FHI - Making Prevention Work Global Lessons Learned from the AIDS Control and Prevention (AIDSCAP) Project 1991-1997 Making Prevention Work 4. Policy Development and HIV/AIDS Prevention: Creating a Supportive Environment for Behavior Change

Table of Contents

4. Policy Development and HIV/AIDS Prevention: Creating a Supportive Environment for Behavior Change (See Below)

5. Behavioral Research: Using Results to Design Behavior Change Interventions

6. Evaluating HIV/AIDS Prevention Programs: Developing New Tools for Meaningful Measurement

7. Women, Men and HIV/AIDS: Building Gender-Sensitive Programs

8. Managing HIV/AIDS Programs and Building Capacity to Sustain Prevention Efforts

9. Prevention and Care: Mutually Reinforcing Approaches

10. Crossing Borders: Reaching Mobile Populations at Risk

Partners and Acronyms

4. Policy Development and HIV/AIDS Prevention: Creating a Supportive Environment for Behavior Change

The social and political environment of a country, community or workplace has a profound influence on efforts to reduce the spread of HIV/AIDS. The laws, rules, policies and practices of governments, religious organizations and the private sector can support or constrain prevention activities. Some policies may even inadvertently promote the transmission of HIV.

Although many governments, businesses and religious organizations have begun to adopt more appropriate HIV/AIDS policies, this progress has not kept pace with the spread of the epidemic. Few countries have responded to HIV/AIDS with comprehensive programs or have committed the resources needed to slow the epidemic. Restrictions on sex education in schools and condom advertising continue to hamper HIV/AIDS programs. And many employers and governments have adopted ad hoc discriminatory testing policies that discourage people from acknowledging their HIV status and acting to protect others from infection.

Growing recognition of the importance of supportive policies has made policy development a key strategy for HIV/AIDS prevention in the second decade of the epidemic. Early policy efforts were based on the assumption that providing accurate data to key decision makers would stimulate swift adoption of appropriate policies. Now it is clear that informing decision makers must be part of a long-term policy development process that includes analysis, strategic planning, dialogue and advocacy.

Influencing Policy

Recognizing that policy development is a complex, gradual process that must be initiated and sustained locally, AIDSCAP focused on building capacity to inform and influence policy. Through training, technical assistance and information dissemination, AIDSCAP helped local individuals and organizations gain new skills and forge new partnerships so that they could work together to create a supportive environment for effective HIV/AIDS interventions.

AIDSCAP developed and used a range of analytic tools, such as policy assessments, computer models of the socioeconomic impact of HIV/AIDS and cost analyses, to guide policy development efforts. But these tools did not stand alone. They were used strategically in a process designed to empower local advocates and officials to develop appropriate and effective HIV/AIDS policy.

Policy assessments proved an effective tool for identifying opportunities to support HIV/AIDS prevention interventions. These qualitative reviews, which were completed in eight countries, identified existing policy responses, important HIV/AIDS issues, and structures and organizations for addressing those issues. Their findings also provided a useful baseline for evaluating the impact of policy efforts.^1-2

Other policy tools were used to gain a better understanding of the HIV/AIDS epidemic and its social and economic impact. AIDSCAP led the way in expanding the scope of economic impact analyses to include information on households, gender and economic sectors and in integrating those analyses into policy development. Socioeconomic impact assessments conducted with AIDSCAP technical assistance in eight countries gave policymakers a clear picture of the economic implications of the epidemic, and strategic dissemination of assessment results helped influence policy.³ In the Dominican Republic and Honduras, for example, presentations of socioeconomic data and projections to senior policymakers resulted in legal reform and increased funding for HIV/AIDS prevention.

Cost-effectiveness data were particularly useful in convincing business owners and managers to support workplace HIV/AIDS prevention policies and programs. AIDSCAP's Private Sector AIDS Policy package, which has been used in more than ten countries, includes spreadsheets and examples to help managers calculate the potential financial impact of HIV/AIDS on their workplaces and the cost of a workplace prevention program (Box 4.3).⁴ The project worked with the managers of hundreds of companies in 27 countries to establish HIV/AIDS prevention interventions for employees and encourage adoption of supportive workplace policies.

