In_A_Life_Prevention

IN A LIFE ACCESS TO PREVENTION

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 PREVENTION Introduction The 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.

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. IPPF’s Member Associations bring to life strategies for preventing HIV/AIDS, sexually transmitted infections and unwanted pregnancy by partnering with people, focusing especially on the marginalized, vulnerable and socially-excluded, including ethnic minorities, refugees, sex workers, males who have sex with males, people living with HIV and AIDS, young people and women.

Mainstreaming HIV/AIDS prevention with sexual and reproductive health services gives people access to a full range of choices to protect themselves from infection.

Dual protection against HIV, sexually transmitted infections (STIs) and unwanted pregnancy helps individuals and couples to enjoy a healthy sexual and reproductive life, and the prevention and treatment of STIs, in turn, helps to prevent HIV transmission. All prevention methods need to be available for all people, and services must be accompanied by information so individuals can choose a method of prevention and use this method competently and with confidence.

For young people to exercise their right to enjoy their sexual and reproductive lives, HIV prevention needs to be sex-positive and youth-friendly. Young people’s vulnerability to HIV obliges us to move beyond the life skills approach towards sexuality education, and to bring sexuality education to schools, the streets and wherever young people are. This comprehensive ‘in-your-face’ approach is part of the mandate of IPPF and it’s Member Associations – working with young people and defending their right to enjoy their sexual lives free from ill-health, unwanted pregnancy, violence and discrimination.

Linking HIV prevention with empowerment of women and male involvement is fundamental to giving women

Photo: IPPF/Liba Taylor

equitable access to prevention. Gender-based violence and sexual coercion leave many women unable to negotiate condom use with their partners. Building women’s skills in condom negotiation addresses the issue on the surface, but needs to be matched by long-term efforts to empower women economically and eliminate barriers to health care. At the same time, men need to be equal partners in HIV prevention efforts to encourage them to protect themselves and their partners from infection.

Increasing infection rates among women throughout the world, many of whom contract HIV from their primary male partner, have made it imperative that prevention efforts renew their focus on those who are most vulnerable. People living with HIV and populations that are especially affected

by HIV/AIDS need to be engaged in prevention initiatives not only to protect themselves from infection – and re-infection – but also to protect their partners, whose vulnerability often derives just from being female.

By mainstreaming HIV prevention with sexual and reproductive health information and services, providing sex-positive prevention services for young people, integrating gender into HIV/AIDS prevention services and developing programmes that meet the prevention needs of people living with HIV and other vulnerable populations, IPPF enables individuals around the world to access vital prevention information and services. The following pages tell the stories of people in countries from Swaziland to Vietnam, and how the services of our Member Associations helped people like Hasan in Bangladesh and Janaki in Nepal to make choices to protect themselves. Through these initiatives IPPF is providing access to prevention information and services that are indeed ‘access to life.’

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IPPF IN A LIFE

INTEGRATED PREVENTION

Photo: IPPF/Jenny Matthews/Bangladesh

“In looking after my own sexual health I am protecting my family.”

Health, Hardship and HIV: Reaching Vulnerable Populations in Chittagong Family Planning Assocation of Bangladesh (FPAB) Hasan drives a truck on the long, lonely roads of Bangladesh, and he always looks forward to pulling into Chittagong. The 31-year-old man only gets to see his family a few days a month, and while he’s away from home “he still needs to enjoy himself.” He sometimes visits sex workers in Chittagong, but he only has sex with young women who ‘look clean’. When he gets a sexually transmitted infection (STIs), he usually just visits a pharmacist for medicine.

Chittagong is a densely populated industrial port city in south-east Bangladesh. Life is hard – Chittagong has one of the country’s largest and fastest growing slum areas.

The population of the slums is growing at a rate of more than four per cent, more than double the growth rate in

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the country as a whole. As a result, a large proportion of its residents are young people – most of them illiterate and many unemployed or working in low paying jobs as day labourers or rickshaw pullers. They have little access to any form of recreational activities and limited access to information and health services, especially concerning STIs and HIV/AIDS. The city is also a major transport hub, with a busy truck interchange, bus terminal and city railway station. These facilities all attract large numbers of people arriving from rural areas to seek work in Chittagong City as well as long distance truck drivers, day labourers and rickshaw pullers. As a result, Chittagong has a significant sex industry with more than 3,000 sex workers, and neighbouring Daulatdia has the largest brothel within Bangladesh. Despite the vulnerability of these groups to sexually transmitted infections and HIV/AIDS, very few prevention services are available.

HIV/AIDS awareness is relatively low in these communities, with more than one third of people having little or no knowledge of the infection. There is also little understanding of the modes of HIV transmission and the ways to prevent infection. In a survey conducted by the Family Planning Association of Bangladesh (FPAB), one third of those sampled had not heard of HIV/AIDS; only 43 per cent were aware that it could be fatal; and only around half of respondents were aware that HIV can be transmitted through sexual intercourse, the sharing of injecting equipment, blood transfusions or from mother-to-child.

When questioned on prevention, only 36 per cent were aware that condoms could prevent transmission and only 24 per cent said they used condoms whenever they had sex.

