities. Organizations working for the community should be ready to be accountable to the community: “This is what we use the money for. This is how you are involved. These are the reports. This is what happened.” When it happens that way, then it is a 50:50 job. You are accountable to us and we help you do this.

This finding parallels Dzodzi Tsikata’s critique of the impact of “national and global neoliberal agendas” on women’s organizations in Ghana, which are characterized by a “lack of a mass base, connection and accountability” (Tsikata 2009, 186). However, Nii raised the issue of financial as well as programmatic accountability, an allusion that reflects broader suspicions among peer educators as to where and how funding for MSM programs is being used in Ghana and the political economy of global development aid. Anthony, another former peer educator, explained further:

Funders and donors always give money to people who are not really doing the work but just sit in their offices. They write big, big reports about MSM and then they collect monies from them. Monies go into the wrong hands and there is mismanagement.

Anthony’s comment about “people who are not really doing the work” reflects the feeling that peer educators are, at best, being inadequately recognized for and, at worst, being exploited by their involvement in HIV prevention work. For Anthony, it is the NGOs writing “big, big reports” that claim recognition and financial reward for peer educators’ work and activism from donors, while at the same time mismanaging and misdirecting funds away from the intended beneficiaries.

Concerns over financial and programmatic mismanagement were echoed by many other research participants and were frequently tied to criticisms of the lack of representation and participation from queer men and the wider LGBTI community within development organizations. As Frankie, a former peer educator now working for a different MSM/HIV organization, noted, “Things for the people must be done by the people.” Frankie’s comment reflects the importance that queer men attach to the right to self-organization and the right to self-determination, a sentiment that has resulted in some peer educators leaving NGO-led sexual rights work in Accra to start up their own more independent, community-focused groups.

Queer caring labor in and beyond peer education

While feminist scholars have largely focused on the gendered implications of development processes for social reproduction, this analysis suggests that these processes also incorporate the unpaid labor of other subordinate subjectivities – namely, working-class queer men. There are obvious parallels here with the ways in which some gay and lesbian communities in Europe and the United States – though not necessarily framed in terms of social reproduction in the literature – played a critical role in providing care and support to those affected by the AIDS crisis during the 1980s, in the face of inadequate institutional response and widespread state indifference (see Shepard 1997; Weeks 2000). Indeed, many of the peer educators I interviewed reported that their work encompasses community aftercare, support, and informal caring for men diagnosed and living with HIV, in addition to the activities detailed in their job description relating to health promotion and prevention. Moreover, the combination of extremely limited resources and structural barriers to treatment means that this work is emotionally challenging and at times distressing, an issue that was raised again and again by activists involved in HIV work in Accra.

One key difference from the situation in the 1980s is that, in the context of MSM interventions, queer men are being formally incorporated into these programs by key policy, government, and civil society actors at local, national, and international levels (and that considerable development funding has been channeled into this approach); in other words, peer education is a widely adopted policy and programmatic priority in development. As in the case of women’s work in the Global South, then, there is theoretical, empirical, and political urgency in rendering visible this type of (racialized and territorialized) social reproductive labor, especially in the African context, where the everyday, intimate practices of queer individuals have been historically overlooked and where queer people continue to face multiple forms of oppression and exploitation.

Conclusion

The findings of this study raise serious questions about how HIV prevention programs are operationalized at the micro level in Ghana, particularly in terms of their reliance on voluntarism and unpaid labor, their effectiveness in relation to supposed empowerment objectives, and the divisive impact that they have on local forms of queer politics. Understanding these dynamics requires us to look beyond the health-related impacts of MSM interventions and to consider how peer education programs are entangled in (and shaped by) neoliberal development processes, structures of heteronormativity, and ongoing crises of social reproduction.

