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This report covers the FHI AIDS Control and Prevention (AIDSCAP) Project (1991-1997). Volume 1 covers regional program overviews, technical strategies, and program support strategies.
Volume 1 |
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"Now I have understood gender for the very first time!" exclaimed AIDSCAP/FHI's resident advisor to Tanzania at the close of a 5-day workshop. She had been among 41 participants brought together for gender training specifically targeting senior-level management of HIV/AIDS prevention programs (USAID health, population, and nutrition specialists; heads of national AIDS control programs and of NGOs; and AIDSCAP/FHI resident advisors). Working as country teams to examine existing projects, participants discovered that addressing issues, policies, and programs from a gender perspective has a critical impact on the success or failure of HIV/AIDS prevention efforts. Determined to ensure that gender would no longer "go missing" from her programs, the resident advisor organized the retraining of NGO leaders to enhance awareness and develop skills for incorporating gender perspectives in projects into two regional projects. She also conducted a series of workshops that resulted in gender training of NGO leaders in the nine regions of Tanzania targeted by AIDSCAP/FHI and assigned an officer to monitor and evaluate progress made in sustaining a gender focus. |
Enhancing Awareness for Action
Enhanced public awareness of gender and AIDS issues has been accomplished through dissemination of materials, media attention, and publications.
- AWI produced and disseminated approximately 20,000 documents that explain and address the gender dimensions of HIV/AIDS prevention. They include A Dialogue Between the Sexes: Men, Women, and AIDS Prevention; a brochure on model interventions supported by AWI; One Strong Voice: Writings on Women and HIV/AIDS; Cairo and Beijing: Defining the Women and AIDS Agenda; and the report and manual set, A Transformation Process: Gender Training for Top-Level Management of HIV/AIDS Prevention. A fact sheet on women and HIV/AIDS was translated into three languages and disseminated at numerous conferences.
The dissemination of AWI materials resulted in increased public awareness of and continued demand for information about gender and HIV/AIDS. For example, more than 500 requests for Cairo and Beijing: Defining the Women and AIDS Agenda were received following its distribution at the Africa regional AIDS conference in Uganda. The Centers for Disease Control and Prevention selected A Dialogue Between the Sexes: Men, Women, and AIDS Prevention from among thousands of publications distributed at the Vancouver Conference for inclusion on its educational materials database website. Four thousand copies of Cairo and Beijing: Defining the Women and AIDS Agenda were distributed at more than 10 conferences worldwide.
- Recognizing the importance of the media in shaping public awareness, AWI developed a media strategy to support improved reporting on women and HIV/AIDS. Journalists, social scientists, and HIV-positive persons were brought together to review articles that had appeared in the print media in 50 countries from September 1995 to April 1996 and to identify a recipient of the Award for Excellence in Writing on Women and AIDS, as well as 10 finalists.
The award, which was sponsored by AWI and UNAIDS, increased the number and the quality of articles published on the subject of women and HIV/AIDS, resulting in heightened public awareness of the vulnerability of women to the epidemic. Participants continued to report on the topic: one finalist wrote a series of radio programs about women and HIV/AIDS. The finalists were recognized in their respective countries, and their articles were compiled and distributed to over 800 persons.
- Women's Experience with HIV/AIDS: An International Perspective, edited by AWI Associate Director Dr. E. Maxine Ankrah and Lynellyn D. Long and published by Columbia University Press in November 1996, was the first book to discuss women and HIV/AIDS in both developing and developed countries. Women and women's organizations in the developing world will directly benefit from the sale of Women's Experience with HIV/AIDS: An International Perspective. AWI and the PANOS Institute of London agreed that royalties from publication sales would be directed back to the communities that are the focus of the book, women and women's groups.
Research
Research was conducted to understand how best to effectively intervene from a gender perspective.
- AWI, in collaboration with a technical working group, developed an innovative research design for introducing the female condom through women's organizations and groups. The research was conducted in Brazil and Kenya in 1996. These studies attracted women from all socioeconomic classes to try the device as a woman-initiated method of protection against HIV infection. Within the two countries, the research raised issues of cost, access, and government policies related to the female condom and generated media attention for the studies and the device. The research demonstrated the potential of women's organizations to introduce the female condom and provide support to women for its sustained use. Areas requiring further research were identified.
- In collaboration with AIDSCAP/FHI country offices, AWI developed research projects to understand HIV risk factors for both men and women and to assess communication among these groups. Research in Kenya looked at intergenerational communication between mothers and daughters, a study in Senegal examined risk factors and perceptions of risk among market women and their children, and focus groups among adolescents in the Dominican Republic explored their attitudes about sexual behavior. Based on research conducted among market women in Senegal, STI/HIV/AIDS prevention interventions have been designed to reach this population that address the multiple economic and social forces affecting their sexual behavior. In addition, findings on the risks facing the daughters of market women were used to design interventions for these girls.
Lessons Learned and Recommendations
Technical Approaches to Gender
The incorporation of gender into institutions, programs, and policies is hampered by the lack of available and sustainable technical approaches. These approaches must be measurable and based on a set of skills derived from a defined and known theoretical framework. Gender and HIV/AIDS approaches frequently require reformulating existing strategies to give programs a new orientation. Because these approaches evolve over time, they must be tested periodically and modified based on field applications.
