Greetings,
Thanks to all participants for a stimulating second week of the form. While we had fewer postings than the previous week, participants offered complex and important questions and points of view. Below is a summary of Week 2 by Dr. Collins.
Next, we will send out an introduction to Week 3, focusing on medical barriers and accessibility issues. The following day, we will send out the next digest, which will include postings received since Digest 8. You may continue to comment on themes raised in the first two weeks. We would particularly like to hear more on projects/interventions that have addressed issues regarding girls and young women.
The six contributions in this digest (from China, Guatemala, Mali, Nigeria, and the U.S.) highlight important issues related to the first two weeks of the forum. Adavi Abraham explains the role of gender inequality in making young girls and boys more vulnerable to the disease and, also, provides a number of potential responses to redressing this problem. Dr. Gustavo Castellanos discusses how cultural factors in Guatemala hinder women's rights and, thereby, compromise their sexual and reproductive health. Marjorie Craig renews attention to values, with an emphasis on ethical implications of putting others, and themselves, at risk.
Amadou Cisse describes the success of voluntary counseling and testing centers, including the role of peer educators. Urging that preventive programs be designed with youth in mind, Dr. Binta Keita discusses a successful approach called, "Competency of Development Personnel." Lastly, Ding Juhong of China notes the need in his country for more training and support in providing interventions targeted to parents and asks for input from participants.
Below is the summary of Week 2 by Dr. Collins, followed by the Digest 8 postings.
Best regards,
Ed Scholl, Forum Moderator
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Week two of the e-forum has been especially poignant, as it has delved into the realities for women and girls as they struggle to cope with the AIDS epidemic in their daily lives. The commentary of Adavi Abraham, alongside the many other thoughtful contributions throughout the lightening speed week, underscores the crux of the issues fuelling the epidemic among young people — poverty, gender inequality, and socio-cultural practices. Striving to achieve the mutually reinforcing Millennium Development Goals in their entirety, although daunting, is absolutely critical for making any significant and lasting headway against the epidemic. The thrust of the week's focus on how the epidemic affects women and adolescent girls drives home the need to maintain sight of the broader development issues, while affecting immediate change relentlessly in whatever capacity we are able.
Adavi Abraham also noted that strong political will to recognize and confront the epidemic is essential. Advocacy efforts at the global, regional and national level are ongoing and making headway, some of which are designed to directly address the epidemic as it impacts women and girls. The Global Coalition on Women and AIDS (GCWA), launched in 2004 is one such initiative. The GCWA is a movement of people, networks, and organizations supported by activists, leaders, government representatives, community workers, and celebrities to raise the visibility of issues related to women, girls, and AIDS and lead to concrete, measurable improvements. It is tackling head-on many of the issues raised during this e-forum. In particular, the GCWA advocates galvanizing country-level action to:
- prevent HIV in young women and girls
- end gender-based violence
- reduce the burden of care
- increase access to treatment
- promote female controlled methods such as the female condom and research on microbicides
- ensure girls have access to education
- reform unfair property and inheritance practices
Among the challenges that were highlighted in week two, the GCWA is specifically speaking out to curtail school fees and to eliminate forced child marriage, both key areas of concern in addressing HIV among young women and girls. For more information on the Global Coalition on Women and AIDS, the UN system and civil society partners encourage you to visit the website.
Many of you have brought up the need for effective education among young people, including sexuality and life skills. We all know that in general, women and girls are less knowledgeable about HIV than their male counterparts for a variety of socially constructed reasons. But even when knowledge of HIV and of the means to prevent it is high, the ability to act is often compromised for women and girls — and the results, as we have been pointing out all week, are devastating. The recent joint publication of UNAIDS/UNIFEM/UNFPA/GCWA report on Women and HIV/AIDS: Confronting the Crisis examines how women are disproportionately affected by the epidemic and calls for their empowerment and an end to the discrimination, poverty, and gender-based violence that drives the epidemic. It contains a wealth of stories of triumph on women and girls that should partially respond to the many queries for successful examples of how to address HIV in women and girls.
