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HOME: STATE OF WORLD POPULATION 2004: Preventing HIV/AIDS
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Preventing HIV/AIDS

Impact and Response
Linking HIV Prevention and Reproductive Health Programmes
Condoms
Voluntary Counselling and Testing
Key Challenges

Key Challenges

EXPANDING ACCESS TO TREATMENT. In the past two years, pledges of expanded funding for treatment efforts and the increased availability of generic ARV drugs have changed the focus of HIV/AIDS programmes. WHO and its partners in the Joint United Nations Programme on HIV/AIDS (UNAIDS) have undertaken the enormous challenge of treating 3 million people with ARVs by 2005.(30) In Africa in 2003, only 100,000 people were receiving ARVs, just 2 per cent of an estimated 4.4 million needing treatment. In South and East Asia, 7 per cent of those who need treatment were covered by ARV services.

The United States has pledged to provide funds to 15 African and Caribbean countries to treat 2 million people over the next five years, as part of a new initiative intended to prevent 7 million new infections and to provide care and support for 10 million people living with HIV/AIDS.

WHO and UNAIDS recognize that treatment initiatives are a long-term commitment. “Lifelong provision of therapy must be guaranteed to everyone who has started antiretroviral therapy. Thus, 3 by 5 is just the beginning of ongoing antiretroviral therapy scale-up and strengthening of health systems.” (31)

Rapid expansion of treatment will require immediate strengthening of health systems—which can benefit sexual and reproductive health programmes as well—and increasing the number of health care providers (a goal of the 3 by 5 Initiative).

Wider availability of treatment will contribute to HIV prevention efforts, as those on ARVs are less likely to spread the virus, and their provision creates opportunities to communicate prevention messages and provide condoms. But it is imperative to increase support for prevention programmes as well, and to integrate prevention into treatment initiatives.

Another key need is to strengthen universal precautions (including safety procedures and proper disposal of gloves and sharp objects). Currently, even when service providers know the precautions to take against HIV transmission, they often lack protective gloves and ARVs (in case of needle sticks or other accidents). A recent study in Zambia found that clinics had no safety guidelines or post-exposure prophylaxis kits. When gloves were in short supply, clients were told to buy them. Addressing occupational risk may boost staff moral and improve client care.(32)

26 REDUCING HIV RATES: LESSONS FROM UGANDA

HIV prevalence in Uganda peaked at around 15 per cent in 1991 and then fell to 5 per cent by 2001. This decline has been attributed to prevention efforts on several fronts, in a combined public health approach to behaviour change described as “ABC”—promotion of abstinence, partner reduction (also called “be faithful”), and consistent and correct condom use, coupled with VCT services.

Abstinence. Data indicate that young Ugandans are increasingly starting sexual relations at a later age. Between 1989 and 2000, the age at onset of sexual relations increased from 15.9 to 16.6 years among young women and from 17.3 to 18.5 among young men. Educational efforts promoting abstinence and increased knowledge about the disease both played a part.

However, the proportion of people who were sexually active dropped substantially only among adolescent women aged 15-17 and not other groups. About half of all unmarried women were sexually experienced in 2000, the same proportion as in the late 1980s. Just over half of unmarried men were sexually experienced, a one third decline.

Be faithful (reduce the number of partners). Monogamy increased between 1989 and 1995, especially among sexually active unmarried women, but changed little thereafter. The proportion of women with multiple partners was cut in half, but from already low levels. In contrast, more than 25 per cent of active unmarried men had multiple partners. Married men with multiple partners increased in some age groups but decreased in others.

Condom use. Dramatic changes occurred in condom use, particularly among unmarried men and women, in the 1990s. Before 1989 use by either sex was negligible. By 1995 it increased to 8 per cent among women and 11 per cent among men. Later increases have been striking, particularly among the youngest (and most vulnerable) age groups.

