In_A_Life_Care_and_Support

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IN A LIFE ACCESS TO CARE AND SUPPORT


IPPF IN A LIFE

Our Vision IPPF envisages a world in which all women, men and young people have access to the information and services they need; a world in which sexuality is recognized both as a natural and precious aspect of life and as a fundamental human right; a world in which choices are fully respected and where stigma and discrimination have no place.

Our Mission • IPPF aims to improve the quality of life of individuals by campaigning for sexual and reproductive health and rights through advocacy and services, especially for poor and vulnerable people. • We defend the right of all young people to enjoy their sexual lives free from ill-health, unwanted pregnancy, violence and discrimination. • We support a woman’s right to choose to terminate her pregnancy legally and safely. • We strive to eliminate STIs and reduce the spread and impact of HIV/AIDS.

Our core values • IPPF believes that sexual and reproductive rights should be guaranteed for everyone because they are internationally recognized basic human rights. • We are committed to gender equality, and to eliminating the discrimination which threatens individual well-being and leads to the widespread violation of health and human rights, particularly those of young women. • We value diversity and especially emphasize the participation of young people and people living with HIV/AIDS in our governance and in our programmes. • We consider the spirit of volunteerism to be central to achieving our mandate and advancing our cause. • We are committed to working in partnership with communities, governments, other organizations and donors.


ACCESS TO CARE AND SUPPORT Introduction The International Planned Parenthood Federation (IPPF) and its Member Associations work to mainstream HIV/AIDS into its sexual and reproductive health policies, programmes and practices. Following a rights-based approach, we work to remove the barriers that make people vulnerable to HIV/AIDS, reduce societal and individual stigma and discrimination, and provide access to information and prevention and care services. IPPF Member Associations address care in the broader sense of the word. All people, positive and negative, have a right to services that prevent and care for HIV/AIDS, sexually transmitted infections and unwanted pregnancy. By focusing on the sexual and reproductive rights of all individuals, with an emphasis on the marginalized, vulnerable and socially excluded, we care for women, men and young people holistically. The increased availability and accessibility of anti-retroviral treatment is making it possible for people living with HIV and AIDS to enjoy full sexual and reproductive health and lead productive lives. Unfortunately, women, young people, and individuals from marginalized populations will face the same barriers accessing HIV care that they face accessing health care in general. Equitable access to care requires empowering women and reducing their care burden when there are other sick persons in the family. It also requires targeting services to young people and other groups with limited access to care, eliminating discrimination against sex workers, males who have sex with males and injecting drug users, and eliminating discrimination against people living with HIV. Efforts to uproot AIDS-related stigma and discrimination require the cooperation of all segments of society. Individuals, families, communities and institutions can all harbour stigma and must be encouraged to critically examine how their words and actions affect people living with or vulnerable to HIV. Most crucial is the meaningful involvement of people living with HIV in all prevention and care efforts. Continued advocacy for prevention is vital in order to keep up with the international momentum of care programmes. HIV prevention and care services are linked, with care

Photo: IPPF/Philip Wolmuth/Dominican Republic

programmes offering an opportunity for increased prevention. As more people access care, HIV/AIDS stigma decreases, leading to more people getting tested, learning their status and seeking care, and encouraging both positive and negative people to be proactive about protecting themselves and their partners. Access to care strengthens access to information and prevention. IPPF Member Associations provide integrated HIV/AIDS and sexual and reproductive health care services. We work to increase access to clinical care services, decrease stigma, discrimination and other barriers to care, and link prevention services to care. The following pages tell how our Member Associations have brought access to care into the lives of women, men and young people. From offering HIV voluntary counselling and testing at churches to Joveria in Uganda to operating a revolving fund for antiretroviral treatment for people like Thomas in Suriname, IPPF gives individuals access to the care services they need to have a healthy sexual and reproductive life, that are indeed ‘access to life.’ 1


IPPF IN A LIFE

INTEGRATING HIV/AIDS AND SEXUAL AND REPRODUCTIVE HEALTH CARE

Photo: IPPF/Jenny Matthews/Bangladesh

“The medicines have given me a life back. I am able to go out again, go shopping.�

Giving Hope in Suriname Stichting Lobi, Suriname Thomas had pretty much given up all hope. He is a 45year-old man living with HIV in Suriname, and antiretroviral (ARV) treatment could save his life. Like most people living with HIV in his country, however, the cost of treatment is far beyond his means. HIV prevention strategies depend on the twin efforts of care and support for those living with HIV/AIDS, and targeted prevention for all people at risk or vulnerable

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to infection. The importance of proactively addressing care issues as a means of preventing an escalation in prevalence rates is globally recognized. And together with a host of in-country partners including the HIVSeropositive Treatment Group, Stichting Lobi (the Suriname Family Planning Association), initiated a campaign to provide accessible and affordable treatment for people living with HIV. Realizing that AIDS-related complications were increasingly becoming one of the leading causes of death and AIDS treatment was out of reach for the majority of the population, a small group of medical doctors who were at the time treating a few HIV-positive people with donated anti-retroviral (ARV) drugs decided to start an emergency Revolving Fund. The Fund’s primary goal is to ensure that life-altering HIV/AIDS medications are within the reach of those most in need. The Anti-Retroviral Revolving Fund is making medication available at a reasonable price in Suriname at a time when the vast majority of those in need cannot access medicines through other channels. It is estimated that over 500 HIVpositive persons will eventually need therapy, of whom 100 are in immediate need of ARV treatment. Although the cost of generic ARV drugs is constantly declining, the cost of treating those 100 persons is well beyond the purchasing power of most patients and the public sector. By providing access to treatment to a network of people living with HIV/AIDS, Stichting Lobi has already witnessed a number of additional results beyond extending the quality of life and care for those infected and affected by the epidemic. The fund has resulted in increased awareness in the Suriname community about people living with HIV. By altering the perception that people living with HIV are victims or sufferers and can – with the right treatment and care – lead productive lives, there has been a reduction in stigma and discrimination towards those infected and affected by HIV/AIDS. Compassion, solidarity and responsibility are now key ingredients in the response towards HIV/AIDS. This was evident in the way people fundraised and donated at a telethon that raised over US$200,000 for the Revolving Fund. With the money raised by the telethon the fund can also take up the treatment of pregnant women in order to prevent transmission from mother-to-child. Improving the quality and length of the mother’s life will decrease the number of AIDS orphans. Since the public announcement about the fund there has been an increase in the number of people seeking counselling and testing services. People living with HIV now have a more positive outlook about their personal circumstances and are more willing to register

IN BRIEF: Merging Sexual Health Services with HIV/AIDS Care Sensoa, Belgium The former association of family planning centres in Belgium (CGSO Trefpunt) made a pioneering step to mainstream HIV/AIDS prevention and care into sexual and reproductive health and rights services in 2003. It merged with Sensoa, an organization focusing on sexually transmitted infections (STIs) and HIV/AIDS. Its objective is to promote sexual health, paying special attention to the quality of life of people living with HIV and AIDS. Sensoa operates from three locations (Antwerp, Ghent and Brussels), with more than 50 dedicated staff members. It is divided into six operational units, and operates five programmes targeted at adolescents, adults, gays/lesbians/bisexuals, migrants and people living with HIV. Sensoa is now the official partner of the Flemish Ministry of Health in sexual health prevention activities. Sensoa is active in HIV/AIDS prevention, care and treatment. Prevention activities are conducted by a number of different programmes, including the HIV/AIDS and STI Hotline. The Living with HIV Unit offers a number of care services, including individual counselling, a buddy system, HIV-cafes and a hotline for family members. In 2003, Sensoa launched the HIV prevention campaign ‘Facing Facts’ with flyers, postcards, posters and a website to target males who have sex with males. For World AIDS Day, Sensoa produced radio and TV spots focused on stigma and discrimination that were broadcast by Flemish public radio and TV and all local TV stations. Sensoa also offers emergency financial support for people living with HIV through its ‘Care for AIDS’ fund.

themselves at a doctor’s office and access the treatment they need. The fact that a larger number of HIV-positive persons are willing to be registered is helping medical specialists, health workers and policy-makers to understand the impact and magnitude of the AIDS epidemic and to better deal with HIV and HIV-related issues. Increased access to life-improving medications has empowered the HIV-positive community to seek out the prevention and care services they need and has improved their quality of life. “The medicines have given me a life back” said Thomas. “I am able to go out again, go shopping. The medicines have really given me my life back while I had already resigned myself that I was close to my death.”