FPAB has been working on HIV/AIDS as a key priority since 1996. As a member of the National AIDS Committee and the technical committee of the UNAIDS Country Coordinating Mechanism in Bangladesh, it is at the forefront of prevention services in the country. FPAB has been responding to the needs of vulnerable groups in Chittagong through a project focusing on HIV prevention through the distribution of condoms, the provision of HIV prevention services, HIV testing, referral services, capacity-building, and a range of IEC and BCC activities including group meetings, short films, street drama, posters and demonstrations. These activities have reached a target population of more than 65,000 people including sex workers, transport workers, adolescents, community gatekeepers and service providers and managers.

The project has achieved considerable success in a short period of time: distributing more than 100,000 condoms; providing clinical services to 9,760 sex workers, truck drivers and young people; and building the capacity of

more than 20 community-based organizations on HIV/AIDS prevention. FPAB has focused on involving the community through the use of peer educators and the participation of religious and other community leaders. As a result, awareness regarding the modes of transmission of HIV/AIDS has increased by more than 15 per cent and knowledge on prevention has increased by more than 22 per cent. There has been a clear and measurable change in the knowledge, attitudes and practices of the various target groups of this project, including increased capacity of sex workers to negotiate condom use with their clients.

Hasan met a peer educator from FPAB who gave him condoms and talked to him about HIV/AIDS and sexually transmitted infections. Hasan didn’t know that even healthy-looking women can be HIV-positive and that he could be putting himself and his wife at risk of HIV infection. He also learned how important it is to get proper treatment for sexually transmitted infections, and he plans to visit one of FPAB’s clinics to get treatment and learn more about getting tested for HIV.

IN BRIEF: Believing in Young People Reproductive Health Association of Cambodia (RHAC) Young people in Cambodia have little access to HIV/AIDS and sexual and reproductive health information and services.

The Reproductive Health Association of Cambodia (RHAC) responds to this situation by providing comprehensive information and services for young people in Phnom Penh, Battambang, Sihanoukville and Kampong Cham. RHAC is developing a long-term communications strategy for youth on sexual and reproductive health issues in order to increase access to HIV/AIDS and sexual and reproductive health information and services for young people.

The project has had a significant impact on youth access to HIV/AIDS and sexual and reproductive health services. Young people now have access to RHAC’s clinics for HIV/AIDS and sexual and reproductive health services in the cities. Clinic attendance by young people jumped from 10,794 in 1999 to 25,425 in 2001. Training teachers and in- and out-of school youth to be counsellors and peer educators on HIV/AIDS and sexual and reproductive health has created greater awareness among young people and made the project sustainable.

Clinical staff were trained to provide quality, youth-friendly sexual and reproductive health services. By establishing a referral system RHAC enabled more young people to access its youth clinics and youth clubs. Involvement of local authorities, parents and the community in project planning and activities facilitated acceptance of HIV/AIDS and sexual and reproductive health education and services for young people, and helped make the project a success.

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IPPF IN A LIFE

IN BRIEF: Doubling the Benefits: Peer Education about Dual Protection Asociación Pro-Bienestar de la Familia de Guatemala (APROFAM) IPPF’s Member Association in Guatemala, Asociación ProBienestar de la Familia (APROFAM), implemented a ‘Dual Protection Project’ that built youth acceptance and practice of dual protection using female and male condoms to prevent sexually transmitted infections (STIs), HIV/AIDS and unwanted pregnancies.

APROFAM trained male and female youth leaders to communicate with their peers about HIV/AIDS, sexual and reproductive health and the proper use of male and female condoms for dual protection. Male and female condoms were distributed to adolescents, students, young sex workers, gang members, military personnel and industrial workers.

APROFAM simultaneously worked to build awareness, increase access to male and female condoms and strengthen community support for the project. Youth leaders talked to their peers about HIV/AIDS and dual protection, and educational videos on this issue were also shown. APROFAM held Educational Fairs on HIV/AIDS during which dual protection packets were sold that included pamphlets with information on sexual and reproductive health and one male and one female condom.

To achieve support for the project, APROFAM advocated to local, municipal, military and police authorities, and leaders in industry, education, health and private organizations about the importance of promoting sexual and reproductive health and preventing sexually transmitted infections, HIV/AIDS and unwanted pregnancies among young people. This project was a success in Guatemala and was later expanded to include IPPF Member Associations in Honduras and Nicaragua.

Youth-Friendly and Stigma-Free: Youth-Centred Approaches Planned Parenthood Association of South Africa (PPASA) In South Africa, unwanted teenage pregnancy is estimated at 33 per cent and new HIV/AIDS infections number 1700 per day. Dual protection of HIV and unwanted pregnancies, either through condom use alone or condoms used in combination with another contraceptive method, addresses both of these issues. Promoting condoms for pregnancy as well as for prevention of HIV and sexually transmitted infections (STIs) also gives women a strategy to negotiate condom use with their

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partners that circumvents the association of condoms with HIV and ‘at risk’ populations. Raising awareness on dual protection from STIs and HIV and unwanted pregnancies is a critical intervention, but awareness will only lead to action if young people can access services to act on what they have learned. Information and services for dual protection need to be integrated into a comprehensive package of sexual and reproductive health services in order to successfully engage young people in preventing STIs, HIV and unwanted pregnancy.

The Planned Parenthood Association of South Africa (PPASA) actively promotes the dual protection approach at each of its youth centres. Most of the young people seeking services from PPASA’s 33 centres are aged between 10 and 20 years. PPASA offers these adolescents sexual and reproductive health education sessions and guarantees access to youth-friendly clinical services.

