Kerry Zaleski
SRHR and HIV Advisor
Global Centre of Learning on HIV and AIDS
Oxfam GB
Table of contents
Summary.........................................................................................................................................5
Acknowledgements ......................................................................................................................6
Part 1. The project: 'Leveraging Opportunities to Integrate Reproductive Health
Services into HIV and AIDS Programming' ............................................................................8
Context ........................................................................................................................................8
Project change strategy ...........................................................................................................10
Lessons learned ........................................................................................................................11
Project design .........................................................................................................................11
District steering committees (DSCs) .....................................................................................12
STAR: 'Societies Tackling AIDS through Rights' ................................................................12
Gender mainstreaming...........................................................................................................16
Working with traditional healers ...........................................................................................17
Integration of services ............................................................................................................21
Traditional attitudes and beliefs among leaders .....................................................................22
Advocacy and policy...............................................................................................................23
Overall project lessons learned...............................................................................................27
Part 2. The deeper-rooted issues associated with sexual and reproductive ill-health and
HIV and AIDS .............................................................................................................................30
Gender inequality and the feminisation of HIV and AIDS................................................30
Unequal power relations.........................................................................................................31
The ABCs of marriage .............................................................................................................32
HIV and young people............................................................................................................33
HIV and older people..............................................................................................................34
Legal frameworks ....................................................................................................................37
The Family Law of Mozambique...........................................................................................37
Violence against women .........................................................................................................39
Sexual and reproductive rights..............................................................................................41
Multiple and concurrent partnerships ..................................................................................42
Stigma and discrimination......................................................................................................42
Part 3. Integrating SRH and HIV and AIDS services and programming .........................44
'One-stop-shop' model ............................................................................................................45
First points of contact ..............................................................................................................45
PMTCT Plus model..................................................................................................................46
Overall recommendations for integrated SRH and HIV and AIDS programmes ..........48
Summary checklist...................................................................................................................50
Bibliography ................................................................................................................................51
Appendices...................................................................................Error! Bookmark not defined.
I. Manica change strategy..................................................................................................56
II. Framework for priority linkages...................................................................................58
III. Key elements of STAR................................................................................................59
Summary
Oxfam GB, in partnership with the Ministry of Health in Mozambique and with
support from the William and Flora Hewlett Foundation, launched a two-year
project in August 2007 that aimed to increase access to and the quality of sexual
and reproductive health (SRH) and HIV and AIDS services, and to reduce the
vulnerabilities associated with sexual and reproductive ill-health and HIV and
AIDS, in Machaze and Mossurize Districts of Manica Province, Mozambique.
Project activities worked towards supporting and building the capacity of local
health workers and traditional healers, tightening the referral chain between
various HIV and SRH services, and strengthening overall systems to be able to
respond to the deeper-rooted issues identified by the community associated with
SRH problems and HIV and AIDS. The project used a rights-based approach
(based on human rights principles of equality, non-discrimination,
accountability, and participation) to empower community members to make
informed choices about their sexual and reproductive health and to demand their
right to essential services from their government. 1
One of the main objectives was to draw out lessons learned for Oxfams global
programming, with a particular focus on access to essential services. Throughout
the projects life cycle, a number of lessons conceptual, programmatic, and
advocacy-linked have been drawn out during implementation and monitoring
and evaluation. These lessons have been documented in order to learn, explore,
and share opportunities for improvement in future integrated sexual and
reproductive health and rights (SRHR) and HIV and AIDS programmes. They
are also intended to point out particular problems or challenges the project faced,
in order to avoid similar constraints in future projects.
Data were gathered from project reports and documents such as surveys, focus
group discussions, key information interviews, semi-structured interviews with
staff and partners, monitoring, evaluation and learning reports, training and
workshop reports, minutes of meetings, clinical records, observations made
during field visits, and secondary data.
Acknowledgements
This project was made possible by the generous funding support of the William
and Flora Hewlett Foundation, Menlo Park, California. Oxfam would like to
especially thank Nicole Gray and Sara Seims of the Population Programme at the
Hewlett Foundation for their steadfast encouragement and support of this pilot
project, and this reflective publication.
The entire IHARM (Integrated HIV and AIDS Response in Manica Province)
programme team.
Finally, thanks to the Global Centre of Learning on HIV and AIDS for its ongoing
technical support and advice in steering the project in the right direction and for
providing funding for learning and innovation.
