In_A_Life_Linking_HIV_and_SRH

From choice, a world of possibilities

In a life

Linking HIV and sexual and reproductive health in peoples’ lives

Who we are The International Planned Parenthood Federation (IPPF) is a global service provider and an advocate of sexual and reproductive health and rights for all. We are a worldwide movement of national organizations working with and for communities and individuals.

IPPF works towards a world where women, men and young people everywhere have control over their own bodies, and therefore their destinies. A world where they are free to choose parenthood or not; free to decide how many children they will have and when; free to pursue healthy sexual lives without fear of unwanted pregnancies and sexually transmitted infections, including HIV. A world where gender or sexuality are no longer a source of inequality or stigma. We will not retreat from doing everything we can to safeguard these important choices and rights for current and future generations.

In a life 3

Contents Introduction

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Reducing HIV-related stigma

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Ethiopia: Self stigma, self denial Thailand: Partnering for life Nepal: Learning to live again Jamaica: Me appreciate mi body Morocco: Taboo topics and challenging norms Russia: Involving people living with HIV and AIDS Providing prevention services

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Kenya: Care at home for people living with HIV Sudan: Access to treatment gives hope Cameroon: Advocacy, action, answers Cambodia: Getting your ducks in a row India: Dropping in to health Lesotho: Loving yourself Linking sexual and reproductive health and HIV

China: Not just another love story Malawi: Vending with hope Bolivia: Crossing streets Swaziland: Under one roof Mexico: Behind bars and across borders Papua New Guinea: And my wife makes three People living with HIV

Expanding treatment, care and support

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South East Asia and the Pacific: Nurturing positive regional HIV competence Arab World Regional Office: The right way of doing VCT Colombia: Celebrating diversity in Bogata high schools Asia and the Pacific: Matching words to actions Global Fund to fight AIDS, Tuberculosis and Malaria: Making the money work for women and girls Mother and child-centred care: Mothers matter Endnotes

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Acronyms and abbreviations

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4 In a life

Introduction Linking sexual and reproductive health and HIV recognizes the vital role that sexuality plays in people’s lives, and the importance of empowering people to make informed choices about their lives, love and intimacy.

AIDS is unique in human history in its rapid spread, its extent and the depth of its impact. Since the first diagnosis in 1981, the world has struggled to come to grips with its multidimensional nature. The HIV epidemic is a human phenomenon with far-reaching implications for individuals, households, communities and countries. No other disease has so radically accentuated global economic disparities, or the present inequalities in healthcare access and people’s ability to exercise their basic human rights. Fortunately HIV can be both prevented and treated, and there is nothing inevitable about the course that it runs.

In the shadow of the G8 Summits, high level meetings, international and regional AIDS conferences and global declarations , the international community has committed to intensify its focus on the bi-directional linkages between sexual and reproductive health and HIV and AIDS at the policy, structural and programme levels. Recognizing that sexual and reproductive ill health and HIV share many root causes including poverty, gender inequality, and social marginalization, it is the responsibility of every HIV and sexual and reproductive health (SRH) programme manager in the public and civil society sectors to ensure that policies are synergized; that services are complementary; that resources are spent wisely and that the needs of each individual are met.

These ‘people centered’ approaches demand a fundamental shift in the way in which both sexual and reproductive health and HIV services are delivered. Increasing our understanding of health systems (especially in developing countries), and the kind of support and strengthening they require, must become a priority. While health systems issues were plaguing many countries long before the debut of HIV and AIDS, the epidemic shows up these constraints in bolder and sharper relief. HIV has created a paradigm shift in the way in which development agendas and priorities work. In the short term we need to provide immediate relief and support and there are many effective examples of programming: from new curricula to ensure that the health personnel of tomorrow are AIDS competent, to improving access to antiretroviral therapy for those who need it. But the true test of our collective mettle will be the challenge of transforming crumbling health systems, correcting past errors and dealing with the realities of a demanding epidemic.

As the leading non-governmental provider of sexual and reproductive health services and advocate of sexual and reproductive rights, the International Planned Parenthood Federation (IPPF) has been at the forefront of efforts to ensure that a comprehensive response to HIV is situated within a larger sexual and reproductive health framework. Whether providing women with family planning services, empowering young women and girls through life skills and vocational training; managing sexually transmitted infections; proactively involving men and boys; increasing access to condoms; addressing the sexual and reproductive health needs of people living with HIV or providing antiretroviral therapy (ART), IPPF

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seeks to place its work as part of a coherent response to HIV and AIDS that links prevention with treatment, care and support and responds to the unique regional and national characteristics of the epidemic.

Underpinning IPPF’s long term commitment to the promotion of human rights, and operating from the belief that ‘access=life’, the following four living principles serve as the foundation blocks of our response to the epidemic: 1 Involvement: Critical to the success of any HIV and AIDS initiative is the meaningful involvement of those most vulnerable to infection. Dependent on both the region and the country, IPPF ensures that those closest to the epidemic are actively involved in the formulation and implementation of programmes and policies that affect their lives and choices. The involvement of people living with HIV is essential to this.

2 Gender: Increasingly in many parts of the world, the engine of the epidemic is the subordination of women and girls, a form of discrimination with particularly lethal consequences in a world with HIV. The vulnerability of women and girls to HIV infection is integrally linked to their unequal social status. In many highly patriarchal societies women and girls play an undervalued role in society and all too often subsequently have fewer rights. It is critical that an enabling and supportive policy environment is encouraged and strengthened.

3 Partnerships: Strategic partnerships with governments, UN agencies and other civil society organizations are a key part of our response. The entry points for linking HIV and sexual and reproductive health are optimized through the strengthening of alliances and partnerships.

4 Capacity Development: Through all its programs IPPF seeks to strengthen and expand the AIDS competency of our staff, volunteers and partners to confront the most complex of issues in relation to HIV and AIDS. The real-life stories in this publication reflect the core characteristics and values that IPPF aims for in linking sexual and reproductive health and HIV: evidence-informed programming, a recognition of vulnerability and the full protection of rights. In a Life highlights how our work – shaped by the efforts of thousands of committed staff, volunteers and partners – is having a real impact in the lives of people the world over.

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Reducing HIV-related stigma Stigma begins and ends with each one of us. As the triple combination of ignorance, prejudice, and fear creates fertile ground for HIV’s continued spread, so openness, acceptance, and accessible comprehensive sexual and reproductive health and HIV services are the key to its containment.

The roots of HIV-related stigma and discrimination run deep. Reducing stigma and discrimination means facing and talking openly about issues and behaviours that are all too often silenced or taboo, such as sex, sexuality, drug use, sex work, gender inequality, poverty, ethnicity and race.

The stigma surrounding HIV frequently overlaps with the stigma faced by certain key populations, making it increasingly difficult to protect the sexual and reproductive health and rights of those at the forefront of the epidemic. This double stigma, faced especially by sex workers, men who have sex with men, and injecting drug users, is exacerbated by the absence of policies that protect their rights, making access to services a greater challenge. A priority in addressing the stigma felt by people living with HIV is listening to and acknowledging their voices and experiences. IPPF – in collaboration with UNAIDS, GNP+ and ICW – has developed The People Living with HIV Stigma Index. This Index and accompanying User’s Guide complement our global understanding of stigma by ensuring that responses deal with the most pressing issues facing the HIV positive community. Roll-out of this Index, which has as its core the involvement of people living with HIV, has commenced in several countries and over time will provide a useful tool to gauge the success of our collective efforts to reduce stigma.

The principle of the Greater Involvement of People living with HIV/AIDS (GIPA) recognizes that the personal experiences of people living with HIV can, and should, be used to shape the response to the epidemic. Increasingly in programmes carried out by IPPF Member Associations around the world, core partnerships have been forged with networks and associations of people living with HIV. This has enabled the Associations to respond better to the sexual and reproductive health needs of people living with HIV, and ensured an increasing presence of HIV positive people on their governing structures.

Key to supporting the GIPA principle are simple, practical steps, such as the implementation of policies to protect rights. HIV workplace policies and programmes are one example. They help ensure that respect and support are formalized in contexts where, previously, many people faced discrimination or chose to remain silent. Although the workplace sector alone cannot end the spread of HIV, workplaces are well positioned to contribute resources and skills, to help influence employee attitudes and sexual behaviours, and to provide clinical services and/ or referrals. By the end of 2007, 74 out of 147 IPPF Member Associations had a workplace policy in place – and this number is expected to increase.

To reduce HIV-related stigma and discrimination, IPPF advocates to overcome barriers to comprehensive services for those living with and affected by HIV. Advocating from an approach that ‘access=life’ ensures that rights are central to our work; from ensuring that young girls and women have equitable access to services, to providing sexual health services to men who have sex with men and injecting drug users.

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Ethiopia

Self stigma, self denial The stigma faced by those living with HIV does not just come from the wider community. Many feel a crippling sense of shame for being HIV positive and are scared to reveal their status because of how they think people will react. However, if family and community members are supportive there is no need for such fears.