The importance of ensuring that education related to HIV does not end with mere provision of information, but rather empowers young people to act responsibly cannot be overstated and has been a recurrent theme of this e-forum, as Marjorie Craig pointed out when she spoke of "empowered sexuality" and skills training. Hopefully the unfounded belief that sex education leads to promiscuity has finally been put to rest. A review of 50 sexual health education programs in different parts of the world found that young people were more likely to delay sexual activity when they had the correct information to make informed decisions (UNICEF 2002, Young People and HIV/AIDS: Opportunity in Crisis, New York, p. 26)
Last year, a global consultation (PDF, 230K) was convened in Talloires, France, from 25-28 May to use a review of the current knowledge base to determine priority interventions to achieve the global goals on HIV/AIDS and young people (10-24 years). Interventions were categorized using a "no go, steady, ready, and go" scheme. Education buttressed by life skills for young people was resoundingly in the "go" category of interventions. HIV voluntary counseling and testing was also found to be worth pursuing, although with less of an evidence base.
E-forum participants pointed out the importance of voluntary and confidential counseling and testing, especially when linked to sexual and reproductive health services. There is recent guidance by IPPF and UNFPA on Integrating HIV Voluntary Counselling and Testing Services into Reproductive Health Settings (PDF, 528K) that benefits from experiences in Cote D'Ivoire, India, and a number of other countries. Up-scaling HIV counseling and testing services in some countries will require addressing national policy frameworks as well, to review the age of consent laws to reach those most in need of services, including condoms. Amadou Cisse shared favorable experiences from Mali employing a peer approach to voluntary counseling and testing, and reinforced the important notion of including a "positive plan for behavior," an issue sometimes neglected in counseling sessions in the rush to dole out test results. The responsibility rests with all of us to adapt and develop the critical interventions in prevention, treatment, care, and support to effectively reach out to underserved populations — especially to the most vulnerable populations such as sex workers and injecting drug users. As we know, many vulnerable populations face multiple intersections of vulnerability and are often not reached by conventional health service delivery systems.
Gustavo Castellanos made a particularly powerful appeal to not lose sight of the fundamental goal of human rights. As we've acknowledged throughout the week, without the ability to exercise rights, women and girls will not be able to protect themselves from HIV or mitigate its consequences. The role of men and boys, often mentioned in passing, is absolutely essential, to reconstruct the vision of gender relations. And yes, statistics only tell part of the story.
And finally, Binta Keita touched on two absolutely fundamental elements in working with young people, recognizing that they are diverse and that they have the intrinsic right to fully participate in designing, implementing, and evaluating the interventions that will affect their lives. As activists, program managers, policy-makers, health providers, and community leaders, we are in a privileged position to support through words and actions the inherent rights of those for whom stigma and discrimination is all too familiar, including people living with HIV, sex workers, injecting drug users, men who have sex with men, young people, especially young women, and to welcome them into the struggle to quell the AIDS epidemic. This requires a new mentality, which will ultimately benefit everyone.
I would like to thank all of those who are contributing to this e-forum, as readers, commentators, moderators, and organizers. The last week concentrated on examining pregnancy in the era of AIDS in the context of women and girls. We certainly covered a lot of ground, but truly that is the nature of this topic. Sexual and reproductive health, including HIV/AIDS, are not concerns that exist apart from the development challenges that we face today — poverty, gender inequality, stigma and discrimination, conflict, and food security. Through the work of all of us, in whatever capacity we contribute, and by empowering those around us, there has to be a timely and significant improvement in the lives of those who are bearing the brunt of this epidemic. Maternal and infant mortality have to be reduced. HIV has to be prevented. Treatment, care and support have to be universally made available. Stigma and discrimination, gender-based violence and poverty have to be eliminated. To accept any less is beneath us all and would simply not be ethical.
Sincerely,
Lynn Collins
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Forum Digest 8
- Gender Inequality Needs Attention
- Sexual Rights Vital Part of Equation
- Skills Training for Girls Critical
- Peers Help VCT Project Succeed
- Youth Vital Partners in Designing Programs
- Parent-Child Interventions: Input Requested
1. Gender Inequality Needs Attention
Like a torn ship sinking on the high sea, HIV/AIDS is steering our world toward calamity while we watch helplessly — though we remain hopeful for a breakthrough soon. Young women, adolescent girls, children from unwanted pregnancies, and orphans are the most vulnerable groups. It is a known fact that youths are sexually active. Their behaviors (sexual escapades and adventures) are unprecedented. Thus, they are especially vulnerable to this epidemic and they are channels for its spread. This, in turn, affects the reproductive health hazards that they are susceptible to.