Condom use by sexually active women aged 15-17 increased from 6 per cent to 25 per cent and by those 18-19 from 3 per cent to 12 per cent. For men aged 15-17, condom use rose from 16 per cent to 55 per cent and in those 18-19, from 20 per cent to 33 per cent. Recent data suggest continued increases in condom use. See Sources

PREVENTION PRIORITIES. A recent study of incidence of HIV in Cambodia, Honduras, Indonesia, Kenya and Russia suggests that the focus of prevention activities should be based on a careful analysis of where infections are occurring and not simply on broad categories of at-risk groups.(33) For example, in Cambodia, new infections acquired as a result of commercial sex have fallen, while the proportion of new infections acquired in marriage has increased from 11 per cent to 46 per cent. Yet the initial transmission of HIV is still heavily linked to sex work and most people becoming infected are those whose partners had high-risk behaviours in the past. Thus, prevention needs to focus on both sex work and prevention within marriage.

FAMILY PLANNING. It is also critical that an increased emphasis on HIV/AIDS prevention and treatment does not come at the expense of other sexual and reproductive health information and services. Data from the 2003 Demographic and Health Survey suggests this has occurred in Kenya, where the family planning programme made gains in the 1990s. Contraceptive prevalence rose steadily from 27 per cent in 1989 to 39 per cent in 1998, but has not increased since.

In the context of high HIV prevalence, it is critical to continue support for family planning, which is a key component of reducing mother-to-child transmission. Recent studies in Kenya and Zambia found that family planning providers, clients for antenatal care and family planning, and HIV-positive women all saw an increased need for family planning to avoid unintended pregnancies.(34)

At the same time, providers need to respect the rights of all people, including those infected, to make their own decisions about having children and to have access to accurate information and humane treatment in order to do so. In many cases, HIV-positive women are told that they should not have children. This discriminatory treatment leads many such women not to disclose their status to health workers.

27 POSITIVE WOMEN: VOICES AND CHOICES

The Positive Women: Voices and Choices advocacy-research project developed by the International Community of Women Living with HIV/AIDS is exploring the impact of HIV/AIDS on women’s sexual and reproductive lives, challenging the violation of their rights and advocating improvements in policies and services.

The effort in Zimbabwe, one of three project countries, was carried out from 1998 to 2001. HIV-positive women were generally unaware of their risk before they were tested. Gender norms and economic dependence on their husbands or partners restricted the women’s control over their sexual and reproductive lives. In the face of prejudices about HIV-positive women being sexually active and having children, they did not tell health workers about their status, making it difficult to address their needs. Using condoms in marriage was not considered appropriate.

The younger women wanted to have children, while older women with several children wanted to limit childbearing after their HIV diagnosis. Condom use and contraceptive use increased markedly among women who attended support groups. The project affirmed that HIV-positive women need better economic opportunities, pregnancy and delivery care integrated with family planning and STI/HIV-related services. See Sources

INTEGRATION CHALLENGES. A recent study found that “many health sector reforms have separated sexuality education, [reproductive health services] and STI/HIV/AIDS programmes from each other, making different ministries or segments of health ministries responsible for them, which also creates potential rivalry for budgetary control and funding.” (35)

An assessment in the Kaolack region of Senegal in 2001 found little evidence of integration of family planning or maternal and child health care with STI/HIV/AIDS services. “The obvious lack of availability of HIV/AIDS services in the districts’ health care and community structures attests once again that the lack of decentralization for these activities is hindering any possibility of discussing integration on these levels.” (36)

Reforms intended to strengthen health systems, including the creation of minimum services packages, should ensure that HIV/AIDS prevention and treatment services are included along with family planning.(37)

Health providers, who face mounting work loads and often staff reductions, must be enabled not only to provide contraceptives to clients, but also to identify related reproductive health problems. They need space to examine and counsel patients in private, and need supplies and equipment that are often missing from clinics in developing countries including gloves, speculums, spotlights and syringes for contraceptive injections.