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IN BRIEF: Integrated HIV/AIDS and Sexual and Reproductive Health Care Services for Soldiers Lebanon Family Planning Association (LFPA) The Lebanon Family Planning Association (LFPA) has been working with the Lebanese Army since 1975 in conducting awareness raising activities and offering HIV/AIDS and sexual and reproductive health care services in Army clinics. LFPA identified the need for sexual and reproductive health information and services among all levels of military personnel, and it has subsequently focused on providing information and ensuring adequate services at military dispensaries. Eleven army barracks throughout the country were targeted by LFPA staff to provide their clinics with sexual and reproductive health services. LFPA reached 141 medical doctors and army chiefs with sexual and reproductive health information through a series of capacity-building sessions over a period of three months. The themes discussed during these sessions included HIV/AIDS, sexually transmitted infections and male involvement in sexual and reproductive heath. In turn, the medical doctors who had been trained by the LFPA staff disseminated information to other medical staff such as male and female nurses who work in the military clinics. Linking capacity-building for clinical services with educational activities means that soldiers in the Lebanese Army get the information they need to make choices about sexual and reproductive health, and have a place to go when they choose to access care.

Integration through Voluntary Counselling and Testing Association Burundaise pour le Bien-être Familiail (ABUBEF) The Burundi Association Burundaise pour le Bien-être Familiail (ABUBEF) began mainstreaming HIV/AIDS services into its sexual and reproductive health programmes in 1994. The focus at that time was on providing information and counselling on the modes of transmission and prevention. Gradually more services have been added, including voluntary counselling and testing (VCT) in 2001. ABUBEF’s teams of trained service providers include counsellors, nurses and laboratory technicians. The nurses are responsible for pre- and post-counselling, taking of blood samples, giving test results to clients and referring those who test positive for treatment. VCT services are available to all clients regardless of gender or age. A review of the services found that the most common reason for wanting an HIV test is to know

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one’s HIV status (69 per cent), followed by the desire to marry (18 per cent) and then testing for pregnant women. These results indicate a growing awareness of the importance of knowing one’s HIV status, especially for couples intending to get married, as well as the need for behaviour change. Demand for STI and HIV/AIDS services has increased in recent years. Data collected in 2001 and 2003 indicates that during this period the number of people seeking treatment for STIs increased by 2.6 per cent, while those coming in for HIV/AIDS services increased by 9.9 per cent. This growth can be attributed to higher awareness about HIV/AIDS and sexual and reproductive health, and knowledge that the ABUBEF clinic provides these services. The clinic has achieved a reputation for providing high-quality services in an atmosphere of confidentiality. Through these services, 11 per cent of clients tested have found out that they are HIV-positive, and as a result have been able to take measures to avoid re-infection and infecting others. Women accounted for 72.7 per cent of people coming in for testing, confirming their vulnerability to HIV in Burundi. In order to meet the demand for services and ensure a continuum of care, ABUBEF has developed partnerships with organizations that specialize in treatment and care. ABUBEF refers pregnant women to the Centre de Médecine Communautaire de Buyenzi for testing and services to prevent mother-to-child transmission of HIV. ABUBEF also refers clients who are HIV-positive to the Association Nationale pour la soutien des Seropositifs et Sideens (ANSS) and the Society for Women Against AIDS in Africa-Burundi, both of which provide treatment and care. These partnerships have enabled ABUBEF to provide a holistic approach to HIV/AIDS services. ABUBEF has increased awareness in the community about the importance of knowing one’s HIV status, and through this is fostering positive attitudes about healthy living. The effective involvement of all staff in the testing process ensures a comfortable, positive and non-judgmental environment that guarantees confidentiality and informed consent while encouraging the use of VCT services. Integrating VCT into sexual and reproductive health services gives all clients – men, women, pregnant women and young people – access to the prevention and care services they need.


CLINICAL CARE

Photo: Planned Parenthood Association of South Africa/South Africa

“FPAU has brought the services nearer to us. I think this is very good, especially for women and youth.”