Strengthening counselling, care and support for those living with HIV, and their families, is vital to reduce this form of stigma.

“My name is Gette Gebretsadik. I am 75 and living in one of the Nazareth kebeles. In 2006, after my husband died of an unknown disease, I became very sick. My neighbours advised me to go to get medical help. I eventually succumbed and at the hospital I was tested for HIV. When I got my result and was told I was HIV positive, I was shocked because I was not expecting to contract HIV at the age of 75. I felt ashamed of having the virus and when I went home I tried to commit suicide. However the medicine I used was not strong enough and I did not die. I started crying and crying because I was helpless, and had never heard of a woman my age contracting HIV.

When my neighbour heard me crying she came to me and told me not to lose hope. She told the Family Guidance Association Ethiopia (FGAE) nurses about me and when they heard I was HIV positive, they started me on antiretroviral therapy. They also assigned me a care giver to provide home based care and support, as well as bring me some nutritional food such as oil and flour fortified with vitamins. My caregiver also brings me the antiretroviral drugs, and since I have started the treatment I feel healthy and am no longer in pain.

Had my friends and the volunteers of FGAE not been with me I would have died. I really felt the shame of HIV at the beginning and thought the only way out was to commit suicide. Now I’ve started treatment and been given a lot of care and support, I’ve begun to feel better. At the beginning I was afraid of stigma and discrimination from my local community but when I told them my status I didn’t actually face any. My neighbours and care givers have been very supportive to me. They have helped me a lot and encouraged me so I no longer feel ashamed of living with HIV.”

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Thailand

Partnering for life

The situation in Chiangmai and Chiangrai Province used to be dire for people living with HIV. The stigma they faced was so strong that if their status was openly known they would not be able to join any social gatherings. Their products such as home-grown vegetables or fruits were totally banned from the community. They were out of work as local people would not hire them because of their HIV status, and their children were not accepted at schools.

The Planned Parenthood Association of Thailand (PPAT) has been working tirelessly to reduce this HIV-related stigma and discrimination. At the core of PPAT’s work has been the long held belief that people who are HIV negative can, must and do live alongside and socialize with people living with HIV. They have promoted knowledge and understanding among community dwellers focusing on HIV and human rights. Ms Runtuan Suya, one community member who is living with HIV commented on this improvement in her province: “People living with HIV including their family members have a better place in the community now. We now truly feel a part of the community being able to sell our products and can join every social gathering.”

As well as reducing stigma, PPAT have provided specialist training for people living with HIV (PLHIV) and their family members. This training covers areas such as care for PLHIV, support through family counselling and information on how to prevent further transmission of the virus. Project volunteers are trained as counsellors to visit PLHIV in their homes and provide knowledge as well as counselling. The commitment of these volunteers has significantly improved living conditions and quality of life for PLHIV. One volunteer, Ms Saitong Rangsri, says, “We are proud and pleased to see how much the quality of life of PLHIV has improved. We can play the crucial role of care giver and can contribute greatly to better living conditions of an individual, a family or a community.”

“Moreover, community development officers from Tambol Administration Organisation (TAO) are giving a lot of support to PLHIV. They provide an allowance of Baht500 (approximately US$16) per person per month, financial support for vocation development, and they provide land for PLHIV and their family to grow some fruit and vegetables.”

Close collaboration with TAO and community leaders, and providing occupational support from well trained volunteers, has changed the lives of PLHIV in these communities. However, to make this possible, there first had to be a long concerted effort to tackle the stigma and discrimination faced by PLHIV and their families.

43% of new HIV infections in Thailand in 2005 were among women, the majority of whom probably acquired HIV from husbands or partners who contracted HIV either during unsafe paid sex or through injecting drug use WHO & UNAIDS, 20071

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Nepal

Learning to live again It is estimated that almost half of all people living with HIV in Nepal have worked as labour migrants WHO & UNAIDS, 20062

Although many women in rural Nepal have heard of HIV and AIDS, they often don’t realize that people can live normal lives despite their status. Unfortunately, it is not that simple because when women in Nepal discover they are HIV positive it will change their world and women who are already marginalized can become outcasts.

“My name is Sarita Tamang. I was born in the rural area of Gorkha district in Nepal. Committed to providing a good future for me, my parents moved from the hills to the plains to first educate me and then to arrange for my marriage.

Soon after my marriage, I realized that my husband had an alcohol habit and not much interest in home and family matters. Life was tough. In the hope of changing his addiction, I asked him to apply for employment in Korea. An HIV blood test during the recruitment process revealed he was HIV positive. At the time of finding out my husband’s status I did not know much about HIV, and thought there was nothing I could do. It was only last year that a friend in the neighbourhood told me about voluntary counselling and testing (VCT) provided by Family Planning Association of Nepal, and I got myself tested.

I was HIV positive too. My whole world fell apart. I lost my school job because of my HIV status. I had no support and no shoulder to cry on. I was only 22 years old and was worried that my daughter would become an orphan. It took me a while, but now I have taken control of my life. I decided I wanted to help women who were in a similar position to me.

I became a member of the National Association of People Living with HIV in Nepal and began my work by creating awareness among women who did not know about HIV. Many women in Nepal feel that it is useless confirming your HIV status if you are going to die anyway, not realizing they can still live a normal life if they are HIV positive. They are scared of becoming outcasts, but getting tested changed my life for the better. I am now more respected for what I do in my community. I have been able to help many women learn their HIV status, and provide them with support and access to treatment. They have overcome the personal stigma often felt by people living with HIV, are healthier now and have a reason to live.”

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Jamaica

Me appreciate mi body

Integrating information about prevention and the treatment, care and support available for young people living with HIV reduces the fear of having an HIV test.

The president of the Youth Advocacy Movement, who is also an elected board member of the Jamaica Family Planning Association (FAMPLAN), gives some concrete advice on how young people can help reduce the stigma associated with HIV. “HIV-related stigma is a big problem in Jamaica and FAMPLAN decided to address it by working with the local Youth Advocacy Movement (YAM) on presentations to raise HIV awareness among young people. FAMPLAN promoted its new voluntary counselling and testing services via radio and newspaper adverts and leaflets. YAM helped to provide community outreach services and referral cards to community members interested in testing, and initiated weekly education groups for the clients at the Beth Jacobs Clinic.

A communication plan is central to ensuring that young people know that they can access HIV counselling and testing in a safe, secure and confidential environment. This spanned several creative channels such radio spots, t-shirts, banners and posters, and involved young people like me in the shaping of the messages. Here’s one of the radio messages:

Female spot (30 seconds) Voice 1 Yuh si me, I am a sexually healthy person! I set my own limit an’ practice safer sex. Me, me appreciate mi body, an mi conscious bout mi responsibility. That’s why I do my HIV test.

Voice 2: Get affordable and confidential HIV counselling and testing with results the same day!

At Beth Jacobs Clinic, 14 King Street, St. Ann’s Bay Call us at 972-2259, that’s 972-2259.

There is also a mixed spot between a man and a woman about how a friend found out he had HIV and was told he could live healthily if he took care of himself in the right way. He learned that free medicine was available and there were also support groups. The woman then says: “That’s why I’m not afraid to do my HIV test!” and then the same clinic information is given.

FAMPLAN and YAM are working hard to reduce the stigma surrounding HIV. I know the problems other people my age face and how they feel about HIV. As the leader of YAM I feel privileged that I can help to change attitudes towards VCT, helping with prevention and reducing HIV-related stigma. As a 22-‑year-old female in the English speaking Caribbean, I believe that the sky is the limit and that if you try hard enough it is possible to achieve anything.’’

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Morocco

Taboo topics and challenging norms The Association Marocaine de Planification Familiale (AMPF) actively involves young people in the fight against HIV and the stigma frequently associated with it. AMPF works to increase knowledge about HIV and condom use across Morocco, especially among young people. Talking about sex and sexuality in a country where these topics are still largely a taboo subject provides unique challenges and opportunities, and young volunteers like Yousseff play an important role in ensuring services like voluntary counselling and testing meet the needs of those who need them most.

“My name is Yousseff El Abissi. I used to be afraid to ask for information on HIV and sexual health because of the stigma and discrimination around the subject of sex in Morocco.

When my friends or I got a sexually transmitted infection (STI), we tried to ignore it and didn’t seek medical care and treatment as we were too embarrassed.

Then I attended a youth HIV prevention workshop at AMPF where I learned a lot about sexual and reproductive health issues. I learned that 19,000 people are living with HIV in Morocco and that teenagers, young people and vulnerable

groups are at greatest risk of infection. Suddenly it all became very real. Unbelievably, I used to think that a condom was only for family planning, so I’d never used one before and neither had my friends. I didn’t know they also prevent STIs and HIV. Now I use a condom every time I have sex.

