Later years HIV prevention and care Comprehensive response

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1 The face of HIV in Asia Successes and Challenges Peter Deutschmann Australian International Health Institute University of Melbourne : 2005 Early years Primary Health Care Principles and approach A teacher and his student: Jamkhed CRHP Equity not equality Participation of the community Comprehensive responses Inherent capacity and resilience in community Sustainable results Later years HIV prevention and care Comprehensive response A teacher and his student: SHALOM Manipur PHC principles and approach Upstream: primary prevention Midstream: secondary prevention Downstream: care, treatment and support Integral Mission and HIV/AIDS 1

2 Today: Project ORCHID HIV prevention A public health approach A population based approach: Concerned for the 95% that an abstinence based approach (alone) neglects Concerned to control the epidemic among the most vulnerable and marginalised of populations Concerned to contain the epidemic to prevent a generalised epidemic HIV prevention A public health approach: harm reduction HIV/AIDS epidemic demands an emergency response = mid stream response Harm reduction approach as a mid stream response Harm reduction an imperfect but necessary response Evidence supports this approach provided it is of sufficient scale More successful (and acceptable) if part of a comprehensive response Successes What works to support behaviour change Success based on evidence Integrated approach: integrating care and prevention efforts Comprehensive approach A Success: Thailand Successes in Thailand and Australia Effective and sustained behaviour change on a national scale requires focussed prevention programs with multiple components Program developed and implemented with input from specific groups with increased vulnerability to infection Prevention strategies that address the specific needs of vulnerable groups Political and community leadership critical for success Partnerships are essential: government-ngo and affected communities and individuals Integral Mission and HIV/AIDS 2

3 Challenges Challenges in perspective Enabling environment that supports behaviour change Hidden vulnerable populations-the bridge to the wider community in low prevalence settings Expanding the scope of responses Increasing the scale of responses Challenges in Asia Challenges to development gains A Challenge: Nepal Vulnerability People who inject drugs Female sex workers and their clients Expectant mothers and their infants Integral Mission and HIV/AIDS 3

4 Vulnerability: inadequate coverage What works National level Community level Program/project level Group level: vulnerability What doesn t work (alone) What doesn t work (alone) Abstinence alone Spiritualise the problem and the solution Prevention (without care and treatment) Public health approach alone Community Level Civil society organisations Engaging the community through existing organisations including faith based organisations Building partnership and trust with both community leaders and the most vulnerable Including people with HIV/AIDS in all stages of the process of response Creating an accepting environment in which HIV/AIDS is acknowledged as everyone s concern In all successful national responses to HIV, civil society has helped lead national efforts on populations, such as sex workers, injecting drug users, men who have sex with men, and migrant workers. They are also essential in reaching young prevention and care. Nongovernmental organizations are especially vital to reach marginalized and sometimes hidden at-risk people. UNAIDS report July 2005 Integral Mission and HIV/AIDS 4

5 Program Level Group Level Provision of culturally appropriate information Inclusion of activities that encourage people to appraise risk Provision of training in skills for communication and negotiation Provision of enhanced access to resources, health services Participation of target groups at all stages of planning, implementation and evaluation Women and men Young People Men who have sex with men People who inject drugs Female sex workers and their clients Expectant mothers and their infants Evidence Based Observation Program monitoring and evaluation Commissioned behavioural studies Prevalence studies of STI and HIV Learning from the experience of others What works Women and men Young people Men who have sex with men People who inject drugs Female sex workers and their clients Expectant mothers and their infants People who inject drugs Risk of HIV transmission related to sharing of injection equipment and unsafe sex practices Undertake HIV prevention services while HIV sero-prevalence is still low Adopt a comprehensive approach including primary prevention, drug treatment and rehabilitation, substitution therapy, and harm reduction Adopt a harm reduction approach that reduces HIV transmission through provision of a minimum package of HIV prevention education, sterile needles, bleach, condoms and PHC People who inject drugs Provide drop-in centres, mobile services and outreach work involving current and ex-drug users in outreach services and peer education Improve sexual health and sexual practices Provide access to Voluntary Counselling and Testing services Establish high levels of knowledge about HIV transmission and infection among drug users Acknowledge the link between IDU and CSW Integral Mission and HIV/AIDS 5

6 Female Sex workers and their clients Acknowledge the wider concerns and priorities of sex workers, including social, legal and economic issues and concern for families and children Consider culture, gender, status and power relationships between men and women in planned responses Acknowledge the prejudice and stigmatisation that sex workers face Provide improved and more accessible health services, especially for the diagnosis and treatment of STI Female Sex workers and their clients Seek the cooperation and support of gatekeepers in the sex industry Legitimise the role of sex workers as educators Work with men as well as with women through a focus on clients, boyfriends and husbands Address where possible alternatives to sex work through vocational training, employment generation and economic independence Expectant Mothers and their newborns Expectant Mothers and their newborns Primary prevention of HIV among prospective parents Increased access of women and their partners to HIV prevention services, reproductive health and family planning services and antenatal clinics Prevention of unwanted pregnancies among HIV infected women Provision of HIV Voluntary Counselling and Testing services Prevention of HIV transmission from mother to child Measures at delivery to reduce transmission Provision of antiretroviral medication to reduce transmission Exclusive breast feeding Integral Mission and HIV/AIDS 6

7 Challenges Enabling environment Enabling environment that supports behaviour change Hidden populations-the bridge Expanding the scope of responses Increasing the scale of responses Supportive of behaviour change: availability and access to the means of prevention Culturally sensitive, appropriate and targeted information Legal support for safe behaviours Peer support for individual change (support groups) Training in negotiation and decision making skills Voluntary Counselling and Testing services: an entry point for behaviour change (motivation linked to support) Hidden populations Hidden populations In low prevalence settings a concentrated epidemic is associated with high risk contexts: People who inject drugs Men who have sex with men Female sex workers and their clients Legal issues Poverty link to vulnerability Stigma, human rights and dignity Access through peers Prevention linked to care and services Voluntary Testing and Counselling services Expanding the scope Increasing the scale Comprehensive program development NGO networks and alliances : model NGO projects Capacity development and training Donor support Community mobilisation and networks National government responsibility NGO networks and alliances: model NGO projects in Nepal (CHR) and India (SHALOM Project) Adequate resources: government and donor Capacity development and training in program management and coordination as well as technical areas Impact evaluation Integral Mission and HIV/AIDS 7

8 Remaining Challenges Remaining Challenges: discrimination Hostile and disabling environment associated with a poor legal framework or poor government Legal and legislative barriers to planned responses associated with illegal activities Conservatism: societal and faith based Availability and affordability of antiretroviral medicines Donor ambivalence and fatigue Major underlying constraints associated with poverty and gender issues Perhaps the greatest obstacle to a successful response is that stigma and discrimination against people living with HIV remain the norm in many Asian countries. For instance, high levels of HIV-related stigma and discrimination deter many individuals from accessing the services they need. Surveys in India, and other Asian countries indicate that more than one in four people with have experienced HIV discrimination in health-care settings. More than one third have had confidentiality about their HIV status breached, and 15% have been refused medical treatment once health care staff learned they were HIV-positive. UNAIDS Report July 2005 Small Group discussion Hidden Populations: identify those in your context for whom responses are needed, the behaviour change strategies required and the obstacles to be overcome. Involving the vulnerable: identify strategies to involve vulnerable groups in planning, implementation and evaluation of your interventions. Consider the role of peer workers. Expanding the response: consider ways in which your church or organisation can contribute to an increase in the scale and scope of the response. Consider training and capacity development requirements for your organisation. Integral Mission and HIV/AIDS 8