In many policy development efforts, AIDSCAP's technical role was to provide a comparative perspective, offering lessons from other countries' experiences with the epidemic. The project shared information about what has and has not worked nationally and internationally, disseminated international guidelines and policy materials that could be adapted to meet local needs, and sponsored study tours to countries with mature HIV/AIDS epidemics and programs. Study tours to Thailand, for example, gave key Indonesian policymakers opportunities to learn about the progressive policies and comprehensive programs of a country that experienced the earliest HIV/AIDS epidemic in Asia. Most of the tour participants formed an informal group that met regularly in Jakarta and helped guide the development of Indonesia's national HIV/AIDS strategic plan.

Although study tours and some other educational efforts targeted policymakers directly, AIDSCAP emphasized training of policy "influencers" -- the technical and policy specialists inside and outside of government who inform and advise policymakers. Through this training, many people who had believed that policy was not their responsibility came to realize that they had important roles to play in policy development. Policy influencers who participated in AIDSCAP's training workshop in Central America were able to target and time the presentation of socioeconomic impact projections to influence the actions of policymakers (Box 4.2). In Senegal, Islamic and Catholic religious representatives recommended that assistants and spokespeople for religious leaders be engaged in initial dialogue so that they could help guide the policy response.

Whether the goal was government or religious policy change, AIDSCAP found that policy identification was a good way to create a network of committed advocates. At the national level, AIDSCAP's approach was to support local organizations in soliciting a list of key policy issues from people working on HIV/AIDS prevention at the district and provincial levels, expressing those issues as policy recommendations, and presenting the recommendations to the appropriate national authorities. The same process was used with church hierarchies and networks of religious organizations. As Kenya's experience with government, NGO and religious groups illustrates, this process can help build a constituency for longer-term policy development (Box 4.1).

AIDSCAP's experience shows that a strategic process and a focus on strengthening local capacity and collaboration can produce results and leave behind the institutional capacity to develop appropriate responses to a complex epidemic. Rigorous analysis of scientific and sociopolitical data, combined with presentations of persuasive recommendations and building constituencies for HIV/AIDS prevention, led to constructive dialogue among political and community leaders on topics such as workplace HIV/AIDS prevention, the human and civil rights of people living with HIV/AIDS, private sector support for prevention, and the organizational and financial sustainability of prevention efforts.

4.1 Changing HIV/AIDS Policy in Kenya
On September 24, 1997, the Kenyan Parliament approved the country's first comprehensive national policy on HIV/AIDS. This Sessional Paper on AIDS calls for a more aggressive response to the epidemic, establishes an independent National AIDS Council to ensure political commitment across government sectors, and states the government's positions on controversial issues such as HIV testing, confidentiality and human rights.

A milestone in HIV/AIDS policy development in Kenya, the Sessional Paper is the result of years of research, dialogue and consensus-building by HIV/AIDS advocates and technical specialists inside and outside of government. This process itself was remarkable, for it marked the first vigorous and inclusive public debate about the Kenyan response to the epidemic in a country where HIV/AIDS policy had long been neglected.

One of the many organizations that advised the Ministry of Health (MOH) as it drafted the Sessional Paper, a consortium of some 200 NGOs, used its own consultative process to develop specific recommendations that were incorporated into the national policy. With technical assistance from AIDSCAP, the Kenya AIDS NGOs Consortium (KANCO) held a series of district and provincial workshops in 1996 and 1997 to solicit the views and experiences of NGO personnel, religious leaders, civil servants and policymakers. Designed to build consensus among diverse groups, these workshops gave those working in HIV/AIDS prevention and care opportunities to identify common concerns and problems and to develop advocacy strategies for advancing priority issues.

Participation in policy identification workshops was an eye-opening experience for many NGO and government personnel, noted KANCO Director Alan Ragi. "Workers at the district level didn't think they had a role to play in policy development," he said.

KANCO showed them that policy was not just the province of the central government. The result was a list of 72 issues affecting HIV/AIDS prevention and care in Kenya.

Representatives of the different groups meeting at a national workshop convened by KANCO narrowed the original list to eight priority issues, which consortium staff then developed into policy recommendations. Some of these recommendations were shared with partners, such as business associations, better placed to pursue them in the policy arena. But most were conveyed, in position papers, presentations and discussions, to members of the government-appointed subcommittees drafting the Sessional Paper on AIDS.

KANCO worked closely with the various subcommittees to inform their members and to advocate for the consortium's recommendations. Ragi even represented KANCO as a member of the MOH subcommittee responsible for the strategies and interventions section of the Sessional Paper. As a result of this collaboration between the consortium and the MOH, all eight priority issues were addressed in the final document.

