Greetings,
This time we have eight postings from Belize, Finland, Kenya, Nigeria, Pakistan, Tanzania, and Thailand. Several follow up on the previous post about adults needing to change their behaviors to set an example for youth, including Michelle Turton and Joyce Kinaro, who describes an interesting project that trains parents as peer educators to talk to other parents and youth.
A second theme is youth empowerment in the context of changing social norms. Duanne Punpiputt describes several projects in Thailand that promote condom use, partner communication, and other initiatives. Omeire Edward of Nigeria addresses how gender inequality makes the "ABC" approach inadequate and the importance of changing social norms beginning at the local level where trust is higher. Josephine Gua of Nigeria asserts that girls and young women need to be empowered
Dr. Ather, of Pakistan, argues that structural changes, especially cultural beliefs, must change. Temitope Abayomi Fadiya of Finland asks for ideas about training and mentoring youth to negotiate sex. Lastly, Ismat Dewji Sheriff asks for assistance on information on HIV transmission between mothers and children.
We look forward to hearing more about projects addressing the needs of young women and girls. If any participants have had experience with an intervention working with especially vulnerable girls, we would very much like to hear about it. If you have a link to a project report on a Web site, let us know. We could also post the study in the Forum Community library.
Below, Dr. Collins offers some resources about points recently raised.
Sincerely,
Ed Scholl, for the Forum Coordinators
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I appreciated hearing from several participants about the importance of addressing the needs of girls and young women, including the need for changes in social norms and gender power relationships. Questions arose about mother-to-child transmission of HIV and negotiating safer sex among youth.
Mother-to-Child Transmission
Ismat Sheriff from Tanzania raises an interesting point about the unpredictable nature of HIV and asks specifically about a point I raised in my introductory remarks, including a 2 percent mother-to-child infection rate. It is perfectly understandable to be confused by all of the statistics being quoted on rates of mother-to-child transmission. Many factors contribute to the varying rates, since HIV can be transmitted to the infant during pregnancy, labor, delivery, or breastfeeding. Without any interventions, the risk of mother-to-child transmission from a woman living with HIV is about 15-30 percent in non-breastfeeding populations. The risk increases to 20-45 percent if the mother breastfeeds. For the latest guidance from WHO, UNICEF, UNAIDS and UNFPA on HIV and infant feeding, please refer to the following resources:
With interventions, however, that include antiretroviral (ARV) prophylaxis given to women during pregnancy and labor and to the infant in the first weeks of life, obstetrical interventions such as elective caesarean delivery (prior to the onset of labor and membrane rupture) and completely avoiding breastfeeding, then the risk of mother-to-child transmission can be reduced to below 2 percent. For a detailed discussion of these rates and the latest recommendations on antiretroviral drugs in the context of maternal and infant health, please refer to the WHO 2004 publication Antiretroviral Drugs for Treating Pregnant Women and Preventing HIV Infection in Infants: Guidelines on Care, Treatment and Support for Women Living with HIV/AIDS and their Children in Resource-Constrained Settings (PDF, 504K).
Of course, we should all do our part to prevent HIV in women in the first place. For related guidance from EngenderHealth and UNFPA, please refer to:
Negotiating Safer Sex among Youth
In a second question, Temitope Abayomi Fadiya emphasizes the importance of training and mentoring in the skills of sex negotiation among youths. I agree with her completely that the development of these skills is essential for young women and girls. She asks for suggestions and comments along this line.
Negotiating safer sex is fraught with inherent difficulties, and women are confronted with poverty, gender inequality, gender-based violence, and lack of empowerment that conspire to compromise their ability to practice safer sex. Out of economic necessity, for example, women might be forced to accept higher payment for sex work without a condom, forgoing safer sex for themselves and their clients. Fear of being accused of being promiscuous or implying that their partners are, and possibly of being subsequently abused, holds some women back from discussing condom use. Cost and embarrassment are also impediments to engaging in safer sex discussions. Clearly, central structural barriers and fears must be addressed.