Health providers also often need to be educated about HIV/AIDS to overcome bias, and taught to communicate prevention messages and to help individuals accessing services assess their risk of infection.

CHANGING BEHAVIOUR. Combating HIV/AIDS calls for addressing the underlying socio-economic, cultural and behavioural factors that contribute to its spread— including the lack of paid jobs, particularly for women, employment and migration policies that force many people to migrate for jobs, gender-based violence and trafficking of women.(38)

Behaviour change is gradual, multifaceted and needs to improve the health and reduce the risks of diverse married and unmarried young populations. As experience in Senegal and Uganda(39) shows, promoting responsible, voluntary and safe behaviour requires comprehensive and multisectoral efforts that foster partnerships involving central and local governments, the private sector, development partners, cultural leaders and a wide range of civil society organizations.

A project in Zimbabwe is seeking to offer a financial shield for girls to resist sexual liaisons with older men, often called “sugar daddies”, who provide support in exchange for sex.(40) The programme offers vocational and life skills training, loans and jobs, linked to education about reproductive health and condom negotiation. A study will assess the impact of the programme on HIV, STIs, the onset of sexual activity and pregnancy.

REACHING HIGH-RISK GROUPS. Attention to reaching high-risk groups with HIV/AIDS prevention information, or treatment and care, has increased substantially in recent years. Most of the countries polled in the UNFPA global survey reported undertaking programmes to reach groups such as sex workers, injecting drug users, long-distance truck drivers, men who have relations with men, street children, soldiers and migrant workers, as well as adolescents and youth.

NGOs are often key partners or initiators. In Kenya, for example, a project that offers education and counselling on responsible sexual behaviour and condom use and provides economic alternatives has reached 15,000 sex workers and their clients. In Bangladesh, a variety of organizations provide sexual health services to commercial sex workers.(41)

Countries in Latin America have been particularly active in educating members of the armed forces to stem HIV/AIDS infection and further transmission.(42)

COMBATING STIGMA AND BIAS. People living with HIV/AIDS still face stigma and legal and social discrimination in all regions. Ghana, South Africa and Uganda are among the countries that have launched programmes to combat this major obstacle to curbing the epidemic. The Bahamas is one of a number of countries that have outlawed discrimination against HIV-infected people in the workplace.

28 COMPREHENSIVE APPROACH TO HIV/AIDS PREVENTION IN SIERRA LEONE

Sierra Leone recently emerged from more than ten years of war that seriously disrupted all sectors of society. Almost two thirds of the population was uprooted, rape and sexual abuse were widespread, and thousands of girls and women who lost their families have turned to sex work to survive. People’s heightened vulnerability to HIV/AIDS has now become a priority concern.

UNFPA has responded through a coordinated initiative that targets different groups and involves a range of national actors and government offices. The overall aim is to reduce the risk of HIV/AIDS and other STIs, reduce women’s need for commercial sex work, alleviate poverty and enhance family life and community security.

Conducted in partnership with the Government, UNAIDS, the UN Department of Peacekeeping Operations, UNIFEM and other partners, UNFPA’s comprehensive approach includes the following:

  • Workshops and other initiatives to promote HIV/AIDS prevention among the Sierra Leone police force, the Sierra Leone military, international peacekeepers, and demobilized soldiers;
  • Promoting HIV/AIDS prevention among sex workers, through both health education and skills training to help them find other sources of income;
  • Strengthening the capacity of partner NGOs;
  • Promoting HIV/AIDS prevention among refugee and IDP populations;
  • Creation of safe blood supply.

In 2003, the UN Security Council recognized the multiparty, multi-pronged initiative as a potential breakthrough in responding to HIV/AIDS in post-war reconstruction, bringing everyone—including ex-combatants, military personnel and international peacekeepers—together to promote improved health and HIV prevention. UNFPA and partners are applying similar approaches in neighbouring Liberia and in the Democratic Republic of the Congo.

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