Training
Training proved effective in making programs and projects more gender-sensitive. Gender training must be supported with appropriate time, resources, and materials. Gender integration necessitates gender training of staff at all levels to promote changes in attitudes and to develop skills. Where seminars and workshops were held and staff participated by choice, country and regional programs were generated with a specific focus on women and girls. Examples include the following:
- a gender training in Tanzania modeled after the regional gender and AIDS workshop AWI organized for senior-level managers from eastern and southern African countries;
- LAC modules for research, service delivery, and interventions that were developed by AIDSCAP/FHI resident advisors following gender training;
- a gender-training manual that was produced and distributed for replication of training among senior-level managers in HIV/AIDS prevention.
Dialogue
Dialogue is a viable HIV/AIDS prevention strategy that can supplement efforts at sexual negotiation. It is defined here as a process through which individuals, couples, families, or communities begin to talk and exchange ideas in ways that result in mutually beneficial decisions and that create situations for change. It is also defined as a tool and strategy for encouraging men and women to share information, opinions, and beliefs directed toward changing practices and behaviors related to sexuality and HIV/AIDS.
The dialogue strategy provides a context where established beliefs and values can be challenged, potentially stimulating sustained behavior change. It was applied at the interpersonal, community, and policy levels. Examples include a national conference of decision makers in India, intervention research with truck drivers and their spouses in India, and focus group discussions on the use of dialogue among various target audiences in Nigeria.
Research
Research is a necessary but often neglected component of gender-sensitive strategies. Much of the clinical research on HIV/AIDS in the early period of the epidemic focused exclusively on male problems, with little attention to women. When women did become the focus of research, it was largely to answer questions about their roles as mothers and "core transmitters."
Gender-sensitive research, the aim set by AWI, not only focuses on women but also includes them in the design and execution of the research. It also includes the dissemination of results among women, since the research is conducted to help improve the quality of their lives. Because gender is about men and women, not just about women, AWI focused on a research agenda that included men's sexual behavior, their power relationships with female partners, and their roles as members of the community.
One of the most significant research projects undertaken by AWI was the intervention research on adoption of the female condom in Kenya and Brazil. Using an innovative approach, this exploratory study examined perceptions of, responses to, and sustained use of the female condom when it was introduced into a partner relationship as a method of HIV/AIDS prevention and contraception. The intervention component of the research consisted of two sessions called peer support group discussions. During these discussions, the women shared experiences related to use of the female condom and its impact on their relationships with husbands and other partners. Focus groups discussions were also held with groups of male partners.
Data collected over 3 months showed that 100 Kenyan and 103 Brazilian women respondents accepted the female condom and continued to use it. Overall, the women were positive about the female condom: 75 percent liked the device and nearly a half of the women preferred it to the male condom. Of the male partners, almost 77 percent liked it. The women viewed the female condom as an option when a partner refused to use a male condom, for women who frequently change partners, and for persons in extramarital relationships. Many women from both countries reported being "empowered" by the female condom in their relationships with male partners. The peer support group sessions appeared to have had an important influence on women's acceptance of the female condom and its continued use.
Two other important research project sponsored by AWI were a study of women's lack of power to negotiate condom use in Haiti and a study of Senegalese market women to assess their perceptions of risk, factors contributing to their vulnerability, and their needs for HIV/AIDS prevention. Results from the Senegal study contributed to the development of an integrated project that provides women with HIV/AIDS information and skills through a project linked with credit and literacy programs.
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Dr. Goyal had a neatly crafted knowledge, attitudes, beliefs, and practices (KABP) study that had been pilot tested and was ready to be administered among truck drivers and their wives in Jaipur. He was sure that truck drivers would not be persuaded to change their behavior significantly as long as they were targeted as unattached individuals on the go, with only casual relationships with CSWs. He argued that while some of the men were single, most were married and belonged to associations and communities. This assumption provided the impetus for his KABP. With technical assistance from AWI, the KABP was transformed into an intervention research project to test the introduction of the dialogue strategy with couples at risk of HIV. Dr. Goyal and his team recruited 170 couples to participate. In less than 2 months, more than 90 percent of the couples had engaged in dialogue about HIV/AIDS, and 53 percent of the truck drivers reported using condoms with their spouses for the first time. Dr. Goyal was selected to make an oral presentation of his results at the Third International Biopsychosocial Conference in Melbourne, Australia, and the MacArthur Foundation awarded him a two-year grant to continue the intervention. Colleagues from Calcutta who helped train his researchers to facilitate a dialogue between the truck drivers and their spouses have since introduced the dialogue as a strategy in their programs with truck drivers in that state. |
Evaluation Indicators
Gender-specific indicators must be developed to monitor and evaluate the impact of interventions on women's ability to negotiate safer sex, women's empowerment, and male involvement in HIV/AIDS prevention. Such indicators give program planners and evaluators a clear picture of the impact of interventions on women and men, document progress made in incorporating gender, and provide evidence of success that can be used to leverage resources for interventions. AIDSCAP/FHI was successful in educating its partners and staff of the importance of collecting and reporting data that are disaggregated by gender and in developing evaluation indicators to measure women's empowerment in HIV/AIDS prevention.