But passage of the Sessional Paper is hardly the culmination of KANCO's policy development efforts. Continued advocacy will be needed to ensure that the papers' guidelines are implemented and follow-up legislation is passed. And the network of KANCO chapters the consortium has built across the country will continue to identify new policy constraints and other issues for policy development and advocacy.

A similar process of policy identification, skills building and advocacy facilitated by MAP International among district and provincial clergy and church members led to a dramatic shift in the attitudes of Kenyan religious leaders. Once skeptical and sometimes even hostile to church involvement in HIV/AIDS prevention and care, the leaders of many different denominations came together in February 1996 and committed their churches to developing policies to address 14 HIV/AIDS issues.

Their statement, later published in a daily newspaper, urged church action on providing education about family life and sexuality, developing support groups for HIV-positive people, offering premarital counseling and HIV testing, caring for orphans and those living with HIV/AIDS, and supporting the rights and needs of women. The leaders said churches should develop policies on "appropriate and acceptable methods of protection," without mentioning condoms or other specific methods. And in an unprecedented acknowledgment that clergy members do not always practice what they preach, they called for a revitalization of moral values in church leadership.

The urgency, unanimity and commitment of the religious leaders' response "was immediately and correctly perceived by local church leadership as empowerment and authorization," said Rev. Chris Mwalwa, who has served as a consultant to MAP. By giving local clergy and congregations the mandate they needed to respond to the epidemic, the policy statement strengthened the emergence of a powerful campaign among local churches and religious organizations to care for those affected by HIV/AIDS and to prevent further spread of the virus.

The experiences of MAP International and KANCO are proof that policy is not only the responsibility of central bureaucracies, and policy change is not always simply imposed from above. Changes in policy can be shaped from the grassroots by carefully executed strategies to engage people at all levels of governmental, organizational and community hierarchies in issue identification and advocacy.

Lessons Learned

Policy Development Partners

The role of an outside agency such as AIDSCAP in policy development is one of advisor, not framer, of policy change.

Outside donors can provide financial support, information, encouragement and technical assistance, but actual policies and processes for achieving policy development will come from local people and institutions.

For example, AIDSCAP provided technical assistance to help the Kenya AIDS NGOs Consortium develop HIV/AIDS policy recommendations based on the views of local constituents, which were solicited during a series of district and provincial policy workshops (Box 4.1). AIDSCAP's role was to assist consortium staff in facilitating the policy development process, not to determine the content of the recommendations. Supporting such a process requires patience and flexibility, for donors and indigenous people might emphasize different priorities, but the policies that result will be more sustainable.

Working with and within coalitions is often the most effective way to advance policy goals.

Coalitions demonstrate commitment, draw upon group expertise and provide a diversity of interests and expertise that can be focused on a single issue. AIDSCAP has worked with NGO, religious, business and government coalitions, providing technical assistance to help these groups remain focused on a defined agenda.

Similarly, a multisectoral group of technical specialists, analysts and advocates brings complementary skills, eprspectives and contacts to the policy development process. This was the approach adopted by AIDSCAP in Central America, where teams of epidemiologists, economists, policy and financial analysts, and policymakers from three countries worked together to assess the socioeconomic impact of HIV/AIDS and to develop strategies for using their results to achieve policy goals (Box 4.2).

The best way to reach policymakers is through their advisors, constituents and already committed peers.

In Kenya, leaders of major religious denominations committed publicly to policy adoption as a result of determined peer interest and constituent pressures demonstrated over two years of awareness raising and consensus building (Box 4.1). AIDSCAP also invited Kenyan policymakers and technical experts to co-author a book about HIV/AIDS in Kenya, which added legitimacy to the findings.5 The country's vice president spoke at the press conference launching the book in Nairobi, where he gave the government's strongest statement to date about the epidemic in Kenya.

When they are respectfully engaged in the policy development process, religious leaders can play a constructive role in HIV/AIDS prevention.

Many religious leaders are concerned that condoms are a form of birth control or that they contribute to promiscuity and youth sexual activity by reducing the risks associated with intercourse. But AIDSCAP's experience in Kenya, Indonesia, Nigeria, Senegal and Tanzania shows that when these concerns are addressed with respect, many religious leaders are willing to participate in coordinated, comprehensive prevention efforts.