However, women for whom it is potentially feasible to attempt to negotiate safer sex may only lack the required skills. There are a number of sources that offer guidance on how to impart negotiation skills, including developing assertiveness, providing caring arguments, overcoming barriers to condom use, employing non-confrontational styles, etc.:
- EngenderHealth has produced a comprehensive training manual, Integration of HIV/STI Prevention, Sexuality, and Dual Protection in Family Planning Counseling (PDF, 1.47MB). The manual has chapters dedicated to risk assessment and safer sex negotiation (see Section II, parts C and D).
- The UN Department of Peacekeeping Operations has provided an instructive PowerPoint presentation (1.59MB) that shares tips on keys to negotiation.
- The Sexuality Information and Education Council of the US (SIECUS) has produced, "Guidelines for Comprehensive Sexuality Education: K-12," a framework to promote and facilitate the development of comprehensive sexuality education programs. The Guidelines identify the goals of comprehensive sexuality education, six key concepts that a comprehensive programs need to cover, as well as a variety of topics that should be included. These guidelines can be adapted to fit cultural contexts of other regions or countries.
- The International Women's Health Coalition (IWHC) has developed a new resource that reviews useful English-language sexuality education materials, one of the cornerstones of effective negotiation, Positively Informed: Lesson Plans and Guidance for Sexuality Educators and Advocates.
- The UNAIDS Interagency Task Team on Condom Programming is about to launch a new publication which provides concrete useful tips on how to overcome the key attitudinal barriers to condom use. "Myths, Perceptions and Fears: Addressing Condom Use Barriers" will soon be listed on this page of UNFPA's Web site.
I would also like to hear ideas and experiences from other participants on what types of programs or approaches they have found that are successful for increasing negotiation skills.
Sincerely,
Lynn Collins
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Forum Digest 6
- Reach Out to Adults, Involve Schools
- Community-Based Program Targets Parents, Tanzania
- Peer Outreach Program Promotes Condom Efficacy, Thailand
- Gender Equality Needed, Start Locally
- Girls and Young Women Need to Be Empowered
- Society Must Change
- How Can We Help Youth Develop Skills to Negotiate Sex?
- Information on Mother to Child HIV Transmission Wanted
1. Reach Out to Adults, Involve Schools
The post, "Adults Must Change Their Behaviors," made me realize the importance of helping adults to address some of the same issues that our young people are faced with. Many times as adults we see issues that young people are faced with and conclude that it is "their" problem — not realizing that it is society as a whole that makes our young people who they are.
Having said this, I think it is important then that we start offering parenting sessions at our schools and in our communities. It is an excellent idea for an adult to accompany a young person whenever they attend training programs or workshops. Similarly, many of these workshops can be offered to adults.
Supervisors working in any organization or company should start organizing staff workshops in which some of these same issues that our young people face are highlighted. The advertisements that are put on radio, TV and newspapers could be produced in such a way that they are not addressed directly to youth but to adults as well. I very much agree with the statement: "It is only when adults change their behaviour and set an example for the young, that youth will also change their behaviour. If we are going to condemn youth, then we should look at ourselves first."
-- Michelle Turton, Belize
2. Community-Based Program Targets Parents, Tanzania
I totally agree with Laurie Maund about adults needing to change their behaviors in order to set a moral example for youth. In Kenya, youth have tried to make the point that their parents do not listen and they do not understand them, that the only thing they (parents) can imagine, when they go out, is that they are indulging in sexual intercourse.
Parents need to be friends with their children and should enhance open discussions on sexuality and how they (youth), especially girls, should be assertive on matters of sex. I believe that more programs focusing on parents and teachers would go a long way in empowering them on how to relate to adolescents and youth on issues of sexuality.
In 2003, I visited a program in Tanzania where the youth had identified adults in the community whom they could consult for information on reproductive health. These parents were then trained as peer counselors. This kind of strategy is very effective because the adults are able to reach other adults with information, and, at the same time, they are able to give updated information to the youth. Since the parents live in the same community, they sometimes have to intervene when there are disagreements between the youth and their parents.