AMPF runs a number of centres specifically for teenagers and young people. Here we can find help for STIs and HIV and there are doctors and counselling available. We can also openly share our experiences and ideas and talk about our problems because a there is no stigma attached to talking about sex here. We reach other young people through information, education and communication activities, especially peer education, which is contributing to the reduction of stigma surrounding STIs and HIV. I am now a volunteer with AMPF and feel like a responsible adult and a leader, but before I was timid and shy and I couldn’t talk openly with others. Over time, and through AMPF activities I have learned how to accept myself and other people for who they are, despite our differences and diversity.”

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Russia

Involving people living with HIV and AIDS Involving people living with HIV and representatives of vulnerable populations such as drug users, sex workers, men who have sex with men, women and young people in HIV programming is essential, especially as these are the people most affected by the epidemic and know first hand about its effects. It is vital that representatives from these groups are involved in the governance and management structures of organizations working with HIV. The Russian Family Planning Association (RFPA) is a nongovernmental network focusing on sexual and reproductive health and rights. RFPA has always paid attention to HIV prevention and the need to counter HIV-related stigma and discrimination among decision makers, health professionals, community leaders and the general population.

A recent evaluation of RFPA’s HIV projects explicitly emphasized the need to incorporate the insight of people living with HIV into the governance and management of the Association, and RFPA has changed their constitution to state that there must be at least one person living with HIV on the board. The person nominated is a journalist and an acting editor of a magazine aimed at HIV positive people.

By following the greater involvement of people living with HIV (GIPA) principle, RFPA now have a greater understanding of the issues faced by people living with HIV (PLHIV) which can be used to promote sexual and reproductive health and rights within the PLHIV community. One of the RFPA board members says, “Nowadays RFPA is proud that all governance and management decisions within the association are getting approval from a representative of the PLHIV community.

We are looking at a number of HIV initiatives including the development of an HIV strategy for RFPA and an HIV workplace policy.”

RFPA plans to strengthen the promotion of the sexual and reproductive health rights of PLHIV. A stronger emphasis will be made on rights and needs, with programmes to ensure referrals to sexual and reproductive health services such as contraception and fertility choices.

Anastasia Lomova from RFPA says, “The GIPA principle is not a matter of political correctness but a right for those living with HIV. It ensures more effective public health responses to the HIV epidemic, allowing PLHIV to access services which are rarely provided for them.”

In Russia, police abuse, harassment, and widespread discrimination against injecting drug users and other groups at high risk for HIV continued to interfere with HIV prevention, care, and treatment efforts in 2006 Human Rights Watch 20073

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Providing prevention services HIV can be prevented. There is nothing inevitable about the course that an HIV epidemic takes if governments and other organizations act with decisive action based on national HIV trends. An enabling environment is needed in which even those from the most vulnerable segments of society can access the services they require.

their own sexuality, so ‘ABC’ is often beyond their control. In response, IPPF, UNFPA and Young Positives, – under the auspices of the UNAIDS Global Coalition on Women and AIDS – have initiated a series of country level HIV Prevention Report Cards to highlight specific areas that if addressed would provide viable prevention options for young women and girls from diverse backgrounds and settings.

AIDS fatigue is a growing reality. The weariness of the ‘post-AIDS generation’, for whom past hard-won battles have little meaning as they explore their own sexuality, is an issue that prevention efforts need to address more boldly. Specific strategies are required to ensure that all populations have access to prevention services, including young people, women and girls, people living with HIV, men who have sex with men, injecting drug users, migrants, refugees, ethnic minorities, and sex workers and their clients.

Meeting the sexual and reproductive health needs of people living with HIV is an area that has only recently begun to receive attention. Many of IPPF’s prevention efforts have been reoriented to ensure they meet the diverse needs of people living with HIV, including providing fertility options for HIV positive women and bespoke counselling for people in serodiscordant relationships.

Integrating HIV prevention efforts within sexual and reproductive health services gives people access to a full range of choices to protect themselves from infection or decrease the chances of transmission. Dual protection against HIV and sexually transmitted infections (STIs) and unintended pregnancy, helps individuals and couples to enjoy healthy sexual and reproductive lives. While there is currently no ‘magic prevention bullet’, and in the absence of a vaccine and microbicide, condoms play a pivotal role. In 2007, IPPF distributed 125,260,968 condoms.4 Much has been learned about how prevention is internalized. Messages like ‘ABC’ (‘abstain, be faithful, use a condom’) – while purported to offer a ‘menu’ of viable options for all people to protect themselves – are simply not practical for many people. Young women and girls in particular frequently do not have control over

Responding to HIV with blame forces the epidemic underground, creating the ideal conditions for its continued spread. Worryingly, a number of countries are doing precisely this by embracing the criminalizing of HIV transmission. The prosecution of individuals not only encourages silence over the epidemic when there should be debate, but also infringes rights. As a rights-based organization, IPPF strongly believes that there are better alternatives to laws and policies that criminalize HIV transmission.

Access to prevention is about making prevention work in people’s lives. Each person has their own prevention needs and faces barriers to prevention particular to their life circumstances. The following pages show how IPPF’s Member Associations bring to life strategies for preventing HIV, STIs, and mother to child transmission of HIV, proving that ‘access=life’.

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China

Not just another love story

In China the number of sex workers consistently using a condom with clients is low; from 20% of those working on the streets or in salons, to 57% of those operating out of expensive hotels Parish & Suiming, 2006

A large number of women move from rural Guangxi Zhuang region to Liuzhou to work in the ‘Entertainment Establishments’. Often these women know little about the dangers of HIV and sexually transmitted infections (STIs). The China Family Planning Association (CFPA) saw that this lack of information was putting these women at greater risk and began conducting workshops on STI and HIV awareness and prevention. Ajiao, who works at one of the Entertainment Establishments in Liuzhou, recalls how she met Sister Qin, one of the outreach doctors.

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“When I first came to Liuzhou I knew very little about how to protect myself from sexually transmitted infections and HIV, even though it is very important for someone like me, who works at the Entertainment Establishments, to know this. Like many others in China I thought that I could protect myself from HIV by washing my vagina with disinfectant after intercourse and taking anti-inflammatory drugs. I also did not know where to get treatment for STIs so when I contracted an infection, I spent thousands of yuan at a small private clinic.

Then I discovered CFPA.

Sister Qin, the outreach doctor at CFPA, treated me for my infection and healed me for only 300 yuan (approximately US$43). I immediately told this to my fellow workers in the Entertainment Establishments. There are four clinics that treat STIs run by CFPA in Liuzhou. They offer a professional confidential service which we can afford and they answer any questions we have. We do not feel that those at the clinic judge us because of our work and we can visit and receive treatment if we contract an STI. Most importantly, we now know how to protect ourselves from risk at work. CFPA designed a handbook for us containing information and knowledge on STI and HIV prevention. In the handbook there is information about using a condom correctly, some skills on self-protection and how to avoid unexpected damage and violence. The handbook gives us the skills we need to protect our health and our lives.

Before I found the clinic run by CFPA I did not know where to receive safe and affordable treatment. Now I know that if I feel unwell I will be able to see a doctor as soon as possible.

I now understand how important it is to use a condom to protect myself from STIs and HIV. The training and the clinics are helping me and my friends.’’

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Malawi

Vending with hope The Family Planning Association of Malawi (FPAM) has increased access to information and integrated services such as the treatment of sexually transmitted infections, opportunistic infections, HIV information, voluntary counselling and testing (VCT) and the distribution of male and female condoms to vendors at a number of markets in Lilongwe. In addition to offering services, they are also offering people hope.

“My name is Cecilia Rodrick. I am a vendor at Mitundu market and I first heard of FPAM when they led an open air information and communication session about HIV at the market. I joined in the session and learnt a lot about sexual and reproductive health issues, including VCT. I thought it would be good to get tested for HIV and went to Mitundu Rural hospital. When the result came back as positive I was referred for counselling and psychosocial support sessions, both of which were conducted at the market by FPAM. I found the sessions very helpful and did not want to miss a single one as they helped me to accept my new status. When my health started deteriorating I was able to talk to an FPAM representative at the market and was referred to a nearby clinic where they assessed me and started me on antiretroviral therapy.

In 2007, I became pregnant and gave birth to a baby boy.

When I first found out I was pregnant, I was scared that my baby would also be HIV positive but FPAM informed me about prevention of mother-to-child transmission (PMTCT) services. I was told that because I was already on antiretroviral therapy

it was very unlikely that I would pass on the infection to my unborn baby but that I should give birth by caesarean and I shouldn’t breast feed my baby. It is difficult not breast feeding my baby because other people think there is something wrong with me. However, as my baby is HIV negative, I am happy to feed him with a bottle as it keeps him safe from infection. My baby is growing up well and I am strong and healthy too.