AIDSCAP and MAP International's efforts to facilitate consensus on HIV/AIDS prevention within religious communities in Kenya were successful because they engaged religious leaders through the hierarchies of their churches, encouraged active discussion and networking, used persuasive results of youth sexual behavior surveys, and did not try to involve the senior hierarchy until near consensus was reached within the lower ranks (Box 4.1).

External organizations can support and strengthen, but not create, effective networks.

Strong networks such as the Kenya AIDS NGOs Consortium and the National AIDS Convention of South Africa have succeeded because they serve the needs of a diverse membership, they have committed, skillful leadership, and they diversified funding sources at an early stage. These organizations came to be seen as providing a service, not only for members, but for government, and they engaged in policy and advocacy activities rather than focusing exclusively on programs and interventions.

Policy Development Tools

Government and business policymakers are responsive to assessments of the potential social and economic impact of HIV/AIDS in a country or company.

Data on the effects of HIV/AIDS on national economies and societies -- particularly data generated and presented by country health officials and analysts -- proved an influential advocacy tool in the 12 countries where AIDSCAP helped conduct such assessments. In El Salvador, for example, numerous presentations on the impact of HIV/AIDS on the national economy and social welfare indicators stimulated the Salvadoran Social Security Institute, which provides health care to both private and public sector employees, to work with businesses to develop HIV/AIDS programs in the workplace (Box 4.2).

Reports of modeling projections can be highly influential if disseminated strategically.

For example, dissemination of a non-technical summary report of modeling projections written for the general population and the news media generated extensive coverage of the epidemic in the Dominican Republic.⁶ This media coverage drew public attention to the growing HIV/AIDS problem in the country, which helped promote passage of a comprehensive AIDS law by the National Assembly.

Epidemiologic and economic impact projections can also strengthen advocates' case for laws protecting the civil rights of people living with HIV/AIDS. In the Dominican Republic, for example, a well-timed presentation of the results of a socioeconomic impact assessment was instrumental in achieving passage of a law that not only requires each ministry to fund prevention activities, but also guarantees human rights for people living with HIV/AIDS. And in Nicaragua, an advocacy NGO used the results of the assessment made during an AIDSCAP training workshop to help pass legislation protecting homosexuals and HIV-positive people (Box 4.2).

Policymakers are often prepared to act on recommendations for HIV/AIDS prevention when they are presented with clear, precise information.

Specific recommendations, substantiated with convincing data and supported by advocacy, can lead to policy change. In Kenya, for example, recommendations from position papers prepared by the Kenya AIDS NGO Consortium were incorporated into the government's Sessional Paper on AIDS (Box 4.1).⁷ And South Africa's minister of health adopted as national policy a comprehensive plan for a national response to HIV/AIDS drafted by local NGOs.

4.2 Policy Development Initiative Reaps Unexpected Benefits
In February 1996, a group of technical specialists, policy analysts and policy influencers from three Central American countries met in Guatemala City to participate in an AIDSCAP-sponsored policy development workshop. The skills and knowledge they gained there and the collaborative relationships they forged continue to have an impact on HIV/AIDS prevention in their countries to this day.

At the workshop, participants learned to estimate the potential socioeconomic impact of HIV/AIDS in their countries and to use their results to inform and guide HIV/AIDS prevention policymaking. They agreed to continue working together after the workshop to develop stronger responses to HIV/AIDS in their respective countries.

After learning how to use computer models and costing methodologies to make epidemiologic and economic projections, the three country teams developed policy recommendations and advocacy strategies to support each recommendation. Initially their action plans for presenting the results were similar, but new strategies emerged as the teams returned home and encountered different constraints and opportunities.

In El Salvador, a presentation of the team's projections at the Instituto Salvadore�o del Seguro Social (ISSS) , a parastatal organization that provides health care to private and public sector employees and their families through its own hospitals and health centers, produced immediate results. The projected impact on health costs and ISSS operating expenses so concerned the institute's board of directors that it established an HIV/AIDS prevention program for its employees and initiated its own project to strengthen the HIV/AIDS prevention efforts of its private sector clients.

The legislative aides on the Salvadoran team also arranged a presentation to members of the National Assembly shortly after the workshop, which resulted in commitments by Assembly members to support passage of HIV/AIDS legislation, such as a safe blood law, being prepared for consideration in the next legislative cycle.