-- Joyce Kinaro, Senior Program Officer, Planned Parenthood Federation of America-International, Africa Regional Office, Nairobi, Kenya
3. Peer Outreach Program Promotes Condom Efficacy, Thailand
I have learnt so much useful and interesting information from Dr. Collins and would like to share my own thoughts and the experiences of my association, Parenthood Association of Thailand (PPAT). As we learned from promoting the prevention of HIV/STIs, people (not only young people) still judge others mainly from their appearance, no matter how hard we try to emphasize that "we cannot judge who have STIs or HIV by their appearance." Thus, condom use is crucial to prevent infections. On that note, trust is always an issue when talking about condom use, especially among married couples and lovers. From my point of view, it would be better for couples/lovers to discuss from the beginning and agree on condom use, instead of oral contraceptives or other birth control methods, as a tool to prevent unplanned pregnancy because the primary concern of young people when engaged in unprotected sex is unplanned pregnancy. This will promote not only male participation and responsibility for sexual and reproductive health issue but also consistent condom use which can prevent both unplanned pregnancies and STIs.
Another point is the availability and accessibility of condoms. Condoms are available widely in drug stores, supermarkets, and convenient stores in Thailand, and the price per pack is affordable (below Baht30 to Baht60; US$1 = Baht37), especially in comparison to the price of a packet of cigarettes (~Baht35). Accessibility is the problem. I once talked to young people about buying condoms and learned that they were shy and felt uncomfortable buying condoms. Is it possible that stigma against unmarried young people carrying condoms adds to their shyness buying condoms?
At one of our projects, Peer Outreach for Reproductive Health in Thailand (PORT), youth can both hang out and get counseling. Condoms and oral contraceptives are sold at a low price through peer motivators and project staff.
Also, at PORT, we had young girls and boys in the same session discussing various issues, including relationships. Questions such as, What would you like your girlfriend/boyfriend to be like? What would you think/feel if your girlfriend/boyfriend said or did ......? This activity helped promote better understanding between female and male youths and enabled them to be more well-adjusted and have better and healthier relationships.
Another project funded by UNFPA aims at increasing access to gender-sensitive reproductive health and HIV/AIDS education and services by young people. Selected young people have been trained as peer educators to further promote correct knowledge and understanding about reproductive health and HIV/AIDS as well as providing condoms and oral contraceptives to their friends.
More complicated strategies and programmes are needed in response to other structural issues mentioned by Dr. Collins. I would love to hear from others who have good practices on the issue to share.
-- Duanne Punpiputt, Planned Parenthood Association of Thailand, Peer Outreach for Reproductive Health in Thailand
4. Gender Equality Needed, Start Locally
I am the program director of Ceasefire Project, which is based in Lagos, Nigeria. Ceasefire is a youth-focused, not-for-profit organization promoting youth leadership and action for sustainable development that was founded in 1999. It has since grown into a national network organization with a major focus on strengthening the capacity of youths/youth organizations and other disadvantaged communities to participate in issues that affect them, such as health, ICT, and governance. Ceasefire has been a forum for hundreds of young people to engage in struggles for socio-economic justice, peace-building, poverty reduction, and the fight against HIV/AIDS.
I want to start my contribution with this quote by Thoraya Obaid, UNFPA Executive Director: "The ABC approach — Abstain, Be Faithful, Use Condoms — is not a sufficient means of prevention for women and adolescent girls. Abstinence is meaningless to women who are coerced into sex. Faithfulness offers little protection to wives whose husbands have several partners or were infected before marriage. And condoms require the cooperation of men. The social and economic empowerment of women is key. The epidemic won't be reversed unless governments provide the resources needed to ensure women's right to sexual and reproductive health."
I believe she had Africa in mind when making this assertion. In many African societies, gender inequality is very obvious and rooted in deeply held, cultural beliefs. They are powerful. Only well-directed efforts that will alter or eliminate gender inequality and its attendant effects on women and adolescent girls will work. And, these changes must originate within the culture that practices them. (Western pressure for change is quite commendable but it is sometimes heavy handed and insensitive and often seen as culturally imperialistic.)