Young people accessing clinical services for contraception are offered both contraception and condoms, and they are educated on how to use them correctly as well as the benefits of using both: prevention of STIs and HIV infection and pregnancy at the same time.

To maximize impact, the dual protection approach is integrated into PPASA’s adolescent sexual and reproductive health services. A broad range of services are available to young people, including peer education, sexual and reproductive health education, counselling for pregnancy, HIV and other health issues, pregnancy testing, management of STIs, provision of contraception and referrals for termination of pregnancy.

Since the inception of the dual protection approach the number of young people using the dual method has steadily increased. The dual protection initiative links increased access to sexual and reproductive health knowledge with opportunities to change behaviour and access clinical services, completing the service continuum from information to prevention to care. Young people are motivated to adopt health-seeking behaviour, and access to the required service is ensured through youth-friendly services.

SEX-POSITIVE PREVENTION

Photo: IPPF/Christian Schwetz/Thailand

“Talking about sex is very important, but we are not encouraged to do so.�

Synergizing Access: Building Support for Adolescent Sexual and Reproductive Health Vietnam Family Planning Association (VINAPFA) Nguyen Thi Huong would like to know more about sexually transmitted infections (STIs) and HIV/AIDS. She is a 17-year-old high school student in Vietnam and like most young people her age, she is not comfortable talking about sexuality or HIV/AIDS. In her community and in most of Vietnam, adolescent sexual and reproductive health is a relatively new concept. Youth are shy to seek services from clinic providers, and they usually lack the means to pay for services. The Vietnam Family Planning Association (VINAPFA) developed a model youth clinic and educated young people so they know where services are available and are able to access them.

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IPPF IN A LIFE

By educating young people through peer educators and building community support through mass media campaigns, VINAPFA is starting to make adolescent sexual and reproductive health an established part of young people’s lives.

The core of VINAPFA’s project is a model youth clinic, and educational outreach helps the clinic build linkages with young people and their communities. A youth-friendly HIV/AIDS and sexual and reproductive health clinic was established in Haiphong, and staff were trained to provide services for youth. Local authorities provided the site for the clinic and health personnel to provide medical advice.

To extend the reach of the clinics, peer educators were trained to target young people with information, and four hundred mobile teams distributed educational materials and condoms to out-of-school youth.

VINAPRA built acceptance for adolescent sexual and reproductive health services by advocating to authorities and the community through multiple channels. VINAPFA conducted ten mass media forums in Hanoi, Hue, Danang and Haiphong that were attended by 800 leaders from local authorities and representatives of national and local broadcasting and news media agencies. The forums resulted in the reporting of adolescent sexual and reproductive health activities by Vietnam Television, Vietnam News and Vietnam Radio broadcast. VINAPFA also carried out public health campaigns and exhibitions in selected provinces and industrial parks to raise awareness on HIV/AIDS and sexual and reproductive health. Twentynine public health campaigns reached 50,000 youth with messages on these issues, and 16 advocacy workshops reached 1,000 leaders of mass organizations and local authorities, including the Youth Union, university and colleges.

Nguyen Thi Huong talked to one of VINAPFA’s peer educators who went to her high school and got some basic information about HIV/AIDS and sexually transmitted infections (STIs). She was also referred to VINAPFA’s youth clinic and was able to get more in-depth information from a counsellor. By establishing youth-friendly clinical services and building linkages with young people and the community through education and advocacy, VINAPFA is not only making adolescent sexual and reproductive health services available for young people but acceptable as well.

Addressing Complacency: Empowering Youth with Knowledge to Make the Right Choice Tonga Family Health Assocation (TFHA) Tonga is a very young country, with youth under 25 years accounting for 60 per cent of the population. A recent survey showed that 40 per cent of out-of-school youth were

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sexually active with only two per cent using condoms.

Adolescent sexually transmitted infections (STIs) and teenage pregnancies are relatively low but have been increasing considerably. All of these factors put young people at risk of HIV infection and increase their need for sexual and reproductive health services.

The Tonga Family Health Association (TFHA) focuses its services primarily on youth. As figures for teenage pregnancies continue to climb TFHA believes that now is the time to do something about it. In 2002 there were 126 cases of adolescent pregnancy. By the time they attended antenatal care 60 per cent had married – a testimony to the role society plays in the lives of youth. An unwed mother in Tonga carries with her and her child the stigma of the illegitimacy accounting for why these teenagers resort to an early marriage. Lack of knowledge about sexuality and reproductive health has been identified as the main factor responsible for recent trends.

The adolescent sexual and reproductive health project implemented by TFHA ran a series of workshops throughout Tonga training peer educators, parents and nurses. TFHA also conducts youth outreach activities targeting adolescents directly and indirectly. These activities inform young people and the community about reproductive health in an interactive and fun manner, making learning easier for participants. Topics that are covered include ‘Sexuality, Anatomy and Physiology,’ ‘Conception and Contraception,’ ‘STIs and HIV/AIDS’ and ‘Values and Decision-Making.’ The project works with large groups through the ‘Fili Tonu’ (Make the Right Choice) drama group in Tongatapu.

Working closely with the Youth Congress, TFHA draws upon local youth resources in the form of youth volunteers and leaders. With the exception of a few senior health professionals much of the project is run by young people.