I have now joined a community based organization in Mitundu where I share information about positive living and my own experience with other vendors. Some of the vendors asked me to provide the same information in neighbouring districts. I was very happy to do this as I want to reach as many people as I can. People are still dying from AIDS related illnesses because they don’t know about the treatment, care and support they could receive. Others become infected with HIV because they don’t understand the importance of using a condom in sexual intercourse. People should not die of ignorance!

Because of the help FPAM have given me, especially with accessing VCT and PMTCT services, I have a new life, as does my baby who is HIV negative. I hope I can continue being a living example for others.”

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Bolivia

Crossing streets CIES, the IPPF Member Association in Bolivia, is making a positive impact on the lives of young Bolivians, empowering them to make informed decisions about their wellbeing. They are providing basic healthcare and sexual and reproductive health services to marginalized and under-served young people through special youth centres offering pap exams, STI and HIV testing and medications. Omar Oxa, a nurse and youth educator at the youth centre in El Alto knows the value of reaching young people where they are.

“The youth centre was specially built for El Alto’s young people and is a combined social, educational and health centre. It has a separate entrance from the main health clinic so there is complete privacy from adults when requesting medications or a pap, STI or HIV test. The centre offers a safe place where young people feel comfortable and can gather to talk or participate in activities including sports, music, and job skills training. It was designed and decorated by the young people and in many ways provides a family structure for kids with nowhere else to go.

Because few street youth used to come directly to the clinic, we decided to set up an outreach team to take basic healthcare and sexual and reproductive health services directly to them. Twice a week a team consisting of a doctor, a peer educator, youth leaders and myself as the nurse, go on visits to street youth communities. We sit down with gang members, shoe-shiners and homeless young people, and drink tea, while speaking about condom use, STIs and self-esteem

issues. This way we begin to gain their trust and confidence.

For more complex procedures we have been successful in gaining their trust and have them coming directly to the clinic.

This has doubled the number of clients who come to the youth clinic for services.

This initiative is beginning to take off with huge potential.

Before we started working with these communities, you’d never see a shoe-shiner come in for services, or a homeless young person, but now you do. The young people I work with now demand high-quality health services and visit the centre often. It’s the most gratifying thing about working here.

Before the centre opened, the street youth didn’t even know that clinics existed or even cared about them. They are really vulnerable and socially marginalized because they have left their homes or been kicked out, and don’t put their health first. Because of the youth club, they tell us they now feel like human beings because there are people who worry about them and want to prevent them from getting STIs or HIV. This is about them, not us.”

In a Life: Providing prevention services 19

Swaziland

Under one roof Sexual and reproductive health (SRH) services and HIV services are often provided in isolation of each other, which limits client access, especially in rural areas. SRH and HIV services need to be better linked so that all service providers can provide a comprehensive range of services to help with HIV prevention. To this end, the Family Life Association of Swaziland (FLAS) is working with Population Services International Swaziland to provide voluntary counselling and testing (VCT), treatment of sexually transmitted infections (STIs), and family planning services in a mobile clinic.

“My name is Henry, but many of my work colleagues call me ‘Pastor’. I work for FLAS as a nurse in the rural areas of Swaziland, bringing clinical services to those who might otherwise not be able to attend our main clinics in Mbabane or Manzini. Although I initially started working for FLAS just two days a week, I soon started working full time because there are so few nurses and so much work to be done, especially in reaching out to the poorest areas.

One area that I go to is the industrial area in Matsapha. It is mainly women who work in these factories. They cannot come to the clinics or hospitals as they work very long hours, so we bring the service to them with a mobile clinic.

The services we provide are primarily aimed at reproductive and sexual health, including family planning, STI care, and VCT. It is important that these women know what their options are and can take care of themselves. Many have sexually transmitted infections and need treatment, and many also have HIV and may need referral for counselling and antiretroviral therapy.

Each person that I work with has their own story, and we try to listen. The women at the factories often have difficulty practising what we teach them or using the protection we provide as their husbands do not want to use family planning methods. It is hard work, but we try to show ways that will give them choices.

Sexual and reproductive health is not well understood in Swaziland and many people do not want to be tested for HIV, but we try to make it easier through making sexual and reproductive health mean something in their lives. By providing services where people are working, we hope that we can help with preventing HIV, especially by treating STIs and encouraging the use of condoms. I enjoy my work. It makes me proud to be a man, a father, and a brother.”

49% of women aged 20–34 years attending antenatal clinics in Swaziland in 2006 were HIV-positive WHO & UNAIDS 20076

20 In a Life: Providing prevention services

Mexico

Behind bars and across borders In 2007 MEXFAM provided HIV counselling services to 12,279 people IPPF 20087

MEXFAM is undertaking an initiative to create awareness about HIV and increase access to services amongst vulnerable populations, especially migrants and prisoners. The project focuses on preventing HIV infection by providing information, knowledge and skills. Access to services (including condom promotion) and voluntary counselling and testing (VCT) is also promoted, along with follow-up services for people living with HIV. A 2006 baseline survey outlined the challenges facing MEXFAM in improving HIV prevention amongst migrant workers and prisoners. For example, almost half of the respondents who were sexually active had had at least one sexual encounter with someone other than their regular partner, but only one in seven had used a condom. Moreover, only 40 per cent of the participants were aware of VCT services, and only one in five had ever been tested.

MEXFAM is working with prisoners by running workshops on HIV prevention and providing VCT. One prisoner says:

“MEXFAM helped us to think over a lot of things, especially the option that we can do things better and look after our sexual lives. Every day we learn something new. Today we learned about HIV and how it can be prevented. I have learned the importance of using a condom with a double purpose: to avoid an unexpected child, and to prevent HIV as well as sexually transmitted infections.”

MEXFAM is also working with illegal migrants from Central America. Setting up a mobile clinic near a railway station where many illegal migrants first arrive in Mexico City was the starting point. This clinic provides the migrants with prevention information, medical referrals to a nearby MEXFAM clinic, and free condoms.

Esperanza Delgado, director of Evaluation and Research at MEXFAM says, “Reaching populations often overlooked or ignored by society is important in preventing the continued spread of HIV because these people have little or no access to sexual and reproductive health services. They have a right and a need to access these services, just like everyone else.”

In a Life: Providing prevention services 21

Papua New Guinea

And my wife makes three Papua New Guinea Family Health Association (PNGFHA) carries out awareness days on HIV and sexually transmitted infections (STIs) on the first Wednesday of each month. Ms Pele Melepia, the provincial programme coordinator for PNGFHA in the Eastern Highlands recalls one of the clients she recently met.

“I first met Andy and his wives when he attended an awareness day on STIs and HIV which PNGFHA had organized in his village. Andy is a 35 year old man who lives in Eastern Province with his two wives and their three children. They are a typical self employed family residing in the highlands province. He works as a subsistence farmer to support his family, growing sweet potatoes, cabbages, tomatoes and carrots. His two wives help him to work and harvest the fresh produce to sell in the town market to earn some money. The family also own two pigs and a few chickens.

We started the training session by introducing the organisation and what we do and then went on to talk about sexually transmitted infections and their signs and symptoms.

While we were still talking, Andy’s wives started whispering amongst themselves about how they had been feeling for the past few months. They had not had time to visit a hospital for a check up because of work and had dismissed their

symptoms as a stomach ache. During our presentation it dawned on them that they may have an STI which they had been ignoring for months.

The next day they turned up at the front door of the PNGFHA clinic. We greeted them and led them into the clinic. Andy introduced himself and his two wives. He explained that he had two wives because the first could not give him a child so he decided to marry a second wife. This is a common practice in the highlands of Papua New Guinea.

After diagnosing and giving Andy and his wives the necessary treatment, I explained how STIs can easily lead to other complications and that it is easier for someone with certain STIs to contract HIV. I taught them how STIs and HIV spread and how they can be prevented. Then I showed Andy and both his wives how to use the male condom if they believed that they were at risk. They realised that ignorance helps to spread infections to other people, and that STIs may cause permanent damage to reproductive organs. Andy and his wives came back for further consultations until they completed their treatments.”

People living with HIV are central to IPPF as staff, volunteers, clients and partners

Involving

Listening

Programmes designed by, as well as for, PLHIV promote the active engagement of those living with HIV in our work

Programmes and networks established by PLHIV ensure that the voices of the most vulnerable and marginalized inform our reponse to HIV

Providing Partnering with PLHIV in the communities where they live by providing comprehensive sexual and reproductive health and HIV services

25

Expanding treatment, care and support An all-encompassing approach to sexual and reproductive health and rights requires linking HIV prevention and care in a seamless continuum. A comprehensive sexual and reproductive health response to HIV necessitates the natural integration of HIV treatment, care and support services.

Utilizing a variety of programmatic entry points – including voluntary counselling and testing, sexually transmitted infection (STI) management and prevention of mother-to-child transmission – provides a unique platform to expand access beyond basic HIV treatment and care services within a sexual and reproductive health setting.