The 19 northern states (apart from Cross River and Akwa Ibom states) lead in the spread of HIV/AIDS. In Nigeria, so many problems are responsible for the rapid spread of this deadly epidemic. Poverty tops the list. Others are socio-cultural attitudes, religion, lack of political will to create awareness on the part of government, and so on.
Gender inequality is a great threat in Nigeria. This is due to the lack of empowerment and neglect of Nigerian youths by government, at all levels. Secondly, the educational system is faulty; it lacks practical and technical qualities of self reliance. Cultural norms, socio-cultural values, and religious ethics (especially, in the northern states that promote polygamy) contribute to gender inequality. As well, many parents in northern Nigeria — due to abject poverty and socio-cultural norms and traditional, religious ethics — give the hands of their daughters in marriage (at very tender and fragile ages) to older men, in exchange for money and property. Boys of 4 to 5 years old are thrown out to face the bitter world alone. These girls and boys often end up as carriers.
The probable solution to gender inequality is to provide practical and technically-oriented education. Government should address the issue of school fees, at least to secondary school level. Government and donor agencies should provide modern farming implements and seedlings at affordable prices. Community theatre could be used to create awareness for these vulnerable groups, like my group is doing presently. Drama is a very powerful form of therapy. Also, multi-purpose, co-operative thrift societies are needed.
Voluntary testing should be provided so that required services can be provided, and care, support, empowerment, and love fostered. Finally, one effective way to tackle sexual and reproductive health challenges in a time of AIDS is for every young woman or girl to adopt the philosophy that, "My body is not meant for sexual immorality."
-- Adavi Abraham, Action Support for Upset Group, Lokoja, Nigeria
2. Sexual Rights Vital Part of Equation
When we talk to the needs of sexually active young women, we, necessarily, have to talk about sexual rights: As it was clearly mentioned in the presentation, most women cannot exercise their sexual rights. In this sense, it is highly important to educate men in this regard because they are the ones who do or not favor women's sexual and reproductive decision-making.
In Guatemala, as in many countries where machismo still persists, many young and adult women are killed each year. The system is not able to provide justice, much less appropriate sexual and reproductive health services. In this sense, statistics might be misleading, in that our health indicators are better but are still far beyond what we need to achieve for the sake of women, men, and society.
-- Dr. Gustavo Castellanos, Centro de Desarrollo Humano de Guatemala
3. Skills Training for Girls Critical
Information from the forum is instructive, challenging, and hopeful. So much of the behaviors and attitudes that fuels the spread of HIV/AIDS everywhere, whether in Africa or the United States, is based on what we think we have a "right to" — even if that means a death warrant for another person (and, sometimes, two, in the case of a pregnancy).
So, one of the areas we might find helpful to explore is this belief that we have a "right" to put another person at risk for premature illness and death. In this context, what responsibilities do we have toward that person? Or is that person so utterly lacking in value that we have none and his/her primary role is to serve another person's needs? Is this a form of slavery?
The call for skill training for girls and women so that they can negotiate their own sexuality is hopeful. Empowered sexuality involves more than biology. It involves values, making choices that help a person to grow and develop the best they can under their circumstances. It involves respect, esteem, and relationships. Skills training can provide discussion, exploration, awareness, new behaviors and practice, and coaching in more healthy behaviors. It is hard work mentally and physically, but worth the effort.
My comments are based on my education and practice in public health and psychiatric nursing and experience as a university counselor in California and volunteer health educator experience in Mombasa/Kanamai, Kenya.
Let us not forget, health disasters of this magnitude are not new. We will work through it. We all have an important responsibility to do what we can to stop the chain of premature deaths and prevent the increase in orphans, who are innocent victims of a situation they have no control over.
-- Marjorie A Craig, RN, PHN, President, Help Kenyan Children Survive and Thrive, Inc., U.S.
4. Peers Help VCT Project Succeed
Sincere greetings to the participants for their quality contributions to the forum, in particular friends in Nigeria, Kenya, Finland, and Thailand... I would like to point out the relationship between the evolution of research and the development of messages. Even a few years ago, the news did not report on mother-to-child transmission of HIV through breast milk because statistics on this were minimal. Messages were addressed to African populations, mostly non-literate ones. Today, the opposite news seems to have created a "surcharge" in the same communities. That is why I think that the development and the diffusion of messages must take account, on the one hand, the evolution of HIV, and, on the other hand, advances in research.