They are responsible for planning and implementing the project, and youth participation has aided in the success of this project.

In the past, teaching sexual and reproductive health to adolescents has been an uncomfortable issue both for parents and teachers. Recent involvement of both has led to significant change in how young people are approached.

Parents are now more informed of the challenges that adolescents are facing, and teachers are now more confident about including sexual and reproductive health in the school curriculum. Public health nurses utilizing the adolescent sexual and reproductive health training manual are now taking over these in-school sessions, a task previously performed by TFHA. Young people have found TFHA’s youth clinics more

comfortable and ‘youth-friendly’ than government facilities. The Youth Health Centre provides information on contraception methods and STI treatment and provides condoms. It is located near several schools and offers activities, such as sewing, cooking, carving, aerobics, barbecues, music, drama, video and sports that attract a steady number of youth.

The realization in the community that there is a need for increased awareness of HIV/AIDS and sexual reproductive health has signaled a change in the Tongan mindset.

No longer is sexual and reproductive health knowledge available only to health professionals and given exclusively to married people. Access to such information has been made possible for young people through the support of TFHA.

Sex and Youth in the City Bem-Estar Familiar no Brasil (BEMFAM) Ensuring access to health services for youth in the streets and in situations of social vulnerability is an on-going challenge in Brasil. Factors such as early sexual activity, low school attendance, experiences of physical abuse and poverty make this population especially vulnerable to HIV infection and difficult to reach with services. The ‘Youth in City’ project, implemented by POMMAR/USAID-Partners and Bem-Estar Familiar no Brasil (BEMFAM) in the state of Ceará, Brasil, helped social workers overcome obstacles to providing sexual and reproductive health care for street youth. The project was developed in three stages. The first stage focused on understanding street youth and other vulnerable young people, and developed an intervention model that would respond to their health needs. BEMFAM and it’s partners established a broad network of institutions offering services to socially vulnerable young people in the state of Ceará. Clinical and educational services were also offered to this population in BEMFAM’s Reproductive Health Clinic.

During the second stage, clinical and educational services were increased. In order to analyze the effects of the project, quantitative and qualitative studies were conducted with the youth served, BEMFAM staff and participating institutions. The third stage maintained clinical and educational services and added an important component: training a group of youth educators selected from the young people served during the first two years of the project.

Because of demand from project partners and social educators, the project also disseminated its methodology by creating a video and booklet relating BEMFAM’s experience that demonstrates how the project can be replicated elsewhere. These materials were used to

sensitize the government and NGOs to the possibility of and need for comprehensive sexual and reproductive health care for youth in situations of extreme social risk.

‘Youth in the City’ fostered youth participation and citizenship, and contributed to the reduction of youth vulnerability to sexually transmitted infections (STIs) and HIV/AIDS in one of the neediest regions in Brasil.

Throughout the project, 1,538 vulnerable youth received services, and more than 8,000 people participated in educational activities with youth educators. In the BEMFAM clinic, 3,300 reproductive health services were provided, and 17,145 male condoms were distributed.

IN BRIEF: Open Days for Young People Sudanese Family Planning Association (SFPA) In many cultures, young people need encouragement to learn about HIV/AIDS and sexual and reproductive health. Integrating these issues into leisure activities creates trust and catches the attention of young people, motivating them to access and use information that they might otherwise ignore. Leisure activities also offer an opportunity to bring this information to marginalized and under-served young people in rural areas, who might have no other channel to access HIV/AIDS and sexual and reproductive health information.

Open days are significant events in Sudan and usually attract large numbers of young people. The Sudanese Family Planning Association (SFPA) carried out several open days to raise HIV/AIDS and sexual and reproductive health awareness among young people, refugees and other rural marginalized groups. In collaboration with the National Youth Union, Faculties of Medicine, University Students’ Networks and other partners, SFPA produced sport competitions, drama and musical nights focusing on HIV/AIDS. Embedded into these recreational activities were distribution of educational materials, awareness raising lectures and mobile pharmacies providing medicines free of charge, condoms and counseling services. SFPA youth volunteers participated in design, implementation and follow-up of this initiative, and they were responsible for coordination of the partner NGOs. Over 7,000 young women and men participated in and benefited from this initiative. Offering a range of activities in one event encouraged more young people to attend the open days and access information. Once they were at the open days, refugees and other young people from rural areas were able to access HIV/AIDS and sexual and reproductive health information and services. Involving youth volunteers in all phases of these events also fostered their sense of ownership and responsibility.

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IPPF IN A LIFE

GENDER-SENSITIVE PREVENTION

Photo: IPPF/Jenny Matthews/Nepal

“I tell the women, I'm from this area and I can show my face. You must be open and greet the world.�

Empowering Women to Speak Out Family Planning Association of Nepal (FPAN) Therakachuri is a small village sandwiched between several lush green paddy fields in the Danusha district of Eastern Nepal. Many of the villagers here are farmers with small plots of land. They earn about Rs 50 (70 US cents) a day. Some men work across the border in India while others earn their living selling cigarettes or driving rickshaws.

Sheltering under a veranda, Janaki Devi Ghimire pulls back her sari pallu and laughs. "I tell the women, I'm from this area and I can show my face. You must be open and greet the world," Janaki is one of 540 women volunteers working with the Family Planning Association

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of Nepal (FPAN) to bring about changes among women in villages like Therakachuri and ensure that communities have access to preventative services for HIV/AIDS, including the use of condoms.