The change must be localized. Locals, community leaders, market women, age groups, religious leaders, and youths must work together to effect the change. Their opinion and views must be reflected in policies or programs that affect them, from the planning stage to the implementation stage. We make a big mistake by trying to start at the governmental level. The majority of people in Africa are totally cut off from governance; they don't believe in their politicians, so anything coming from the government is often looked at with suspicion. When we take the top-bottom approach, we end up having a mere policy change and no behavioral change.
-- Omeire Edward, Ceasefire Project, Lagos, Nigeria
5. Girls and Young Women Need to Be Empowered
I want to add that women, and especially young girls, should be empowered, both educationally and economically. Projects that will support the empowerment of women should be implemented in the rural areas. A woman who is educated and has a means of livelihood can make decisions that affect her life. If more projects that focus on women's empowerment are implemented, a lot of difference will be made.
-- Josephine Gua, Africare/Nigeria, Rivers State, Nigeria
6. Society Must Change
I agree with the role of the adults in promoting health education and especially sex education, however, I have seen how reluctant society is in promoting life skills and sex education. It also requires political will and participation of the programmers — especially, the departments of health and education — and I think, in developing countries like Pakistan, a lot needs to be done in this regards. I also think that, even if we get the political will in promoting sex education among adolescents, cultural factors will remain an obstacle. It would still be difficult to promote such things, especially in closed societies. I see a limited role of NGOs in this. Behavioural change or change in social values altogether seems impossible in recent times.
-- Dr. Ather, Epidemiology, Pakistan
7. How Can We Help Youth Develop Skills to Negotiate Sex?
When I made my contributions to last week's discussion, I made some statistics known to all discussants about the prevalence of HIV/AIDS amongst the vulnerable young women and men in sub-Saharan Africa. For example, over 1.3 million young Nigerians are infected with HIV/AIDS, which is more than any other African country expect South Africa! I also said that there is need for training and mentoring in the skills of sex negotiation among youths. Development of these skills is essential if the overall goal of our preventive programs is to work. I would like some suggestions and comments along this line.
-- Temitope Abayomi Fadiya, Dept. of Public Health and General Practice, University of Kuopio, Finland
8. Information on Mother to Child HIV Transmission Wanted
In working with PMTCT [Preventing Mother to Child Transmission] projects locally, we have been struck by how contradictory the HIV virus is. For example, a mother can deliver and feed for six months without passing on the virus, while, other times, the virus is passed on through bodily fluids. At our last project meeting, a health-worker was questioning the mother-to-child rate of transmission and several figures were quoted. I would be interested in finding out the source of the information cited below [from Dr. Collins] and the data [in the last sentence].
"Conceiving children at young ages poses risks for young women, but now there is the additional risk of HIV infection. Trying to prevent HIV transmission while conceiving obviously poses particular problems. Some microbicides are under development that would enable protection from HIV transmission without interfering with conception, but these products are under research and not expected to be on the market for quite some time. Sperm washing is technologically feasible, but has limitations. HIV voluntary counseling and testing can help partners become aware of their status, but can also provide a false sense of security, since staying HIV negative is not guaranteed. Young women often fear disclosing their status to their partners for fear of recriminations. The postpartum period is also one of considerable risk for young women, since partners may have sought other non-pregnant partners and acquired HIV during their partner's pregnancy, since some cultures expect women to cease sexual relations during pregnancy. For young women who are living with HIV childbearing is a right, but there are disturbing reports of forced abortion or sterilization. More must be done to ensure that women living with HIV are aware that with appropriate treatment, care and support, there is less than a two percent rate of transmission to their children, and that healthy labor and delivery, and postpartum care can be achieved."
-- Ismat Dewji Sheriff, Research, Communication and Documentation Officer, Health Sector, CARE International, Dar-es-Salaam, Tanzania
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