The Guatemalan team benefited from the participation of the chief of the military health service (Servicio de Sanidad Militar, or SSM), whose experience at the workshop made him an advocate for HIV/AIDS prevention and care in the military. After the workshop, the SSM chief quoted the team's projections in a number of media interviews and publicly called for a review of policies and practices related to HIV-positive members of the military. He continues to be involved in disseminating the study results and in HIV/AIDS policy development as the military representative on the new National HIV/AIDS Coordinating Committee.

Another benefit of the AIDSCAP workshop is the improved relationship between the national AIDS control program and the Asociaci�n Guatemalteca para la Prevenci�n y Control de SIDA, an HIV/AIDS service and advocacy organization, in Nicaragua. Despite prior tensions, representatives of the two groups were able to work together on the socioeconomic impact project. This collaboration bodes well for the efforts of the National HIV/AIDS Coordinating Committee, a multisectoral coalition that brings together diverse, and in some cases historically antagonistic, interests and perspectives to strengthen Guatemala's HIV/AIDS prevention and care programs.

A severe economic downturn, a series of public health crises and an upcoming national election made it difficult for the Nicaraguan team to follow through on the activities defined in its action plan. Fortunately, however, a Nicaraguan NGO that was unable to participate in the workshop but was involved in follow-up meetings and strategic planning used the team's results to work with the national AIDS control program to pass legislation protecting the rights of people living with HIV/AIDS. When this legislative effort led to the reconvening of Nicaragua's National AIDS Committee, the assessment team used the opportunity to share its results with committee members.

Success in policy development is often incremental and can take unexpected forms, as the experiences of the three Central American teams illustrate. For example, the Salvadoran team's work inspired the Social Security Institute to use socioeconomic impact analysis to sensitize other members of the private sector to HIV/AIDS. Likewise, the collaboration fostered by the workshop had unanticipated benefits in Guatemala, where it contributed to energizing the National HIV/AIDS Coordinating Committee. And in Nicaragua, Fundaci�n Nimehautzin -- an NGO that could not send a representative to the AIDSCAP workshop -- linked data generated by the team with advocacy to help steer the country's legislative response to the epidemic.

The experiences of all three country teams reflect a central lesson from AIDSCAP's experience: that policy development success arises from good data, sound analysis, thorough planning and true collaboration. The way that these elements come together depends, in part, on recognition that policy development is a process. Like all good processes, it can be enhanced with strategic planning and the ability to take advantage of unexpected opportunities.

Involving Employers

Workplace HIV/AIDS prevention activities are acceptable to business managers when the interests of the business are considered.

By working with managers to help them understand the impact of HIV/AIDS on their businesses and to tailor interventions to meet the needs of workers and management, AIDSCAP and its partners helped establish prevention programs in hundreds of workplaces throughout the world.

AIDSCAP's Private Sector AIDS Policy (PSAP) materials encourage managers to establish constructive HIV/AIDS policies and support prevention programs in the workplace. PSAP uses rapid analysis of the potential financial impact of HIV/AIDS on a business and the expected effects of workplace HIV/AIDS prevention activities to demonstrate the benefits of prevention policies and programs (Box 4.3).

The greatest impact of HIV/AIDS on the financial well-being of companies occurs in the disruption of production because of absenteeism, labor turnover due to illness or death of HIV-positive employees, and the need to train new employees.

Even in low-wage, labor-intensive industries, productivity is affected, and company profits suffer. In Thailand, for example, an AIDSCAP study of the affiliates of two multinational companies found that absenteeism due to AIDS represented over 40 percent of the total cost of HIV/AIDS on the businesses. Labor turnover and training of new workers added up to another 30 percent of total costs. The study estimated that HIV/AIDS had cost each company $20,000 in 1994 and projected that AIDS-related expenses would rise to $100,000 per company by 2005.⁸

Essential management support for prevention policies and programs can be gained by identifying key allies in a company and providing data to support the need for a workplace project.

An assessment of AIDSCAP-supported workplace programs in three African countries found that it is often most effective to approach managers in training, human resources and health departments who are familiar with the impact of the epidemic on the work force.⁹

Experience in Africa also showed that working with an industry association rather than individual companies makes "entree" and later expansion easier. In Zimbabwe, for example, regional coordinators of the Commercial Farmers Union recruit new farms to participate in the AIDSCAP-supported program and provide training in HIV/AIDS prevention education to farm employees and their families. The Organization of Tanzanian Trade Unions has also trained regional officers who approach employers in their areas. And in Eldoret, Kenya, AIDSCAP reached employers through the local branch of the Kenya Association of Manufacturers, which then decided to hold orientation workshops for business owners and managers in neighboring districts.