While the HIV/AIDS epidemic is relatively new in Nepal – the first case was reported in 1988 – it is progressing rapidly from a ‘low’ to a ‘concentrated’ epidemic. Although actual reported figures remain low, UNIADS estimates that, as of December 2002, there were 60,000 people living with HIV/AIDS and 2,958 AIDS-related deaths.

Under-reporting of HIV/AIDS is a symptom of various factors including a lack of access to counselling and testing facilities; a fear of discrimination; ignorance; and the non-availability of condoms – all factors that also contribute to the threat of a more rapid spread of the infection. Young people are particularly vulnerable to HIV and an estimated 60 per cent of those living with HIV/AIDS are between the ages of 14 and 29 years. The government has estimated that by 2005 between 100,000 and 200,000 young adults will be infected, and 10,000 to 15,000 AIDSrelated deaths might occur annually if preventative services are not strengthened.

Janaki knows she faces an uphill task but talks about her job with relish. She is a community-based distributor (CBD) and goes from house-to-house talking to women about sexual and reproductive health and, in particular, the threat of HIV/AIDS. A key aspect of her role is the distribution of condoms for sexually transmitted infections (STI) and HIV/AIDS prevention, as well raising awareness on issues such as decision-making and empowerment. This approach aims to create community awareness about HIV/AIDS, particularly for those most at risk such as young people. Surrounded by her women clients, Janaki encourages them to speak up. She believes she has made some progress. “Women are now demanding condoms and are aware of the dangers of HIV/AIDS.” One of her clients, Banarashi Devi, 30, says she values the services because they are free and reliable.

The project works with the community to highlight issues around HIV/AIDS prevention and encourage behaviour change, and its list of achievements is impressive. It has recruited and trained 540 female community-based distributors of condoms, established 47 clinics and 60 libraries, and conducted more than 300 literacy classes.

Despite these successes, the project still faces considerable challenges. In particular, worsening poverty in Nepal, the migration from rural to urban areas and continuing political instability are a real threat to the future health prospects of the 332,000 people in the project area. As one of FPAN’s clients explains "There is a lot at stake here. People cannot afford to buy condoms

Photo: IPPF/Christian Shwetz/Thailand

in this area – they barely have enough to eat. It's vital this project continues."

FPAN’s Danusha District Branch Manager, Chandra Dhungana, is committed to meeting these challenges and has ensured that there are linkages with the government and other organizations to ensure that preventative services for HIV/AIDS can be sustained.

This includes working closely with village development committees (VDCs), which have been involved right from the beginning. Chairman of the Council of District Development Committee, Ram Charitra, a charismatic man in his mid-fifties, explains how the village committees contribute to the remuneration for women distributors: "The government has implemented a policy whereby five per cent of the VDC budget has to be spent on health, so we are able to contribute something but it's not a lot." He is enthusiastic about the project and says it is nothing short of revolutionary. "This area is very backward compared with other regions. Women are very shy and this contributes to their vulnerability to HIV/AIDS. Before FPAN started working to highlight the threat of HIV/AIDS, they wouldn’t speak openly in front of their husbands. If they had a problem, they wouldn’t raise it – but now, thanks to the activities being coordinated by FPAN, they are willing to speak up on the threat of the epidemic and have access to condoms and information to protect themselves and their community from infection.”

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IPPF IN A LIFE

Talking Prevention with Sex Workers and ‘Mama Rosas’ Uzbek Association for Reproductive Health (UARH) The sex industry in the Central Asian Republics has been growing rapidly since the fall of the Soviet Union. Poor economic conditions and mass migration between the Republics as well as from Afghanistan have led to increasing numbers of sex workers, many of whom are refugees or internally-displaced persons.

The swelling sex worker population is threatened by the fastest-growing rate of HIV infection in the world, and the unfortunate reality that Central Asian countries still lack an adequate health care infrastructure. Sex workers and refugees urgently need HIV prevention and sexual and reproductive health services that are tailored to the circumstances of their lives.

In Samarkand and Navoiy, Uzbekistan, the Uzbek Association for Reproductive Health (UARH) carried out a project for sex workers. UARH worked with sex workers to give them access to HIV prevention and sexual and reproductive health services that are sensitive to gender and the economic barriers of their profession.

UARH provided reproductive health information to sex workers by going to the places where they work:

Photo: Spanish Family Planning Association/Paul Weinberg/South Africa

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at markets, on main motorways and at discos and bars.

The Member Association held peer training seminars for sex workers covering contraception, reproductive health and rights, sexually transmitted infections and HIV/AIDS. Seminars were also held to help sex workers develop negotiating skills for condom use with clients.

In order to create a supportive environment for these activities, UARH also worked with the ‘Mama Rosas’ who ‘employ’ sex workers. UARH staff and volunteers held discussion sessions with the ‘Mama Rosas’ about the importance of condom use, clinic visits and the prevention of HIV/AIDS and drug use. Working with ‘Mama Rosas’ enabled UARH to reach more sex workers with informative literature, contraceptives and counselling.

In all, 3,500 sex workers were helped through confidential, face-to-face counselling that was provided free of charge. To reach the many sex workers who are reluctant to seek services, UARH set up a confidential telephone hot-line to address their needs.