Integrating HIV treatment, care and support services into a sexual and reproductive health setting delivers a number of primary benefits to both clients and service providers. It optimizes the use of existing sexual and reproductive health infrastructure – an especially valuable approach in resource-poor settings. A continuing characteristic of the epidemic is its concentration in the poorest areas, and using existing infrastructure, staff and expertise avoids wasting scarce resources.

Offering treatment and care through sexual and reproductive health clinics also acts as a way to reduce stigma. Many people may be discouraged from visiting HIV-only clinics for fear of being stigmatized or discriminated against by their communities.

There is often more confidentiality in settings where other, non-related services are provided. A ‘one stop approach’ where clients are able to access different services under one roof or through a robust referral system reduces the time, money and effort clients have to spend seeking healthcare. This encourages the use of these services and in IPPF Member Associations around the world we have witnessed an

increase in both the use of other services and also in reaching non-traditional clients.

In 2007, 75.5 per cent of IPPF Member Associations had programmes specifically reaching vulnerable populations with sexual and reproductive health and HIV services.8 Global universal access targets will only be met with the concerted effort of all stakeholders and partners. Contributing towards the attainment of these goals, IPPF Member Associations are providing more comprehensive care by integrating HIV treatment and support into a broader sexual and reproductive health response.

Recent innovations in integration have focused on the delivery of antiretroviral therapy (ART) and opportunistic illness management through existing sexual and reproductive health infrastructure. This is crucial for ensuring universal access to necessary medications. An IPPF, UNAIDS, UNFPA and WHO case study, Gateways to integration: A Case Study from Kenya (2008), celebrates the provision of antiretroviral therapy in a sexual and reproductive health setting. Providing family planning and fertility counselling, adherence support, nutritional advice, links with income generation and microfinance activities, palliative care and psycho-social support are all necessary ingredients of a comprehensive package.

The following pages demonstrate how IPPF Member Associations have brought access to treatment, care and support into the lives of women, men and young people. Whether this is through innovative strategies to provide ART, referral mechanisms for rural clients, or management of STIs and opportunistic illnesses, IPPF gives individuals access to the comprehensive and linked HIV care services they need to have a healthy sexual and reproductive life.

26 In a Life: Expanding treatment, care and support

Kenya

Care at home for people living with HIV Family Health Options Kenya (FHOK) has an innovative approach integrating comprehensive HIV services within a sexual and reproductive health setting, including the provision of home based care and psychosocial support.

Community health workers are trained in home based care, counselling and HIV prevention education, and each clinic has formed a psychosocial support group (PSSG) for people living with HIV accessing services at FHOK and other nearby clinics. Nairobi West Family Care Medical Centre initiated this approach in the nearby Mutumba slum.

“My name is Helen. I’m 34 and I have three children. I tested positive for HIV 12 years ago. When I was diagnosed with HIV I was devastated and thought life no longer had any meaning.

I didn’t know how to tell my family, especially my children, and I was on the verge of losing hope. However, the support I received from the FHOK staff strengthened my resolve to live and enabled me to disclose my status to my family and the community. The disclosure made it easier for me because I no longer stigmatised myself and my family was very supportive. The PSSG became more or less my second family as the sharing of experiences during group meetings made me realize that I was not alone.

When FHOK wanted to expand this approach to improve home based care and support, I volunteered to become a Community Health Worker. I was trained and began work last year. My job has enabled me to serve other people living with HIV in the community. I offer home based care and also link

them to other local organizations for training and support in starting income generation projects. For example, the PSSG group in Mutumba now has a successful handcraft making business. I feel proud that I am part of this life improving work.

Even though I was diagnosed with HIV 12 years ago I am not yet on antiretrovirals. I attribute this to the care and support, including the nutrition education I received. My 12-year-old son is also living with HIV like me. I always think that if only this project had begun earlier then maybe my son would have been born HIV negative because I am certain I would have benefited from prevention of mother-to-child transmission services. However, whenever he has an infection he can receive treatment in FHOK clinics so I don’t have to worry about him.

I am always eager to help many more people know their status through voluntary counselling and testing and for those who test positive, I help them to live positively. One of my most gratifying experiences is to see bed-ridden clients regain their health through home based care and the antiretroviral therapy they receive from FHOK clinics. Then they get given the opportunity to earn an income through income generating activities and projects. This is so much more than just providing health services.”

In a Life: Expanding treatment, care and support 27

Sudan

Access to treatment gives hope The Sudan Family Planning Association (SFPA) runs training centres for HIV counsellors in Khartoum and employs many of these counsellors to give treatment, care and support services both in the clinics and in the homes of those living with HIV. Khalid volunteers at the clinic in Omdurman, a suburb of Khartoum. “My name is Khalid Mohamed Saeed. I was working in the south of Sudan in 2002 when I contracted HIV. Over the next few years, due to my loss of immunity, I became sick and very weak. I lost the desire to do anything, even to eat. I was in a bad way.

Not knowing what to do, I moved to Khartoum where I discovered a clinic in Omdurman run by the Sudan Family Planning Association. I was given counselling and care and I was respected and supported. This is when my life began to turn around.

From the SFPA counsellors, I learned about antiretroviral therapy (ART); drugs that could suppress the HIV in my body and make me feel much better. Since I have begun antiretroviral therapy I am feeling much happier. I am now able to look after myself and am more optimistic about the future.

When the doctor from the Sennar Integrated Reproductive Health Centre, run by the Sudan Family Planning Association asked me to join them as a volunteer I accepted straight away. The SFPA helped me to realise that my life was not over because I had contracted HIV, and I want to reach out to others in my situation and give them the same good news.

One of the biggest problems that I see in Sudan at the moment is that all of us living with HIV are suffering from stigma and discrimination from those around us. A lot of work must be done to eradicate stigma and discrimination from the workplace and community to allow people living with HIV (PLHIV) to live normally. Working together with SFPA and PLHIV associations, we can continue to give PLHIV hope and educate others about HIV to reduce the stigma we face.�

Between 2004 and 2005 the number of people receiving antiretroviral therapy in Sudan rose from 400 to 13,000 people WHO 20069

28 In a Life: Expanding treatment, care and support

Cameroon

Advocacy, action, and answers In 2005, nearly half a million adults were living with HIV in Cameroon and adult national prevalence was estimated at 5.4% WHO & UNAIDS, 200610

On 19 April 2007, the lives of many Cameroonians living with HIV changed for the better when the government announced that antiretroviral therapy would be free of charge, thanks to a finance agreement of US$77 million signed in Switzerland with the Global Fund to fight AIDS, Tuberculosis and Malaria. This decision changed the lives of 47,000 people already on antiretroviral therapy and many others who were previously unable to access treatment due to its cost.

It has taken many years to get to the stage of free antiretroviral therapy in Cameroon and civil society organizations have had to fight hard for the government to adopt this policy. To this end, the Cameroon National Association for Family Welfare (CAMNAFAW), and other civil society organizations carried out an advocacy campaign for free treatment for people living with HIV, including an initiative to expose and stamp out the mis-spending and corrupt use of international funds earmarked for HIV. Ultimately the campaign was successful and the life saving decision to provide free antiretroviral therapy has instilled an air of hope. Lives are changing for the better, as Martha, a retailer at the central market in Yaounde, tells us.

“I am a mother of four children. My husband died of an AIDS related illness and when I fell sick, I went for voluntary counselling and testing. I found out that I was also HIV positive and needed to go on ART. The cost of antiretroviral therapy at the time was 3,000 Francs (approximately US$7) a day, but I could not even make 300 Francs (approximately US$0.70) profit from my market stall each day because I was sick, and I needed to use this money to feed my children. Now antiretroviral therapy is free, I no longer have a dilemma about whether to spend my money on antiretroviral (ARV) drugs or food. This has changed my life, especially as now I am well, I am able to work hard and earn a larger profit at the market and afford more nutritious food for myself and my family.”

Martha’s story is not unique. There are many other such cases, shown by the ever increasing number of people queuing up at ARV distribution centres. Whilst people can now receive the treatment they need for free, there is still stigma and a lack of care and support. People who queue up at distribution centres are given inquisitive looks as it makes it clear to others that they are living with HIV, and more now needs to be done to improve their right to confidentiality, and to reduce HIV-related stigma across Cameroon. Despite these ongoing problems however, free ARV delivery has improved the life expectancy and quality of life of many Cameroonians living with HIV.

In a Life: Expanding treatment, care and support 29

Cambodia

Getting your ducks in a row In 2006 the Reproductive Health Association of Cambodia (RHAC) began a community HIV programme in Kum Potproh in Cambodia to increase awareness about HIV transmission and prevention and to encourage people to access appropriate services. The programme facilitates acceptance of home based care and access to antiretroviral therapy (ART) and encourages people living with HIV (PLHIV) to participate in social village activities. Ms Neang Somuntha is a role model for other PLHIV in her village. “I live in Kum Potproh village, in the Svay Rieng Province of Cambodia. I am HIV positive. Since RHAC have helped me, I have a source of income which is sufficient to meet my daily needs and I am no longer worried about the future. However this has not always been the case.