Requiring some contribution from companies from the start facilitates increased cost-sharing as workplace prevention needs and activities expand.

Cost-sharing is introduced most effectively during negotiations with an association or company on the services to be provided. Once a program proves itself, companies may assume an even greater share of the costs. For example, two Zimbabwean companies that have collaborated with AIDSCAP to establish workplace prevention programs -- the Commercial Farmers Union and Triangle Industries -- now include funds for HIV/AIDS prevention in their annual budgets. In Tanzania, companies were asked to contribute 25 to 50 percent of the cost of workplace prevention.

4.3 Private Sector AIDS Policy: Helping Businesses Respond to HIV/AIDS
With a few notable exceptions, private industry worldwide has been slow to adopt policies and mount programs to protect workers from HIV/AIDS. Through its support of hundreds of workplace prevention projects in 27 countries, AIDSCAP found that many business owners and managers did not understand the threat the epidemic posed to their workforces and their businesses. Others simply did not know what to do.

AIDSCAP's Private Sector AIDS Policy: Businesses Managing HIV/AIDS is designed to address both problems. Known as PSAP, it helps managers gauge the potential impact of HIV/AIDS on their businesses and design appropriate workplace policies and prevention programs to respond to the epidemic.

The PSAP kit is one of the few HIV/AIDS prevention resources written specifically for private sector managers in the developing world, and it is the most comprehensive of its kind. It contains a manual to help businesses estimate the potential impact of the epidemic on their operations and profits and to plan prevention interventions, case studies of 17 African businesses' responses to HIV/AIDS, guidelines for assessing prevention needs in the workplace, and a facilitators' guide for trainers working with businesses.

The facilitators' guide helps trainers use the PSAP materials to give short presentations to sensitize business owners and managers to the need for a vigorous response to HIV/AIDS and to conduct two-day workshops on designing appropriate prevention policies and programs. But PSAP can also stand alone as a guide for private sector managers who want to develop HIV/AIDS policies and prevention programs.

Before its publication in November 1996, PSAP was pretested at business leader workshops, luncheon presentations and training-of-trainer seminars in Kenya, Nigeria and Senegal. Interviews with participants and questionnaires they completed yielded useful suggestions for improving the materials, but the response was overwhelmingly favorable. In fact, many business owners and managers said they would be willing to pay to attend additional PSAP workshops.

Ministries of health, business federations, unions, individual businesses, NGOs and international organizations in at least ten countries are using PSAP to promote greater private sector involvement in HIV/AIDS prevention. The Joint United Nations Programme on HIV/AIDS (UNAIDS) has included the PSAP kit in its "best practices" library, and copies are available in all UNAIDS offices.

Although PSAP was originally developed for use in Africa, it is already in demand in countries throughout the world. Parts of the kit have been translated into Spanish for use in Latin America, and the entire kit will be translated into Portuguese in Brazil.

Zimbabwe's minister of industry and commerce, Herbert M. Murerwa, noted that PSAP is unique because it recognizes the needs of employers and goes beyond simply offering guidelines. "This guide provides business-based rationale for recommendations, encourages the generation of options, and offers a process for HIV/AIDS policy and program formulation," he said.

Evaluation

Changes in policies and the policy environment can be measured by using both quantitative and qualitative indicators.

Evaluation of policy work is complex for a number of reasons, including the difficulty of attributing policy changes to specific interventions and of quantifying changes in the policy environment. In addition, because much of policy change is incremental and attitudinal, it is often hidden from evaluation efforts.

AIDSCAP overcame these limitations by using a combination of quantitative and qualitative indicators of change. Simple quantitative indicators, for example, can measure changes in the level of governmental or business funding for HIV/AIDS prevention. Assessments that include two sets of in-depth interviews with key policymakers and advocates carried out two or three years apart provide information on changes in attitudes and policies, institutional mechanisms that may affect policy, and organizational dynamics. A policy assessment in Kenya found significant changes in the policy climate, improved institutional mechanisms for facilitating policy development, and movement among major religious groups from institutional denial and occasional open opposition to HIV/AIDS prevention to a public commitment to develop appropriate denominational policies (Box 4.1).