Providing counselling and contraceptives to sex workers was a first step. The Samarkand branch is building on this foundation and has begun providing medical services to sex workers at its reproductive health facility, making pregnancy, sexually transmitted infections and HIV tests available for this highly vulnerable group.

Fighting HIV/AIDS by Promoting New Masculinities Planned Parenthood Association of South Africa (PPASA) Anita Joubert is 29 and married with a three year old child. She is also a professional soldier. Anita was nominated by her Commanding Officer to attend the Gender Equity Project’s Peer Educators training course at Lohatla, a military base in the Northern Province of South Africa.

In 2002 the South African National Defense Force (SANDF) partnered with EngenderHealth, Planned Parenthood Association of South Africa (PPASA) and the Women’s Health Project (WHP) to develop the Gender Equity Project. The goal of this programme is to reduce HIV transmission within the South African military by addressing pervasive and destructive gender stereotypes related to sexual and reproductive health that contribute to the prevalence of the HIV/AIDS epidemic. The Gender Equity Project is being rolled out as a part of the SANDF’s existing Masibambisane HIV/AIDS programme.

Gender Equity Project staff have trained one hundred social workers in the South African Military Health Services social work directorate, all of whom were identified and selected from the nine provinces of South Africa. The social workers in turn trained 1200 peer educators, who will run three-day workshops with 12,000 troops and their spouses. A comprehensive evaluation is currently being carried out with SANDF participants and a subset of their spouses to determine the impact of the programme.

Promoting new models of masculinity within an institution like the SANDF is challenging, but there are windows of opportunity. SANDF is undergoing a process of transformation from being an all-white and maledominated organization into an institution that reflects post-apartheid South African society. Such a transition offers unique opportunities for changing gender norms.

Over time, Engenderhealth, PPASA and WHP educators have intensified the technical assistance provided to SANDF master trainers to assist them with the delivery of the Gender Equity Project workshops. Discussions have focused on the challenges inherent in promoting ‘new masculinities’ within a male-dominated structure like the SANDF, and how to adapt the content of the workshops to overcome these challenges. To sustain this initiative, SANDF will be encouraged to hold on-going support group meetings.

The master trainers are offering support to their peer educators and are getting buy-in from management.

Open-ended communication with spouses and family members of deployed staff is being promoted as well in order to involve the community as a partner in the project.

After the course, Anita began to understand the stigma and discrimination that HIV-positive people experience.

She has already begun sharing what she learned in the course with other people in the military and her community, and she wants to get involved in other programmes that address gender and HIV/AIDS.

IN BRIEF: Promoting the Female Condom Family Planning Association of Kenya (FPAK) The female condom is currently the only available femalecontrolled method for preventing both HIV infection and pregnancy. It gives women and couples another option for HIV prevention and puts the decision to use protection in women’s hands. Unfortunately, access to the female condom is still restricted by high prices and limited distribution.

The Family Planning Association of Kenya (FPAK) is giving women, men and young people access to female condoms as part of a larger initiative to promote dual protection from HIV infection and pregnancy. FPAK provides individualized interactive counselling services to clients on contraceptive methods and their selection. Skills building on barrier method use and other prevention strategies are also provided to help clients make informed choices to protect themselves from HIV, sexually transmitted infections (STIs) and pregnancy.

FPAK’s Family Care Medical Centres help clients assess their STI and HIV risks and motivate them to initiate protective measures. They provide follow up counselling in order to help clients identify barriers that limit use of specific methods and develop problem solving strategies.

Voluntary counselling and testing (VCT) and treatment for sexually transmitted infections and HIV are also offered.

This initiative empowered many women to negotiate condom use for contraception while simultaneously achieving the important goal of protecting them from HIV and STIs. FPAK found that the provision of female condoms allowed inconsistent users of male condoms to achieve high protection rates by mixing condom types over a period of time. Community Based Delivery agents have reported an increase in the uptake of male and female condoms, and the number of STI cases seen by service providers at the Family Care Medical Centres decreased.

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IPPF IN A LIFE

POSITIVE PREVENTION

Photo: IPPF/Chole Hall/India

"It is important that specific prevention messages reach my HIV positive colleagues too.�

Involving Female Sex Workers in HIV Prevention Family Life Association of Swaziland (FLAS) Aziza is 28 years old and lives in a town in Swaziland near the border close to one of the main truck routes. Truckers often stop in Aziza’s town looking to engage in sex with sex workers. Poverty, high unemployment and the marginalization of women lead many women in Swaziland to engage in sex work.

The Family Life Association of Swaziland (FLAS) pioneered a peer education project that reaches out to promote behaviour change amongst sex workers and their partners, who are often truck drivers. FLAS also reaches out to low-income women and other members of the community with whom truckers often have sexual intercourse.

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FLAS has trained a group of peer educators who communicate with sex workers, truckers and trucker’s partners. The peer educators, many of whom are sex workers, live close to border areas, and they conduct their education in hot spots such as bars, sheebens, market places and shopping complexes where they meet groups of people and individuals. They discuss topics like HIV/AIDS, sexually transmitted infections (STIs), family planning, gender-based violence, condom use, behaviour change and decision-making, as well as distributing free condoms.