In 2006 I became seriously sick and I was diagnosed with HIV. I spent nearly all of my money on HIV treatment and was too sick to earn any more money. The situation got so bad that I even had no money to buy food. Just when I thought that I could not go on, the RHAC started a community HIV programme in my village. Volunteers came to see me at my

home and told me about the treatment I could receive for free because I was poor and gave me the bus fare to travel to the provincial town to receive ART. They also gave me some rice and other food to eat and told me how important it was to eat well as this would help me to regain my health.

With this help my health quickly improved but I still could not earn much money as I had no money to start a business.

Therefore RHAC lent me US$30 to start my own business.

With this money I bought 40 chicks and 10 ducklings to rear myself. Now, I am so happy because I have many chickens and ducks. If I can increase my capital, I plan to buy four or five pigs and start a pond at home for rearing fish.

I no longer fear death from AIDS related illnesses because I have learned how to take care of myself, especially how to prevent opportunistic diseases. I also know that I need to remember to take my antiretroviral therapy drugs every day without forgetting them. I now work to help other PLHIV in my village and with the help of RHAC, 447 PLHIV like me have had their lives turned around and are now able to earn an income and live as other people in the community do.�

30 In a Life: Expanding treatment, care and support

India

Dropping in to health

Nagaland is a small north-eastern state in India, with a population of two million, where injecting drug use has been the driving force behind the spread of HIV. Due to fear and stigma, injecting drug users (IDUs) and their partners do not come forward to access the services available at government hospitals. Providing all the services (including harm reduction) under one roof will encourage IDUs and their partners to use these services.

The drop-in centre provides injecting drug users and their sexual partners in and around Kohima Town with comprehensive health services including clean needles and syringes. The centre has a peer driven outreach programme and in this way, HIV can be prevented in IDUs who are HIV negative and treatment, care and support can be given to those who are living with HIV or other conditions, like Hepatitis.

Chang was born and brought up in Kohima, Nagaland. At 14 he began taking drugs out of curiosity and because of peer pressure, little knowing that he would develop an addiction. By the age of 16 he was using multiple drugs, and started injecting once or twice a month. Whilst attending college Chang stopped using drugs for most of time, but when he dropped out in 2001, he resumed his drug taking once more and he started injecting drugs regularly. In 2004, after complaining of joint pain and diarrhoea, Chang was diagnosed with Hepatitis C but was found to be HIV negative.

Chang has been trained as a peer counsellor and shares his experience with other IDUs, encourages them to avoid sharing needles and guides them to decide about seeking treatment and other services. He also talks about the rights of IDUs and of people living with HIV. Most days on the way to the centre he visits friends who are living with HIV to check how they are and ensure that they are adhering to antiretroviral therapy.

Chang has brought many people to the drop-in centre by informing them of the services the clinic provides and the health benefits of accessing these services.

Chang underwent two drug rehabilitation programmes, one in Kolkata and then in Kohima, but relapsed each time. Then in September 2006 he discovered a drop-in centre run by the Family Planning Association of India (FPAI) which he now visits at least once a day.

Chang likes coming to the centre because he feels accepted and gains comfort from sharing his experience with others, especially young people. He is also keen on staying away from drugs and likes to visit the centre as others there are also trying to do the same.

In a Life: Expanding treatment, care and support 31

Lesotho

Loving yourself Despite an estimated HIV prevalence rate of 23.3 per cent, most people in Lesotho are unaware of their status. To tackle this problem the Lesotho government began the ‘Know Your Status’ campaign in July 2007 and became the first country ever to offer voluntary and confidential HIV counselling and testing (VCT) to every male and female above the age of 12 in the nation. The Lesotho Planned Parenthood Association (LPPA) provides VCT services for the government as part of this campaign.

LPPA visited Ha-Ramapepe village, 25km north east of Hlotse. Mrs Dorah Rampapepe, an LPPF volunteer, highlights the importance that volunteerism plays in a sustained HIV response. “LPPA were invited to Ha-Ramapepe to inform, educate and provide access to VCT services to those individuals wishing to know their status. More than 100 people attended the session – mostly young people from the neighbouring schools in Thaba-Phat sˆ oa constituency. We believe that undergoing an early HIV test is beneficial because it leads to early treatment for those who are living with HIV and antiretroviral drugs can prolong their lives. Also, support groups within the village, such as the Society for Women and AIDS in Lesotho, of which I am also a member, are united in taking care of those who are living with HIV by providing support, advice and help to ensure adherence to antiretroviral therapy.”

In Ha-Mopeli, a village in the Botha-Bothe district in the far north of Lesotho, an LPPA volunteer, Mr Machefo Thobileng, disclosed his HIV status at another VCT access day run by LPPA. After revealing that he had lived with the virus for seven years, he said: “I want to encourage those who are still silent to be open about their HIV status. Because of antiretroviral drugs HIV is no longer a death sentence!” He added, “You see, who can tell that I am living with the virus right now? I am fit and going about my business! Brothers and sisters, I urge you to take responsibility and know your HIV status and live longer.” Amidst applause from the crowd, 89 people volunteered to find out their HIV status through the VCT service offered by LPPA. Part of the value of the VCT service provided by LPPA is its insistence on the inherent benefits of the ‘3 Cs’ – confidentiality, consent and counselling. “The importance of stressing all three elements ensures that HIV counselling and testing is not about the numbers, but about the quality of the service,” says a staff member at the Association. “It’s about knowing yourself and being in touch with your community.”

23% of adults (15–49 years) were living with HIV in Lesotho in 2005 WHO & UNAIDS, 200611

33

Linking sexual and reproductive health and HIV The 2006 review of the United Nations General Assembly Special Session on HIV/AIDS in New York clearly highlighted the need to strengthen the policy and programmatic linkages between HIV and sexual and reproductive health. There is, however, still a lack of evidence to demonstrate the intrinsic value – both in terms of HIV and sexual and reproductive health outcomes – of various HIV and sexual and reproductive health linkage models.

Internationally there is increased recognition of the role of sexual and reproductive health providers play in linking HIV into their work along the prevention-to-care continuum. From providing family planning in a voluntary counselling and testing session to ensuring that antiretroviral therapy can be provided in a traditional sexual and reproductive health setting, it is clear that HIV, sex and reproduction are intimately linked and that together they provide an avenue to innovate and respond. A number of international statements, position papers, advocacy efforts and programmes have succinctly highlighted the moral and programmatic imperative of bringing the HIV and sexual and reproductive health responses into closer unison.

These linkages must be both bi-directional and address structural, policy and programmatic elements.

Enabling partnerships, as well as advocacy and capacity building based on partnership, is what makes access to HIV information, prevention, care and support a possibility for all. IPPF Member Associations have been cementing partnerships and exploring new ways of expanding access to a wider range of sexual and reproductive health services.

While the rhetoric on linkages may have grown louder, questions of cost, efficiency, impact and identifying the most effective entry points for programmatic integration remain largely unanswered. To address this, IPPF – in collaboration with UNFPA and WHO and in partnership with the Cochrane Collaboration Review Group – are currently determining the status of the sexual and reproductive health and HIV evidence base. This will provide a unique opportunity to systematically address the practicalities of integration. Answering the ‘how’ of integration will provide an opportunity to strengthen both the resolve and commitment of donors and governments to prioritize the linkages agenda. At the beginning of 2008, IPPF – in collaboration with the London School of Hygiene and Tropical Medicine, and the Population Council –commenced a five-year linkages research study in Kenya, Malawi and Swaziland.

Globally, IPPF works to influence HIV-related policy on a variety of issues. We aim to ensure that global HIV financing mechanisms recognize the breadth and scope of the sexual and reproductive health community in meeting HIV outcomes. We also emphasize the importance of mother-and-child-centered care within a prevention of mother-to-child transmission approach that includes a heightened focus on primary prevention of HIV and the prevention of unintended pregnancies in HIV positive women.

The following pages tell the stories of how IPPF Member Associations are using advocacy, capacity-building and partnerships to bring information and services into people’s lives, ensuring that the intrinsic links between HIV and sexual and reproductive health become a tangible reality.

34 In a Life: Linking sexual and reproductive health and HIV

South East Asia and the Pacific

Nurturing positive regional HIV competence

Funding for HIV and AIDS has grown ten fold in less than a decade to $10 billion in 2007 UNGASS, 200812

Countries and their communities across Southeast Asia and the Pacific have limited capacity in the public, private and civil society sectors to tackle HIV and AIDS on the required scale. Funding for HIV has grown significantly over the past decade, but many countries require rapid and adequate technical support to effectively implement HIV programmes and ensure HIV resources are used effectively and efficiently.