Faith in Action: Expanding Voluntary Counselling and Testing to Rural Settings Family Planning Association of Uganda (FPAU) Joveria has heard of HIV voluntary counselling and testing (VCT) and has thought about getting tested, but she doesn’t know where to go. She is 27 years old and lives with her family in a rural part of Uganda. The only VCT clinics she has heard of are in the cities, and there is no way she could afford to leave her responsibilities at home to go all the way to the city to get tested. Uganda has turned from an epicentre of HIV/AIDS to a country noted for best practices in HIV/AIDS interventions. Unfortunately, access to VCT services remains limited to a few urban settings, while 80 per cent of the Ugandan population lives in rural under-served areas. Many people are still not aware of the benefits of VCT or where it is provided, yet these people still need access to such services.

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IN BRIEF: Access to Clinical Care for People Living with HIV Family Planning Association of Kenya (FPAK) Comprehensive care for people living with HIV does not start with the provision of anti-retroviral (ARV) therapy, nor does it end there. Care involves HIV voluntary counselling and testing (VCT), food and nutrition advice, support for preventing HIV transmission to partners, follow-up counselling, spiritual support, treatment of sexually transmitted infections, family and orphan support and many other elements. The Family Planning Association of Kenya (FPAK) realized that a number of clients that had used its VCT services and tested positive wanted ARV treatment, and many of them did not want to be referred to other partners. FPAK already has four wellequipped clinics with laboratories in Nairobi West, Thika, Eldoret and Nakuru, and decided to train doctors, nurses and clinical officers to respond to the growing demand for ARVs. Many people living with HIV have been able to access ARV therapy through the FPAK Family Care Medical Centres under the management of qualified service providers. FPAK has established links with a pharmaceutical company which is selling ARVs at a discounted rate. On-going counselling and education sessions are provided to clients before putting them on ARVs and throughout the actual therapy. Referral services enable people living with HIV, especially young people, to access a complete range of care services including food and nutrition advice, protection from discrimination and spiritual nourishment.

Photo: IPPF/Jenny Matthews/Bangladesh

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“FPAU has brought the services nearer to us, at a reasonable cost and no transportation costs. I think this is very good, especially for women and youth,” says Joveria. The Family Planning Association of Uganda (FPAU) with the support of the AIDS Control Project of the Ministry of Health gives out-of-school youth and the rural and urban poor access to VCT by bringing these services to churches and seasonal markets in the Mbarara, Mubende and Luwero Districts. Peer education, information and worksite educational activities are also offered to encourage safer sex practices and motivate these populations to access VCT and sexually transmitted infection (STI) treatment services. VCT and STI treatment services are offered in the vestries of churches and in portable tents on Sundays and during Seasonal Markets. During Church-based VCT, a drama group performs for church members while people are being tested, encouraging more people to be tested for HIV. Since men do not restrict women from going to church, FPAU was able to bring VCT services to more women. FPAU referred people who tested positive to AIDS care organizations such as The AIDS Service Organisation and the AIDS Information Centre for further support. Providing VCT at community events are great opportunities to give people in rural areas – especially women – access to vital information and services. “I am very grateful about the educative music and drama that young people present at our church,” says Joveria. “As women, we have so many responsibilities in the home, so we do not have the time or the opportunity to go for educational meetings. I had heard of VCT before, but I did not know where to get it.”


FIGHTING STIGMA AND DISCRIMINATION

Photo: IPPF/Philip Wolmuth

“Family planning providers need to be supported to examine their own beliefs and attitudes about sexual behaviour and practices, in order to better meet the sexual health needs of their clients.”

Reducing Stigma with a Story UMATI, Tanzania Aisha is a married woman who lives in Mlali in Morogoro Rural District, one of the six districts of Morogoro Region in Tanzania. She has one child. She delivered twice but her first born died of tuberculosis while he was only nine months old. Her ambition is to have three healthy children. During the time her son was sick, the neighbours were saying that it was impossible for such a child to get tuberculosis unless the parents were HIV-positive. They were pointing fingers at Aisha and her husband saying they were HIV-positive. HIV/AIDS-related stigma is experienced and perpetuated by individuals and communities. Without community participation, it is impossible to reduce stigma and discrimination. UMATI, in collaboration with the Japanese Organization for International Cooperation in Family Planning, worked with a community in Tanzania to develop a “picture drama” used by community-based service providers to deliver information, stir emotions and stimulate open discussion about HIV/AIDS. The picture drama tells a story about a family that has been affected greatly by HIV/AIDS. In this family a young man gets