Recommendations

External agencies should limit their role in policy development to enabling local people and institutions to develop their own policy recommendations and plans for enacting them through training, technical assistance and information dissemination.

Technical assistance should not be overly directive, and expatriates should not be put in a position to act as spokespeople to senior officials. Policies developed locally will have a stronger constituency and are more likely to be adopted and sustained.

HIV/AIDS programs should work with religious communities and their leaders to encourage their active participation in prevention efforts.

Religious leaders are playing a constructive role in HIV/AIDS prevention in several countries as a result of approaches that respected their values and engaged them through the hierarchies of their churches.

Outcomes of technical assessments and analysis must be translated into concise, nontechnical summaries accessible to both policymakers and the media.
To ensure that policymaker education results in policy initiatives, presentations of the projected social and economic impact of the epidemic should be accompanied by specific recommendations for preventing HIV/AIDS.

These recommendations should be supported by persuasive data, including estimates of implementation costs when possible. Local advocates should follow up presentations with additional information, reminders of the proposed actions, and advocacy.

Workplace HIV/AIDS prevention programs should begin with a concerted effort to identify allies in a company and to provide data to support the need for such a program.

Managers need to understand how HIV/AIDS is affecting their industries and the potential impact on labor costs and productivity if prevention efforts are not instituted.

HIV/AIDS programs should require an employer contribution to workplace prevention projects from the beginning to ensure further cost-sharing as prevention needs and activities expand.

Future Challenges

Encouraging Early Response

Engaging the interest, concern and support of policymakers at early stages of the epidemic continues to be challenging, particularly when prevalence is low and the potential for a future problem may not be apparent. Exchanges between policymakers from countries at different stages of the epidemic have helped raise awareness of the need for early intervention in a few countries, but appropriate measures to contain early HIV/AIDS epidemics are rare. Early interventions are particularly important to offer viable protection to monogamous women and to youth.

Leveraging Private Support

Businesses are often reluctant to dedicate resources for HIV/AIDS prevention, though most owners and managers are willing to allow such projects to operate in the workplace as long someone else pays for them. Systematic advocacy campaigns, better information about the impact of HIV/AIDS on businesses, and delivery of professional prevention services on a fee-for-services basis are needed to encourage businesses to dedicate more of their own resources to prevention.

Understanding Impact

Although it is clear that social and economic factors contribute to HIV vulnerability and transmission of the virus, more specific data are needed to make a persuasive case. The relationship between HIV/AIDS vulnerability and poverty is assumed but has not been sufficiently described or analyzed. Socioeconomic data on specific groups of people are needed to clarify this relationship and provide a better understanding of the link between HIV/AIDS and multisectoral development.

Improving HIV Testing Policies

As HIV testing becomes less expensive and more available, there will be a growing need to ensure that it is not used to discriminate against people living with HIV and that voluntary testing is linked with effective counseling. Policymakers need to be educated about the negative effects of discriminatory testing policies.

Supporting Prevention and Care

The emerging availability of and options for HIV/AIDS treatment will place greater demands on medical systems and national governments to provide new, expensive drugs. Some countries may respond by moving funding allocated for HIV/AIDS programs from prevention to treatment, care, support and mitigation. Competition for scarce resources would ill serve those who need these services. Advocacy efforts are needed to convince policymakers of the importance of increasing funding for both care and prevention

References

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Rau B, Roberts M, eds. (1996). Private Sector AIDS Policy: Businesses Managing HIV/AIDS. AIDSCAP/Family Health International, Arlington, Virginia.
Forsythe S, Rau B. eds. (1996). AIDS in Kenya. Family Health International, Arlington, Virginia.
Arbaje M, Gomez E, Butler de Lister M, Sweat M. Sida en la Republica Dominica: Situaci�n Actual e Impacto Socio-Economico. AIDSCAP/Family Health International, Arlington, Virginia, and Santo Domingo, Dominican Republic.
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Making Prevention WorkGlobal Lessons Learned from the AIDS Control and Prevention (AIDSCAP) Project 1991-1997

4. Policy Development and HIV/AIDS Prevention: Creating a Supportive Environment for Behavior Change

Making Prevention Work
Global Lessons Learned from the AIDS Control and Prevention (AIDSCAP) Project 1991-1997