To address this, UNAIDS has established five ‘Technical Support Facilities’ (TSFs) across the world that together cover over 60 countries. The TSFs help match countries’ technical assistance needs with the best-suited technical assistance in the form of individuals and/or companies. One of these facilities is the IPPF-managed Technical Support Facility for Southeast Asia and the Pacific (TSF SEAP), which has four primary aims: To improve access to timely and quality-assured technical assistance in selected priority areas. These priority areas are vulnerable populations such as people living with HIV, injecting drug users, men who have sex with men, sex workers, women and young people.

To build, strengthen and expand a pool of local, national and regional consultants and assist in their professional development through a professional development programme.

To strengthen the capacity of country partners and recipients of technical assistance to effectively manage

technical assistance.

To encourage a harmonized and collaborative approach to the delivery of technical assistance across the region.

The TSF SEAP is currently building the management capacity of in-country consultants in Indonesia. Working with the UNAIDS Country Office in Indonesia and Spiritia, an activist group of HIV positive people based in Jakarta, TSF’s professional development programme is training 25 local consultants who are HIV positive or affected by HIV, in a year long programme.

It includes a week long residential course that covers issues ranging from business skills for effective consultants (including marketing and business planning) to critical path management, data collection, cultural issues and report writing. Following the course, participants conduct ‘real’ consulting assignments on HIV programmes in Indonesia where they receive mentoring and coaching from senior consultants.

HIV positive participants on the course are delighted that instead of just being the beneficiaries of HIV programmes, their energy, knowledge and skills are being used to tackle the HIV epidemic in Indonesia. This intensive training programme is producing new, capable, confident middle level local consultants to support the needs of HIV programme managers in Indonesia, and lead to a better response to HIV.

In a Life: Linking sexual and reproductive health and HIV 35

Arab World Regional Office

The right way of doing VCT IPPF Arab World Regional Office (AWR) organized a workshop on voluntary counselling and testing (VCT) issues to enhance the varied capacity of Member Associations in the region to integrate VCT within their existing sexual and reproductive heath and rights packages.

Recent advances in HIV prevention and medical care have, rightly, fuelled a new urgency to ensure access to voluntary HIV counselling and testing. A number of influential policy makers and programmers have called for greater reliance on testing initiated by health care providers rather than by the individual being tested – but this shift could modify the voluntary nature of HIV testing and reduce the counselling provided. This raises serious ethical and human rights questions, especially if extra provisions are not made for posttest counselling services and medical and psychosocial support for those testing positive.

Participants from over the all Arab World came to the workshop, each with their own unique experiences and ideas.

It gave everyone an opportunity to share the lessons they

had learned, as well as obstacles and barriers to providing voluntary counselling and testing they had faced. The discussion encouraged all of the participants to work together effectively in partnership, despite the social, religious and cultural barriers that exist across the Arab World.

The most important outcome of the training workshop was the development of a common understanding on voluntary counselling and testing issues based around IPPF standards.

Each Member Association now has unified guidelines for integrating voluntary counselling and testing with other sexual and reproductive health services. After the workshop each Member Association who attended organized similar twoday orientation sessions in their own country to disseminate the information and knowledge they had learned to other national family planning and HIV service providers.

The long term result of the initial VCT workshop is that currently nine out of 13 Member Associations in AWR are providing VCT, either directly at sexual and reproductive health centres or through a strong referral system based on written and signed agreements with concerned partners.

36 In a Life: Linking sexual and reproductive health and HIV

Colombia

Celebrating diversity in Bogata high schools Current debates on linking sexual and reproductive health (SRH) and HIV are progressing towards the practicalities of integration: the ‘what’ and the ‘why’ are clear and largely agreed but the real issue now is ‘how?’ The answer rests in ensuring that linkages are maximized in programmes, services and advocacy efforts, and it necessitates new working relationships between the HIV and SRH communities. In Colombia, Profamilia has partnered with LigaSida to work with young people in seven state run high schools in Bogota.

Both LigaSida, an HIV organization, and Profamilia, a leading sexual and reproductive health service provider, have long seen the importance of linking of SRH and HIV. A spokesperson from Profamilia says “From the broader viewpoint of sexual health, all the services that we offer place emphasis on protection, prevention of unwanted pregnancies, prevention of STIs (including HIV), empowerment and decision making – all of which are included under the framework of sexual and reproductive rights. Integration is a permanent component of our individual institutional health policy with HIV being seen a matter of sexual health.”

A collaborative initiative called Empoderate (Empower yourself) strives to empower young people to respond to the HIV epidemic and exercise their sexual and reproductive rights responsibly. It emphasises sexual diversity and the nurturing of leadership skills among gay, lesbian, bisexual, transgender, and questioning (GLBTQ) young people, and gives workshops and training in high schools according to a linked vision shared by both organizations, namely that students understand sexuality is a right that should be respected. Interactive media and activities is central to the approach, and a newly designed website (www.empoderate.org) has received over 70,000 visits during the first six months.

The collaboration has been beneficial for both organizations and their clients, nurturing a strong and sustained working relationship, with both organizations now offering their respective clients comprehensive sexual and reproductive health and HIV services. After a workshop one student said, “I learned that when people have sex they not only have to be careful of pregnancy but also of sexually transmitted infections such as HIV. The safest method to protect yourself is by using a condom and loving safely.”

In a Life: Linking sexual and reproductive health and HIV 37

Asia and the Pacific

Matching words to actions

IPPF was a co-sponsor of the Eighth International Congress on AIDS in Asia and the Pacific (ICAAP) in Colombo in August 2007. IPPF organized a Round Table of health ministers from Asia and the Pacific on ‘Moving closer to the integration of HIV and sexual and reproductive health (SRH): Challenges of moving from the corridors of power to people’s backyards.’ This regional meeting aimed to develop an operational mechanism to integrate HIV and SRH more efficiently.

A number of international statements, position papers and advocacy efforts have succinctly highlighted the need to link HIV and SRH responses. The ‘Glion Call for Action’ and the final declaration from the 2006 review of the United Nations General Assembly Special Session on HIV in New York clearly showed the importance of strengthening policy and programmatic linkages between HIV and SRH. Work on the ground has been slower to catch up with these international declarations and many of these important ideas remain just that: ideas which have not been made a reality.

The Round Table at ICAAP brought together health ministers and senior bureaucrats from Asia and the Pacific to discuss these challenges and look for possible practical solutions.

Participants included ministers and high-level government officials from Bhutan, Cambodia, China, Indonesia, Iran, Maldives, Myanmar, Nepal, and Pakistan and Thailand. The lively discussion focussed on topics such as the feasibility of SRH service providers taking on HIV-related work, and the importance of ensuring that all SRH responses adequately address HIV, including meeting the sexual and reproductive health needs of the HIV positive community. All governments were asked to act on issues of integration, and the Round Table culminated in a call for new policies from all participating countries to promote integration and put political declarations into action.

Together with WHO, UNFPA and UNAIDS, IPPF aims to support country application of the linkages agenda through the development of a ‘Global Sexual and Reproductive Health and HIV Linkages Needs Assessment Tool’. This tool, which will be completed towards the end of 2008, aims to address all of the most important subject areas to ensure a more synergistic SRH and HIV response.

Almost 100 of IPPF’s Member Associations are now providing their clients with Voluntary Counselling and Testing, or are referring them for VCT Gill Greer, June 200713

38 In a Life: Linking sexual and reproductive health and HIV

Global Fund to fight AIDS, Tuberculosis and Malaria

Making the money work for women and girls

Since 2002 the Global Fund to fight AIDS, TB and Malaria has provided more than 20% of international funding to respond to the HIV epidemic Global Fund, 200814

The ‘Mobilizing for Reproductive Health and HIV Integration’ initiative was launched in 2008. It has been developed by a number of organizations including IPPF, Population Services International, the Global AIDS Alliance, the International HIV/AIDS Alliance, Interact Worldwide, and Friends Africa. It aims to accelerate country demand and Global Fund support for integrated sexual and reproductive health and HIV programmes and services.

As part of this initiative, technical assistance is being offered to all participating countries to improve the technical quality of their proposals. Small sub-grants have also been made available to sexual and reproductive health organizations to build their capacity to begin accessing the Global Fund. In a 2005 survey conducted among IPPF Member Associations, just over 50 per cent were CCM members. Nearly half of those who were not CCM members identified a lack of information on the Global Fund as the key reason for not being involved.

The Global Fund to fight AIDS, Tuberculosis and Malaria is a global public-private partnership dedicated to attracting and disbursing additional resources to prevent and treat HIV, tuberculosis and malaria. The Global Fund is the largest funder of HIV programming worldwide, offering US$4.7 billion since 2002 to national level HIV strategies. It is a complicated mechanism with strict funding criteria for Country Coordinating Mechanisms (CCM), recipients and subrecipients.