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married, and after having a baby girl his wife dies. Without going for any check up, he marries a second wife who delivers a second child, and the baby dies at the age of three months. A month later, the father dies leaving behind a widow with two children. Because of rumours that the man’s first wife and child died of AIDS and the stigma and discrimination in the community, the second wife poisons herself. The two children are left with their grandparents, who cannot produce enough to feed the children. At the end of the story the future of the children is unclear. The community-based service providers present this picture drama to people in communities and then facilitate a discussion about HIV/AIDS and stigma and discrimination. UMATI staff also collaborates with District HIV/AIDS Coordinators and local authorities to introduce guided in- and out-of-school health talks where they discuss HIV/AIDS with teachers, pupils, and local leaders. For the communities involved, the picture drama and guided health talks have been eye openers and avenues for breaking down the silence about HIV/AIDS. These activities create an environment conducive for learning and cross fertilization of ideas, experience and practice, thus helping reduce stigma and discrimination. People in the community see this programme as their own, because they developed and use the materials and are motivated to take action. Communities are condemning stigma and discrimination, especially against HIV-positive children, and are asking community leaders to devote funds to support and care for orphans. There has also been an increase in the number of people opting for voluntary counselling and testing for HIV. After the death of their son, Aisha and her husband’s parents advised them to have a check up. Before they decided to go for HIV voluntary counselling and testing (VCT), they went to visit Zena, the community-based service provider who works with UMATI’s community-based services project.

win-win combination. People who test positive can get psychosocial support through the clubs once they test positive. And by reducing the stigma experienced by people who test positive, the clubs motivate more people to get tested and learn their status, strengthening HIV prevention and care efforts. In order to reduce stigma and discrimination experienced by youth who test positive for HIV, FPAK works with young people to create post-test clubs. The clubs conduct group discussions and provide on-going counselling and psychosocial support. Radio shows and video viewing groups provide additional channels to equip youth living with HIV with knowledge and benefits about positive living. The post-test clubs also reach out into the community to fight stigma and promote VCT. Using outreach activities such as video shows, drama, theatre art, ball games and personal testimonies, the clubs sensitize the community about HIV stigma and discrimination. Educational sessions are conducted for in- and out-of-school youth groups to promote VCT services. A total of 78,000 youth have been sensitized through the clubs and have undergone VCT at the seven different FPAK VCT sites established in the country since June 2003. Post-test clubs play a critical role cushioning the anxiety that comes with the knowledge of being HIV-positive. The clubs help youth develop a personal risk reduction plan, including positive prevention to protect their partners as well as assessment of the risk of re-infection. Clubs also increase the members’ awareness of care, treatment and support services and give them opportunities to network with other organizations serving people living with HIV. Through the clubs, youth living with HIV have a voice and strength to work with FPAK to advocate for free antiretroviral therapy, treatment of opportunistic infections and functional referral services.

Aisha and Zena discussed the facts about HIV/AIDS. Using the picture drama and supporting booklets, Zena was able to share with Aisha accurate information about HIV/AIDS. Aisha began to understand how stigma caused people in the community to react so harshly to her son’s death, and learned that VCT is the only way for a person to know his or her HIV status. After the discussion Aisha and her husband went for VCT, they tested negative.

The clubs have registered a strong and dedicated membership of 210 youth who participate in numerous activities. The work of these young people has helped change the negative perception of youth and community members towards PLWA. Through their living examples, youth club members have personalized the epidemic. At the same time, they have helped other youth accept their status and taught them that there is still more to life after testing HIV positive.

Post-test Clubs for Young People

Fighting Stigma in Health Care Settings

Family Planning Association of Kenya (FPAK)

Family Planning Association of India (FPAI)

Linking HIV voluntary counselling and testing (VCT) services with stigma reduction through post-test clubs is a

Arif, the manager of the Family Planning Association of India’s (FPAI) Lucknow clinic, knows that stigma around