Involvement of Men
To ensure the success of HIV/AIDS prevention strategies, men must be drawn into the process of gaining mutual protection. Prevention programs need to move beyond viewing men primarily as sexual beings and recognize their multiple roles in production, reproduction, and participation in the community. Examples of AWI-supported projects that used this approach include intervention research on the dialogue strategy with Indian truck drivers and their wives; the use of clinical settings to counsel men and women on reproductive and sexual health in Brazil; and gender-sensitivity training for Kenyan drivers of matatus (vans that serve as informal public transport) that succeeded in encouraging them to treat their partners and female passengers as they would their mothers, sisters, wives, and daughters.
Coalition Building/Collaboration
Collaboration and coalition building should be encouraged as a technical strategy for resource mobilization. In particular, women's organizations and related groups should be targeted and trained in advocacy to influence policies and programs. In Asia and the Pacific, for example, a workshop of women and AIDS networks resulted in (1) a subregional seminar on HIV/AIDS at which representatives from five neighboring Indian states met to create multistate strategies and coordinate the allocation of scarce resources and (2) a project to strengthen an existing network of HIV-positive persons in northeast Thailand by increasing information sharing, income-generation activities, and outreach. The success of the coalition AWI organized to highlight HIV/AIDS at the Fourth United Nations World Conference on Women and of the international journalist's award cosponsored by AWI and UNAIDS are other examples of the benefits of coalition building and collaboration.
Mechanisms for Institutionalizing Gender
Organizations need a specific mechanism to sharpen and sustain the focus on gender concerns, as AWI's success in institutionalizing gender in AIDSCAP/FHI programs illustrates. While explicit gender language is necessary for documenting activity, changing staff perceptions, and ensuring that gender is included in project design and implementation, it is not sufficient. Institutionalization of gender requires defined, concrete technical approaches and policy and resource support.
Women-Initiated Barrier Methods
Increased research is needed to develop new women-initiated STI/HIV/AIDS prevention methods and to improve women's access to these methods. Research and experience have shown that the male condom is not a feasible HIV prevention option for many women. In AWI's female condom study, for example, more than 70 percent of women from both Brazil and Kenya said they could not convince their partners to use male condoms; none of the women were able or willing to buy male condoms.
Participants at AIDSCAP/FHI's female condom conference in May 1997 agreed on the following recommendations for immediately increasing the availability of female condoms to the general population: (1) begin large-scale introduction in two to three countries; (2) promote the female condom for men as well as women; (3) market the female condom simultaneously through interpersonal and mass media strategies; (4) expedite research on whether the female condom can be used more than once; (5) provide incentives for alternative, less expensive product designs; and (6) disseminate information widely, including to the media.
Women in Development
Globally, women have solved problems, addressed concerns, and established priorities by organizing groups or by networking with other women and organizations that share their interests. Women's groups and indigenous organizations are found in most countries and should be considered as potential implementing agencies for HIV/AIDS prevention activities.
Partnerships with such organizations also facilitate the integration of HIV/AIDS prevention into programs that address broader development concerns. Among the AWI-supported activities that specifically incorporated broader development concerns were an intervention to educate Senegalese market women and their daughters about HIV/AIDS prevention within an integrated credit and literacy program; a project that addressed women's issues in the workplace in Kenya; and credit programs for CSWs in the Dominican Republic.
Challenges for the Future
Understanding Stable Relationships
Few studies have explored the dynamics of sexual communication and control between couples. More research is needed to understand how to help couples develop safe, respectful, mutually satisfactory sexual relationships.
Increasing Women's Options
The enthusiastic response to the female condom in studies and pilot projects throughout the developing world confirms the urgent need for HIV/STI methods that women can initiate and control. Female condoms are a promising option, but their cost has limited their availability to a few developing countries. Efforts to improve access to affordable female condoms and concurrent research to develop microbicides that protect women against HIV and other STIs must be top priorities for prevention programs.
Integrating Reproductive Health
The promise of integrating family planning, HIV and STI prevention, and STI treatment services to reach millions of women through family planning, maternal-child health, and primary health care clinics has yet to be realized. One result is persistent denial, stigma, and lack of commitment to HIV/AIDS prevention. Obstacles include inadequate resources, providers' reluctance to address HIV/AIDS and STIs, a lack of clear technical guidance on how to provide integrated services in a range of settings, and an emphasis on treating and counseling women rather than couples. Operations research is needed to address these constraints before a truly integrated approach to reproductive health can be achieved.
Empowering Women
In many developing countries, women's vulnerability to HIV/AIDS will continue without fundamental changes in their social, economic, and legal status. Income-generating activities linked with HIV/AIDS prevention can empower women to protect themselves from infection, but to date the scope of such activities has been too limited to have a significant impact on the status of women in society or on the spread of the epidemic among women. Political commitment, human and financial resources, and true collaboration among health and development agencies and other organizations are required to empower women through legal reform, increased educational opportunity, and greater access to employment and credit.