Peer educators have the opportunity to reach many sex workers, truckers and other women with knowledge on HIV and STIs, encouraging individuals to then protect themselves and their partners. Peer educators have cleared many myths and misconceptions surrounding condoms, STIs and HIV/AIDS. Their work has also contributed to an increase in condom distribution. More than 98,000 free condoms were distributed in 2003 at the project sites, and many of the people contacted by the peer educators have been referred to nearby clinics.

The peer educators themselves benefit from the project as well. During one of the peer educator trainings some female sex workers were shocked to learn that they were so vulnerable to HIV, because they were sure they used condoms correctly. They discussed an all-too-common scenario whereby a client had engaged in sex with three sex workers at the same time. Although he was wearing a condom, he used the same one whilst having sex with each of the three women. They were surprised that HIV could be transmitted that way and how vulnerable to HIV they were. The training was an eye-opener for them.

FLAS has found that female sex workers often make great peer educators because they are straight talkers and ‘tell it like it is.’ This is an advantage when they conduct their educational talks because they ‘don’t beat about the bush.’

They are also very easy to communicate with because people know that sex workers as they are very open.

The peer educators are also encouraged to know their HIV status. Aziza was asked to be a peer educator, and when she was tested for HIV she was shocked to find she was HIV negative. Aziza has realized that because many of her friends are HIV positive, “it is important that specific prevention messages reach my HIV positive colleagues too.”

Reaching Truckers, Injecting Drug Users and their Partners Family Planning Association of India (FPAI) Truck drivers and injecting drug users in India are extremely vulnerable to HIV infection, and their partners

IN BRIEF: HIV Prevention for Sex Workers and Injecting Drug Users Associação Para o Planeamento da Familia (APF), Portugal The North branch of Associação Para o Planeamento da Família (APF) ran ‘Espaço Pessoa’, a service directed at male and female sex workers in the city of Oporto. As in many countries, the sex worker population in Portugal is hidden and hard to define. Complicating the situation is the fact that the populations of sex workers and injecting drug users often overlap: many sex workers also inject drugs, and many injecting drug users also sell sex.

Rather than compartmentalize sex workers and injecting drug users, APF took a broad view of the prevention needs of this population and the multiple behaviours that make them vulnerable to HIV. More than 37,000 condoms and more than 6,700 syringes were distributed to this especially vulnerable population, helping them protect themselves and their partners from HIV infection and re-infection.

are equally vulnerable. Truck drivers are known to have unprotected sex with sex workers and with other men, leaving themselves and their partners, including their wives, vulnerable to infection. Injecting drug users put themselves and their partners at risk by practicing unprotected sex, in addition to exposing themselves to the risk of sharing injecting equipment. The Family Planning Association of India (FPAI) worked with truck drivers and their partners in Mohali, Punjab State, and injecting drug users and their partners in Imphal, Manipur State, to give them access to sexually transmitted infections (STI) and HIV/AIDS prevention information and services.

Building support among community stakeholders was essential before starting the project. FPAI held training sessions for volunteers and staff at both project locations.

Advocacy programmes were organized for government authorities, NGOs, local voluntary groups, religious leaders, panchayat members, opinion leaders and other stakeholders.

Partnerships were developed with religious leaders as well.

This led to the opening of the first-ever clinic for truck drivers at Gurudwara.

Peer educators were the key ingredient for bringing access to HIV/AIDS prevention services to truckers, injecting drug users and their partners. Sixty truck drivers in Mohali and 15 young persons in Imphal were carefully selected and trained as peer educators. In Imphal, self-help groups of widows and wives of injecting drug users were formed as well. By establishing these groups, the project provided a forum for these women to discuss HIV/AIDS and their own health.

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IPPF IN A LIFE

FPAI conducted various types of awareness programmes in order to disseminate HIV/AIDS information and encourage people to come to the clinics. These programmes included basic information about STIs and HIV/AIDS as well as more specific behaviour change messages including correct use of condoms, information on needle and syringe usage, sterilization techniques and detoxification programmes. Folk media, street plays, films, music and peer education were used to spread this information. These awareness and education programmes reached a wide section of the community including truckers, their helpers and families, sex workers, youth, widows and wives of injecting drug users, and military and paramilitary groups. Condoms were also made easily available and accessible to truckers, injecting drug users and their partners through networks and social marketing outlets.

Peer education and the awareness programmes caused a rapid increase in demand for clinical services. People from far off places were drawn to seek clinical services for a wide range of reproductive health issues. Clinical services were provided through two static clinics and outreach programmes. Referrals for detoxification, treatment, investigations and other services were made whenever required to government hospitals, private institutions and NGOs. After the project concluded, the clients continued to receive services from these referral centres.

Truck drivers, injecting drugs users and their partners in Mohali and Imphal gained a new understanding of risk behaviours and how to protect themselves from HIV infection. They also sought reproductive health care services and STI diagnosis and treatment for themselves and their partners. FPAI’s holistic approach helps build trust and confidence among truckers and injecting drug users in sexual and reproductive health services. In a world of increased HIV/AIDS-related stigma, because other groups access these services as well, HIV positive truckers and injecting drug users feel comfortable accessing services, rather than feeling that they are the primary targets of a disease prevention programme.

Helping Prisoners Protect Themselves and their Partners Association Rwandaise Pour le Bien Etre Familial (ARBEF) Rwanda In the decade following the Rwandan genocide enormous social, economic and political progress has been made.