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HIV/AIDS and sexuality are common in clinical settings. "Traditional family planning service providers deal with sexual health in a clinical manner. For example, they examine a client’s symptoms and provide treatment. There is little discussion on sexual behaviour and practices. Our culture does not encourage open discussion on sex, and service providers are embedded in this same cultural milieu. They too carry the same inhibitions. Skills need to be developed to remove these inhibitions. Family planning providers need to be supported to examine their own beliefs and attitudes about sexual behaviour and practices, in order to better meet the sexual health needs of their clients." There are many advantages to establishing HIV voluntary counselling and testing (VCT) services within existing sexual and reproductive health settings, but the benefits of integration can only be realized if providers can overcome the stigma surrounding sexuality and HIV/AIDS. Considering this, staff at a FPAI clinic in Lucknow weighed the benefits and challenges of integrating VCT services into their work. The Lucknow clinic, located in the largely rural state of Uttar Pradesh, provides a range of sexual and reproductive health services to approximately 9,000 people each year. HIV prevalence rates are relatively low in Uttar Pradesh: the 2002 National AIDS Control Programme’s HIV sentinel surveillance study found that 1.37 per cent of sexually transmitted infection (STI) clients tested HIV positive in Uttar Pradesh, and 0.37 per cent of antenatal care clients tested HIV positive. Integrating HIV/AIDS services into sexual and reproductive health services takes advantage of synergies that can reach even more people with the services they need. Integrating VCT is more cost effective than establishing the services in freestanding sites, and sexual and reproductive health services and VCT have similar aims of reaching sexually active people and promoting safe and healthy sexuality, including the prevention of HIV, STIs and unwanted pregnancy. Sexual and reproductive health services also offer specific opportunities for reaching women with VCT. However, many providers have biases against integrating HIV/AIDS. At first, FPAI clinic staff were reluctant to integrate VCT services. They felt that the clinic should only integrate services so long as the new VCT service would not change the profile of service users, and client perception of the clinic would not change. Staff were concerned that HIV services might ‘take over’ the clinic, and they were anxious about the increased workload to identify clients at risk to whom they should recommend VCT. Also, they felt that clients should not feel forced to have HIV counselling and testing. Staff also expressed concerns about their own occupational exposure to HIV. The clinic made addressing concerns about occupational exposure a priority. Procedures for universal precautions and sterilization of equipment were reviewed and

revised, resulting in staff feeling more at ease about their risk of occupational exposure. The discussions also provided an opportunity for people to examine their own personal risk levels. Nurses started to explore how to determine if clients were at increased risk of HIV or STIs, and began implementing a low-key risk assessment procedure to enable them to refer clients to VCT services. The next step in the process was to reach out to the community itself. Arif explained the challenges involved: "In India, some of the messages still being used have inadvertently promoted a culture of fear, denial, and blame. The purpose of communicating messages should be focused on normalizing attitudes to HIV/AIDS. The messages used for educating the community and promoting VCT should be moulded by the values that form the basis of the principles of counselling, such as care, support, openness, and practical actions to address people’s situations." Counsellors started developing and using sensitive educational materials on HIV prevention and care. One counsellor was employed for outreach education in the communities in and around Lucknow. All of the staff were involved in performing dramas in and near the clinic to promote the benefits of knowing one’s HIV status through VCT. Several months after the start of the new service, all staff at the clinic – from the programme leader to nurses, reception staff and cleaning staff – saw that they had a role in the new service, and in maintaining the low rate of HIV prevalence in Uttar Pradesh. Through their outreach work, staff learned that the community’s understanding of HIV/AIDS issues was low and characterized by fear and denial. Staff decided to embark on an extensive community education campaign focused on normalizing attitudes of the community to HIV/AIDS, breaking down the culture of denial, stigma, and discrimination, reducing anxiety, and developing people’s confidence to seek information and take the test. This campaign received a positive response, opening up discussions about HIV/AIDS, sexuality, and reproductive health in new ways. From initial reluctance, the FPAI Lucknow clinic has come to understand the benefits of integrating VCT services into their family planning work. Even though HIV prevalence is low, the VCT service – including the new community education work on HIV/AIDS – provides an opportunity for people to explore and understand their level of risk. The clinic has also expanded their STI services as a result of their work to build greater understanding of HIV/AIDS.