Dr. Collins, whose efforts I admire, wishes to have more information on peer education. I would like to add that it consists of reinforcing capacities of young people (15-24 years) in the field of reproductive health, so that they can communicate with and educate their counterparts. The approach is so effective that one could credit it as the major factor for the good results registered in my country, Mali, where the prevalence rate of HIV infection has declined (EDS'S 3, 2003).
The latest approach consists of expanding the number of voluntary counseling and testing centers, where peer educators work with their counterparts. That is one of best the ways to slow down the propagation of the virus because, after testing, clients are encouraged to develop a positive plan for behavior. To that, it is necessary to add the testing of pregnant women (with their consent) during antenatal consultations.
The executive director of UNFPA is right to call into question the insufficiency of the ABC approach. From my experience working on the ground in communities, I think that the policy of social marketing of condoms creates a climate of hesitation. In fact we find a multitude of condoms, of varying quality, in the markets. This is not likely to reassure consumers, who note the difference in quality. That is why it would be preferable to universalize the product; the ones used in the USA would be the same ones used in France and Africa. That will resolve suspicions created by the varying quality of different condoms.
-- Amadou Cisse, Programme Sante USAID Keneya Ciwara, Bamako, Mali
5. Youth Vital Partners in Designing Programs
In Mali, the vulnerability of young people to HIV/AIDS is associated with cultural factors, education, poor access to health services, and poverty, which is worsened by the phenomenon of migration. This threat is even more burdensome in the context of a 29% unmet need for family planning. It results in the following consequences: unwanted pregnancies, induced abortions, and infanticides. Indeed, a low rate of contraceptive use increases the risks of early pregnancies, births that are too closely spaced, births at older ages, and induced abortions. High fertility (6.7 total fertility rate) weakens the health of women, increases maternal mortality (582 per 100,000 live births) and infant mortality (113 per 1,000 live births). It also handicaps women's participation in development activities. Nevertheless, the right to use contraception is clearly recognized by law #02-044 of June 24, 2002, relating to reproductive health adopted by the National Assembly of Mali.
A study, undertaken by ISBS in 2003, reported the average age of first sexual relations was 15.1 years and 15.3 years, respectively, for family helpers and traveling saleswomen; 14.6 years for family helpers in Sikasso, and 16.5, for sex workers.
Up to now, our response to problems related to the sexual and reproductive health of young people has been insufficient. Programs often do not take into account that young people are divided between various sectors, including schools and other formal, structured settings and out-of-school youth in informal settings. In practice services, including in the field of peer-education, remain largely conceived for and centered towards young people in the formal sector.
Programs and services do take into account how diverse young people are. To fill the gap in programs for youth, the following strategies and interventions will be necessary: (1) promotion of behavior change related to family planning, (2) improvement of the quality of service, (3) promotion of working in many sectors and in partnerships, and (4) the implementation of programs specifically for young people.
Experience has shown that to be really effective, programs combating HIV/AIDS/STIs and unwanted pregnancies among young people must be developed together with young people (from both formal and informal settings) acting both as designers and recipients. These programs should use an approach called "Competency of Development Personnel" (CDP). Using participatory methods and video, the CDP approach seeks to promote and develop, in a concrete way, the following in young people: self respect, self-confidence, leadership, interpersonal and public communication skills, negotiation, the capacity to solve problems, and the faculty of positive response.
By training young people in this approach and asking them to sensitize and advise their peers, we will be able to have a great impact on the prevention of HIV/AIDS/STIs and unwanted pregnancies.
Finally, teachers can educate adolescents before they are confronted with the need to make decisions about sexuality. They can help them to acquire knowledge, values, competencies, and the behaviors necessary to avoid HIV/STIs.
-- Dr. Binta Keita, Chief of the RH Division, Direction Nationale de la Sante, Bamako, Mali
6. Parent-Child Interventions: Input Requested
I think it is a good idea for intervention to focus on parents with their children. But, in China we don't have too much experience with this. Are there any projects about interventions with parents?
-- Ding Juhong, China
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