By examining queer men’s experiences as peer educators in detail, this article has conceptualized peer education as a form of queer social reproductive labor that is articulated and mobilized through neoliberal development discourses of empowerment. The contingent, contradictory, and (as I have argued) exploitative ways in which MSM are incorporated into development policy and practice shows how queer bodies and labor, like women’s bodies and labor, effectively act as “shock absorbers” in the crises of social reproduction characteristic of the neoliberal era. While the contribution of MSM peer educators to this type of caring labor may be relatively small in global terms, in the context of a health emergency such as the HIV epidemic, it plays a critical role in tackling the effects and spread of the disease (and, in so doing, in maintaining the health of the working-age population). It also fits into broader shifts in how social reproduction is organized, managed, and distributed across the globe. This has important implications not only for how we conceptualize the everyday political economy of the global HIV response, but also for how we understand the relationship between social reproduction and the global governance of health and human development more broadly.

My intention here has not been to attribute responsibility for these dynamics to the small, local NGOs involved in HIV/MSM and LGBTI rights work in Ghana. Rather, the frustration of peer educators and other community activists with existing HIV/MSM organizations reflects the limitations of global health/human rights approaches in development, how development processes work through (and reproduce) structural inequalities (including the uneven distribution of resources), and the negative consequences of NGO-ization for political activism in this setting. Put more simply, in a context where HIV/MSM organizations compete for a highly circumscribed set of funding opportunities and are subject to top-down, bureaucratic, and frequently unrealistic management and performance targets, they struggle to connect with the concerns and needs of working-class queer communities. At a macro level, this is similarly not to suggest that these patterns form part of a joined-up or universally agreed-upon ideological strategy in development to co-opt working-class queer men (or to tap systematically into the power of queer reproductive labor). Rather, the actors driving these processes are best understood as a multifarious coalition that includes donor governments, IFIs, and international development agencies, as well as activist groups and NGOs, whose varying agendas and priorities have cohered around HIV prevention within the broader context of neoliberal restructuring. In this way, the organizational and community power dynamics, inequalities, and labor relations that arise from peer education-led HIV prevention initiatives are both shaped by and constitutive of more macro-level transformations in the global economy.

Theoretically, the findings of this article suggest that future studies of the health–rights nexus in development should pay greater attention to social reproduction approaches and to the types of labor and laborer on which these interventions rely, particularly where the interventions focus on sexual rights. They also suggest that queer social reproduction should be studied in specific relation to neoliberalism’s crises of social reproduction both within and beyond the Global North, to illuminate how these crises are constitutively sexualized in character (in addition to being gendered, racialized, and territorialized, and bound up in relations of class domination). Finally, the accounts of peer educators and community activists in Ghana reveal queer intimate practices as a site of both exploitation and resistance, with queer men such as Adam continuing to assert agency in the face of profound structural inequalities and forms of oppression. This challenges reductive narratives of “African homophobia” and underscores the importance of centering everyday forms of resistance in international political economy, across diverse terrains of struggle.

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No potential conflict of interest was reported by the author.

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Notes on contributors

Ellie Gore

Ellie Gore is a Lecturer in Global Political Economy in the Department of Politics at the University of Manchester, UK. They have published various journal articles and book chapters on sexuality, labor relations, and the political economy of development, with a geographic focus on Ghana. Their monograph Between HIV Prevention and LGBTI Rights: The Political Economy of Queer Activism in Ghana is forthcoming with University of Michigan Press (2024).

Notes

1 For an important exception, see Ye (2021).

2 As Lyn Ossome (2021, 71) notes, however, the political economic roots of this crisis in Africa and other postcolonial states predate neoliberalism and must be understood in relation to “the structure of economic monopolies created by colonialism, sustained by an imperialist neocolonial order, and entrenched by neoliberal capitalism.”

3 There is a lack of good-quality data on the effectiveness of peer education interventions in sub-Saharan Africa, especially when it comes to assessing the impact of individual- and group-level interventions on reducing HIV incidence (Beyrer et al. 2012) and on increasing testing in low- and middle-income countries such as Ghana (Shangani et al. 2017).

4 For a fuller discussion of feminist ethics and reflexivity in the context of this study, see Gore (2018).

5 As part of the “cash-and-carry” system, new patients are required to pay a small fee to set up a folder pertaining to their care.