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PREVENTION AND CARE

Photo: IPPF/Mark Edwards/Gaza

“Beer promotion girls and other indirect sex workers in Cambodia are extremely vulnerable to HIV infection, yet there are few HIV prevention services available to them.� 10

Beer Promotion Girls Promoting Sexual and Reproductive Health Reproductive Health Association of Cambodia (RHAC) Phally is a 22-year old beer promotion girl in Phnom Penh. Occasionally she has sex with some of the customers at her bar for money - few of them ever want to use condoms. She has heard about sexually transmitted infections (STIs) and HIV/AIDS, and would like to know if she is at risk and how she can protect herself. There are clinics she can go to in Phnom Penh, but some of the other girls at work have told her that these places are too expensive and lack privacy. Beer promotion girls and other indirect sex workers in Cambodia are extremely vulnerable to HIV infection, yet there are few HIV prevention services available to them.


The Reproductive Health Association of Cambodia (RHAC) developed a project to reduce the spread of HIV/AIDS among female beer promoters in Phnom Penh by giving them access to HIV/AIDS prevention information, condoms, and condom negotiating skills, and to increase linkages to care at RHAC’s clinics. The project was implemented in conjunction with the Municipal Health Department of the Ministry of Health, the Ministry of Women’s Affairs, local government authorities and beer companies. Three-day training courses on STIs, HIV/AIDS, and communication skills were provided for beer promoters who were selected as Peer Educators. The 85 Peer Educators were trained to provide face-to-face education and counselling, and refer STI cases to RHAC clinics for treatment. The Peer Educators provided condoms to their friends and other Beer Promotion Girls in their respective places of work. Besides giving information on STIs and HIV/AIDS, they educated their friends on how to negotiate with their clients to practice safer sex and encouraged them to attend RHAC clinics for treatment, as needed. Clinic visits for the target group were facilitated by issuing referral slips. These slips enabled the RHAC clinic to estimate the number of beer promotion girls seeking treatment. Condoms were provided to them through their Peer Educators and through specially made ‘condom boxes’ conveniently located at their places of work. A total of 200,000 of condoms were distributed. Four HIV/AIDS video tapes and 2,000 STI leaflets were used for training purposes and distributed to the participants. Bi-monthly meetings were held for Peer Educators for the purposes of sharing their experiences, updating them with information about the project, resupplying them with condoms, and collecting reports from Peer Educators. The project has influenced NGOs, government institutions and other stakeholders to support programmes addressing HIV/AIDS among indirect sex workers. Beer company owners were involved in the project as well, supporting peer educators and providing space and time for RHAC staff to conduct education sessions. They allowed RHAC to install large condom boxes in their companies and also helped encourage beer girls to attend the group education sessions. The project increased awareness among beer promotion girls about HIV/AIDS and STIs. It also strengthened their condom negotiation skills with clients and increased their knowledge on where they could get quality treatment in complete privacy at a reasonable price. The project’s faceto-face education on sexual health between peer educators

IN BRIEF: Linking Voluntary Counselling and Testing, Prevention and Care Family Life Association of Swaziland (FLAS) The Family Life Association of Swaziland (FLAS) runs two youth clinics and two adult clinics in the cities of Mbabane and Manzini, as well as a mobile clinic that concentrates on the busy industrial area of Matsapha. These clinics offer sexual and reproductive health information, contraception, treatment of sexually transmitted infections (STIs) and HIV voluntary counselling and testing (VCT). HIV counselling and testing is one of the most highly sought services by clients, in part because STI and HIV counselling is integrated into all FLAS services. Since it began offering VCT services at its clinics in 2002, FLAS has witnessed a dramatic increase in the number of people seeking VCT, with a 101.4 per cent increase in the number of clients from 2002 to 2003. FLAS sends a mobile VCT clinic to communities to provide free testing services during promotional events, and people have formed long queues hoping to get tested at these events. In addition, FLAS is receiving more and more requests from companies to provide VCT services to their employees. Although many people are still reluctant to access VCT, dissemination of information has helped reduce AIDSrelated stigma and is encouraging more and more people to access VCT services. Besides integrating VCT into its sexual and reproductive health services, FLAS also implements a number of HIV prevention outreach projects, including one project that educates young people in rural areas on dual protection for HIV and STIs. Youth educators give their peers information on HIV and STI prevention and STI treatment. FLAS clinics have recorded a high number of young people seeking treatment as a result of the information.

and their friends was very effective, and established an important link between beer promotion girls in Phnom Penh and RHAC's clinics. The sharing of experiences during the bi-monthly meeting among peer educators has also made them more confident talking about sexuality. Phally talked with a beer promotion girl from another bar who was a peer educator and learned from her that she might have contracted an STI. The peer educator gave Phally condoms and taught ways in which to encourage clients to use condoms, and also gave her a referral slip to go to the RHAC clinic and get STI treatment. Phally found that RHAC clinics provide sexual and reproductive health services at reasonable price, and ensure privacy and confidentially. Since then, she has arranged for the peer educator to give an educational talk at her bar, and has told the other beer promotion girls at her bar about the RHAC clinic.