It is widely recognized that weak health systems are a major bottleneck in the effort to fight HIV in resource-poor countries. The ‘Integration Initiative’ seeks to persuade Global Fund actors and stakeholders to prioritize sexual and reproductive health and HIV integration as a critical component of scaling up access to HIV prevention, treatment, and care. Whilst progress has been made and the Global Fund has begun to recognize the importance of linking sexual and reproductive health and HIV, much still needs to be done to increase the capacity and technical expertise of sexual and reproductive health organizations to access and utilize these funds effectively.

The initiative organized a meeting in Addis Ababa in February 2008 to give focussed assistance to 10 countries in Africa (Ghana, Cameroon, Tanzania, Burundi, Namibia, Zambia, Mozambique, Madagascar, Burkina Faso and Nigeria) in order to raise global, regional and national stakeholders’ awareness of the importance of integrated proposals, and assist sexual and reproductive health organizations to better engage with the Global Fund in future rounds. At the meeting, each country delegation shared a work plan of how they intend to integrate sexual and reproductive health into their HIV proposals for Round 8.

In a Life: Linking sexual and reproductive health and HIV 39

Mother and child-centred care

Mothers matter

In 2007, 420,000 children under 15 years were infected with HIV, bringing the total number of children living with HIV to 2.5 million worldwide – nine out of ten of whom live in sub-Saharan Africa. Well over 90 per cent of new infections among infants and young children occur through mother-to-child transmission, but this could be largely prevented with proper education and treatment. However, global coverage for prevention of mother-to-child transmission (PMTCT) remains low.

The 2001 United Nations General Assembly Special Session on HIV/AIDS set an ambitious target of reaching at least 80 per cent of all women who need access to PMTCT by 2010. Low and middle income countries are working hard to achieve this target but if long term progress is going to be made, more needs to be done across the continuum of care. A broader and more comprehensive approach is required: one that centres care on the parents and the child.

The four-prong strategy for an effective PMTCT response includes: 1 Primary prevention of HIV infection: placing the spotlight firmly on primary prevention aimed at young women and girls should be the minimum standard expected of all HIV prevention programmes. Prevention programmes need to become less focused on a ‘disease avoidance’ approach and more focused on safer sex linked to human sexuality.

2 Prevention of unintended pregnancies among women living with HIV: sexual and reproductive health services, including family planning, need to be made available to every woman irrespective of HIV status.

Addressing the sexual and reproductive health needs of women living with HIV should become the cornerstone of all prevention initiatives. A rights-based approach will ensure that choice is respected.

3 Preventing HIV transmission from a woman living with HIV to her infant: these strategies include the provision of antiretroviral therapy during pregnancy and after delivery, safe delivery practices, and provision of infant feeding counselling. Pregnant women living with HIV are at high risk of transmitting HIV to their infants during pregnancy, during birth or through breastfeeding.

4 Provision of appropriate treatment, care and support to mothers living with HIV, their children, partners and families: strengthening the linkages between PMTCT and the provision of antiretroviral therapy after pregnancy for mothers, their infants and families will contribute to a more comprehensive response to HIV. As a new member of the Interagency Task Team (IATT) on PMTCT, IPPF is committed to using its network of sexual and reproductive health clinics for scaling up PMTCT programmes.

In 2007 this programme was being delivered in 30.6 per cent of IPPF Member Associations15, up from 18.1 per cent in 2006, and will continue to increase through 2008 as a comprehensive approach towards PMTCT is prioritized.

41

Endnotes 1 WHO & UNAIDS (2007) AIDS Epidemic Update 2007 Regional Summaries: Asia, http://data.unaids.org/pub/Report/2008/jc1527_epibriefs_asia_en.pdf

9 WHO (2006) Country stories fact sheet for media, http://www.who.int/hiv/countrystories.pdf

2 Ibid.

10 WHO & UNAIDS (2007) AIDS Epidemic Update 2007 Regional Summaries: Sub-Saharan Africa, http://data.unaids.org/pub/Report/2008/jc1526_epibriefs_ssafrica_en.pdf

3 Human Rights Watch (2007) World Report 2007, http://hrw.org/englishwr2k7/docs/2007/01/11/russia14838.htm

11 Ibid.

4 IPPF (forthcoming November 2008) Annual performance report 2007-08, www.ippf.org. [NB: Initial figures and subject to revision].

5 Parish W.L., Suiming P. (2006). ‘Sexual partners in China: risk patterns for infection by HIV and possible interventions.’ In: Kaufman et al., eds. Social policy and HIV/AIDS in China. Cambridge, MA, Harvard University Press.

6 WHO & UNAIDS (2007) AIDS Epidemic Update 2007 Regional Summaries Sub-Saharan: Africa, http://data.unaids.org/pub/Report/2008/jc1526_epibriefs_ssafrica_en.pdf 7 IPPF (forthcoming November 2008) Annual performance report 2007-2008, www.ippf.org. [NB: Initial figures and subject to revision] 8 Ibid.

12 UNGASS (1 April 2008) Midway to the Millennium Development Goals: Report of the Secretary General, http://www.un.org/ga/president/62/issues/hiv/A-62-780. pdf 13 IPPF (2007) Voluntary Counselling and Testing: A gateway to linking HIV and sexual and reproductive health, http://www.ippf.org/en/Resources/Guides-toolkits/Voluntary+ Counselling+and+Testing.htm 14 Global Fund (2008) The Global Fund Opens its Eighth Round, www.theglobalfund.org/en/media_center/press/pr_080303.asp 15 IPPF (forthcoming November 2008) Annual performance report 2007-08, www.ippf.org. [NB: Initial figures and subject to revision].

42

Acronyms and abbreviations ABC Abstain, Be faithful, use a Condom AIDS Acquired Immunodeficiency Syndrome AMPF Association Marocaine de Planification Familiale ART Antiretroviral therapy ARV Antiretroviral AWR Arab World Region CAMNAFAW Cameroon National Association for Family Welfare CCM Country Coordinating Mechanism CFPA China Family Planning Association CIES Centro de Investigaciรณn, Educaciรณn y Servicios FAMPLAN Jamaica Family Planning Association FGAE Family Guidance Association Ethiopia FHOK Family Health Options Kenya FLAS Family Life Association Swaziland FPAI Family Planning Association of India FPAM Family Planning Association of Malawi G8 Group of Eight countries (Canada, France, Germany, Italy, Japan, Russia, UK and USA) GIPA Greater involvement of people living with HIV/AIDS GLBTQ Gay, lesbian, bisexual, transgender and questioning GNP+ Global Network of People living with HIV HIV Human Immunodeficiency Virus IATT Interagency Task Team ICAAP International Congress on AIDS in Asia and the Pacific ICW International Community of Women living with HIV/AIDS

IDU Injecting drug user IPPF International Planned Parenthood Federation LPPA Lesotho Planned Parenthood Association MEXFAM Fundaciรณn Mexicana para la Planeaciรณn Familiar, A.C. MSM Men who have sex with men PLHIV People living with HIV PMTCT Prevention of mother-to-child transmission PNGFHA Papua New Guinea Family Health Association PPAT Planned Parenthood Association of Thailand PROFAMILIA (Colombia) Asociaciรณn Pro-Bienestar de la Familia Colombiana PSSG Psychosocial support group RFPA Russian Family Planning Association RHAC Reproductive Health Association Cambodia SRH Sexual and reproductive health STI Sexually transmitted infection SFPA Sudan Family Planning Association TAO Tambol Administration Organisation TSF Technical Support Facility TSF SEAP Technical Support Facility for Southeast Asia and the Pacific UNAIDS Joint United Nations Programme on HIV/AIDS UNGASS United Nations General Assembly Special Session on HIV/AIDS UNFPA United Nations Population Fund VCT Voluntary counselling and testing WHO World Health Organization YAM Youth Advocacy Movement

Published in June 2008 by the International Planned Parenthood Federation 4 Newhams Row London SE1 3UZ United Kingdom

Illustrations by Martin Alonso Photography on pages 22–23: IPPF/Jon Spaull – Colombia IPPF/Chloe Hall – Ethiopia IPPF/Peter Caton – India

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Kevin Osborne, Jon Hopkins, Laura Feeney, Karla Fitzhugh, Adam Garner, Dieneke ter Huurne, Yasmin Khan; Nono Simelela, Alejandra Trossero (London) Hugues Lago (African Regional Office) Nathalie Nkoume (Cameroon) Mathias Chatuluka (Malawi) Glenda Stanislaw (Swaziland) Sana Nemer (Arab World Region Office) Nagat Elhadi (Sudan) Anna de Guzman (East and South East Asia Regional Office) James Rock (TSF SEAP) Lena Luyckfasseel (European Office) Anastasia Lomova (Russia) Arushi Singh, Prasanta Bandyopadhyay (South Asia Regional Office) Jessica Halverson (Western Hemisphere Regional Office) Esperanza Delgado (Mexico) A special thanks to those whose stories feature in this publication

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