In the midst of rebuilding its society, however, this small developing country currently faces a crisis that once again threatens to dismantle its progress – HIV/AIDS.

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The estimated HIV prevalence rate in Rwanda stands at 13.5 per cent, making Rwanda one of most affected countries in sub-Saharan Africa. Following the genocide of 1994, a number of populations have emerged as especially vulnerable to the spread of HIV/AIDS. Women have been affected by the epidemic due to their economic, social and sexual vulnerability, as have young people, who comprise over 60 per cent of the population. Rwanda’s imprisoned population, in particular, has been especially affected by the spread of HIV. Since the genocide of 1994 Rwanda has put more than 100,000 individuals into its 18 prisons. Faced with the difficulty of rendering judgements for such a significant population within a reasonable time frame, the government of Rwanda decided in 2002 to speed up the release of innocent defendants and encourage national reconciliation. A recent presidential decree has authorized the release of nearly 30,000 prisoners. The release of prisoners, a significant number of whom are living with HIV, makes their current and future partners outside of prison extremely vulnerable to HIV infection.

With the prison population severely lacking general health services, in 2002 ARBEF implemented a programme extending its resources and capacity to this vulnerable group. The initiative was the first of its kind in Rwanda to advocate to government and prison officials about the need for HIV/AIDS information and prevention in prisons. The project increased prisoners’ knowledge of HIV prevention and promoted behaviour change, successfully reaching 17 of Rwanda’s 18 prisons.

A large group of ARBEF volunteers assisted in training peer educators within the prison, capitalizing on the wellorganized, internal prison structure. This permitted peer educators to reach almost all of the prisoners, ensured that prison authorities were well informed and educated about HIV/AIDS activities, and facilitated the exchange of information and material within prisons.

No public or private agencies are known to have provided HIV/AIDS-related services to such a large prison population. The project mobilized and trained selected volunteers, partners and ARBEF staff on HIV/AIDS and prevention issues specific to prison populations. Training sessions focused on a number of areas including sexually transmitted infections (STIs), the means of transmission of STIs, consequences of contracting such diseases, measures of prevention and HIV/AIDS sensitization techniques. The project sensitized prison inmates about HIV/AIDS in order to motivate them to adopt prevention strategies. HIV/AIDS clubs were developed within prisons as well, further reinforcing the messages disseminated by ARBEF staff and volunteers.

Since the project began, prisoners and prison officials have observed changes in behaviour with respect to sexual and reproductive health. The number of cases of STIs and unsafe sexual behaviour has decreased as a result of the sensitization. Prisoners’ interest in becoming more knowledgeable about HIV/AIDS is evident through increased requests for further information about the disease and for HIV tests. Prison officials also incorporated sensitization on HIV/AIDS within their medical services programming.

The project continues to raise awareness of the need for sexual and reproductive health programmes for prisoners. ARBEF is currently working to reinforce existing HIV/AIDS clubs within prisons by incorporating safer sex information and gender issues within their mandates, and plans to provide voluntary counselling and testing (VCT) services to eight thousand clients by the end of 2004.

Prisoners are one of the most vulnerable populations to HIV, and they are also one of the most neglected. ARBEF is not only helping to reduce the further spread of HIV among prisoners, but helping those prisoners who are HIV positive to protect their partners once they get out of prison as well.

Photo: IPPF/Maryse Hodgson/Rwanda

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IN BRIEF: Partnering with Vulnerable Populations to Prevent HIV/AIDS Asociaci贸n Pro Bienestar de la Familia Ecuatoriana (APROFE), Ecuador Asociasi贸n Pro Bienestar de la Familia Ecuatoriana (APROFE) is a partner in the Frontiers of the Epidemic Prevention Project in Ecuador, an international HIV/AIDS prevention initiative. This project works to prevent HIV through collaborative work, participation, and inclusion of affected populations such as sex workers, males who have sex with males and people living with HIV and AIDS. Involving these populations empowers them to defend and regain their rights, reduce stigma and discrimination in society and decrease the incidence of HIV/AIDS. APROFE, in partnership with the NGO KIMIRINA, works to optimize the availability of information about prevention, increase access to diagnostics and treatments of sexually transmitted infections (STIs), and strengthen the technical competence of providers to diagnose and treat STIs among those who attend sexual and reproductive health services.

All discussions and seminars offered on STIs and HIV/AIDS incorporate the promotion of healthy behaviours and information to counteract the stigma and discrimination towards people living with HIV or infected with an STI. APROFE trains and sensitizes its staff on HIV prevention, gender, rights, sexuality and sexual diversity to make sure that all of these issues are integrated into its sexual and reproductive health services. APROFE understands that many of its staff and clients also belong to populations especially vulnerable to HIV, and so they deserve specific health provider sensitization.

Although APROFE does not offer services exclusive to sex workers, males who have sex with males, people living with HIV and AIDS or other vulnerable populations, the organization considers it a priority to make sure that its services meet the needs of whomever walks in the door.

In order to reduce the vulnerability of populations affected

by HIV/AIDS, it is necessary to empower them. Involving members of vulnerable populations in HIV and STI prevention and treatment gives them a decisive role in reducing HIV/AIDS stigma and discrimination.

IPPF/Maryse Hodgson/Vietnam

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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/Révész Tamas/Egypt