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IPPF IN A LIFE

Developing the Prevention to Care Continuum with Outreach Associação Moçambicana para Desenvolvimento da Família (AMODEFA), Mozambique HIV care services strengthen HIV prevention efforts, and HIV prevention services support HIV care efforts. Initiated in 1996, the Associação Moçambicana para Desenvolvimento da Família (AMODEFA) home-based care (HBC) project uses outreach workers to give miners, their partners, families and communities access to HIV/AIDS prevention information, condoms, STI treatment and VCT. The outreach workers provide home-based care themselves, and provide referrals for clinical care services. By linking prevention and care services through outreach, AMODEFA brings access to HIV/AIDS services to whole communities, and developing the prevention to care continuum. AMODEFA trained 360 home-based care outreach workers (Activistas) who are the backbone of the project. The training covered HIV/AIDS and STI prevention, care and support. More specifically, Activistas learned about psychosocial and palliative support, counselling, and positive living as well as giving care by cooking, cleaning and maintaining sanitation for those living with HIV. MODEFA established a network of referral services, and Activistas are trained to refer infected and affected persons and families to government health institutions and other organizations for food and other kinds of support. The Activistas conduct community outreach on HIV/AIDS, stigma and discrimination. In addition, behaviour change initiatives using approaches like home visits, individual and group education, debates, and advocacy to community leaders. Bus stations and buses running between Mozambique and South Africa are targeted in order to reach miners. In- and out-of-school youth are targeted as well. Radios are distributed to families and communities to increase access to radio messages on HIV/AIDS and other reproductive health issues. Activistas distribute condoms door-to-door and during educational programmes, counselling and home visit programmes, with the message that condoms can prevent HIV and STI infection as well as unwanted pregnancy. Activistas also provide referrals for STI treatment and VCT. More and more people are now accessing VCT, and those who test positive are given counselling, support and care. People living with HIV are encouraged not to give birth to other children and to use condoms both to prevent pregnancy and avoid transmitting HIV to their partners. AMODEFA provides first aid, treatment for

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opportunistic infections and anti-retroviral therapy through government hospitals. Activistas then work at the community level to ensure the proper utilization of treatments given to people living with HIV. AMODEFA also implements income generating programmes for the widows of miners and introduced ‘memory books’ to children who lost their parents to AIDS. AMODEFA pioneered and established the first national Association for People Living with HIV/AIDS in Mozambique. Currently, AMODEFA is establishing support groups for people living with HIV that will visit and give assistance to infected and affected families. AMODEFA has also built the capacity of other organizations in HIV/AIDS home-based care and support, including the Mozambican Association of Widowed and Single Mothers, youth associations and the Ministry of Health. Using community-based home-based care agents enables AMODEFA to reach more people living with HIV with prevention and care and to make more referrals for VCT and STI treatment. Because of this project, more and more people are using VCT, prevention, care and support services. Moreover, quality of life for people living with HIV has improved and stigma and discrimination has decreased, especially after the training of home-based care givers. Members of nearby communities have asked for expansion of the project to their localities, demonstrating the high demand for AMODEFA’s homebased care outreach services.


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International Planned Parenthood Federation Regent’s College, Inner Circle, Regent’s Park, London NW1 4NS United Kingdom Telephone +44 20 7487 7900 Fax +44 20 7487 7950 Email info@ippf.org www.ippf.org Designed by Spencer du Bois UK Registered Charity No. 229476 The International Planned Parenthood Federation (IPPF) is a global network of Member Associations in 149 countries and the world’s foremost voluntary, non-governmental provider and advocate of sexual and reproductive health and rights. Photo: IPPF/Jenny Matthews/Afghan Refugees/Pakistan


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