Context
Mozambiques population is estimated at 20.5 million, with a life expectancy at
birth of 37 years. 3 It is one of the 20 poorest countries in the world and ranks 175
out of 179 countries on the 2008 Human Development Index, which factors in life
expectancy, adult literacy, school enrolments, and GDP per capita. There is a
population growth rate of 1.79 per cent. Sixty-three per cent of the population
live in rural areas. 4 In 2007, the maternal death rate was 163 per 100,000 live
births and the infant mortality rate was 115 per 1,000 births. The fertility rate was
5.2 children born per woman. 5
Approximately half of the adult population lives in poverty and close to 58 per
cent of children live below the poverty line of less than $2 per day. Sixty-six per
cent of men and only 33 per cent of women are literate. 6
Mozambique has a high HIV prevalence, with 1.5 million people living with the
virus, including 100,000 children. Adult HIV prevalence is estimated at 12.5 per
cent of the population. 7 Sixty per cent of those infected are women. Infection is
significantly higher among young women and adolescent girls in the age group
1524 years. UNAIDS and WHO estimates for 2007 show HIV prevalence among
young women at 8.7 per cent, compared with 2.9 per cent for young men,
demonstrating how HIV is disproportionately affecting women and girls. The
multiple effects that make women and girls in Mozambique vulnerable include
low literacy; low use of contraceptives, particularly condoms; gender and power
inequalities, including sexual and domestic violence; early marriages in
traditional communities; poverty and lack of economic opportunities (which
contribute to girls and young women engaging in sexual transactions or abusive
relationships); multiple and concurrent partnerships; and cultural taboos against
discussing sex among young people, despite the fact that the median age for first
experience of sexual intercourse is 16 years.
In summary, the phases and steps of the change process were as follows:
A) Start-up phase: making sense of the issues and building a platform for
change between key players
1- Building a platform, or holding space, around the intent of the project.
2- Scanning the field of change.
3- Joint reflection: revisit the information and kick off the project.
This document highlights lessons from various phases of the change strategy, as
well as specific methodologies and approaches used throughout the process.
Project design
Leveraging Opportunities to Integrate Reproductive Health into HIV and AIDS
Programming was designed to work with the provincial and district levels of the
Ministry of Health (MOH) in Mozambique as the key implementing partner. The
strategy focused on influencing change at individual, family, community, and
systems levels through: 1) training of health workers in areas of sexual and
reproductive health and HIV and AIDS service provision, 2) community
empowerment and 3) multi-sectoral collaboration and action
Lessons learned
1. Investing more in strengthening civil society to demand rights from
government is likely to be more cost-effective and sustainable in the long run
than providing direct grants to government.
2. Frequent turnover of MOH staff over the course of the programme
including four district directors of health, the provincial director, and five
district doctors/medical directors, who were key players during the design
of the project made continuity challenging. This turnover was partly due to
government policy of rotating staff every year. Future projects should
consider such challenges and how they will affect programming during
selection and initial discussions with partners.
The DSCs (one in each district) were made up of representatives from the MOH,
Ministry of Women and Social Welfare, police officers, womens organisations,
traditional healers, religious leaders, people living with HIV (PLHIV), the media,
the private sector (owners of guesthouses where transactional sex is commonly
practised), NGOs, district doctors, and peer workers (representing communities).
The DSCs discussed key issues presented throughout the lifespan of the project,
including domestic violence, sexual exploitation and abuse of minors, and
harmful traditional practices such as widow inheritance 9 , and developed action
plans to try and tackle the issues through a combined effort.
Lessons learned
Participatory methodologies
STAR: Societies Tackling AIDS through Rights
In an effort to strengthen civil society and empower communities to hold their
governments accountable with regards to essential services, the project team
originally sought to use Stepping Stones 10 as a community empowerment
approach to behaviour change.
The aims of STAR are commensurate with the objectives of this project,
including:
Increase access to information and knowledge on HIV and SRHR;
After learning about STAR through research and a number of discussions with
partners who have had experience with it, the project team decided to test it out.
The idea behind the decision was that bringing together literacy and HIV and
AIDS prevention strategies would not only empower communities to make
healthier, informed choices about their sexual and reproductive health, but also
empower them to demand access to essential services from their government.
After the initial training, there were a number of follow-up trainings to support
the ongoing roll-out of STAR in various skill and subject areas, including
participatory methods, gender analysis, advocacy, stigma and discrimination,
and documentation. Four of the 20 peer workers (one male and one female per
district) participated in an exposure visit to observe a local partner of ActionAid
in Malawi, and also represented communities at DSC meetings.
Peer workers expressed the feeling that change had taken place in their own
individual behaviours and relationships with spouses, as well as among
members of STAR circles with whom they shared information. For example,
some of the female peer workers said that, after the initial STAR workshop, they
themselves were able to take the information home and discuss with their
husbands how HIV is spread. Some of them even reported showing their
husbands how to use a condom, which was a big step up from the silence that
had previously existed around any topic that had to do with sex. Peer workers
14 Integrated HIV and AIDS Response in Manica Province, Mozambique
Oxfam GB, August 2009
said that their circles were increasing communities understanding of unequal
power relations and how this affected the overall health status of communities.
Successes
Exposure visit: Selected peer workers and partners visited SASO (Salima AIDS
Support Organisation), a local partner of ActionAid in Malawi, to observe the
facilitation of STAR circles in rural communities. This gave them an
opportunity to ask questions and discuss challenges as well as receive tips on
running the sessions effectively. The exposure boosted their confidence in
facilitating their own circle sessions.
STAR tool kit: A user-friendly tool kit was produced for peer workers to guide
them in conducting circle group sessions. The tool kit contains worksheets
including an introduction to STAR, energisers, exercises, fact sheets, and key
points.
During STAR circle groups, both men and women revealed that by learning
to use a condom correctly and understanding its purpose in preventing HIV
and STIs, the uptake of condoms was increasing as a means to prevent HIV,
as well as enabling child spacing among married couples. This was an
achievement, as the baseline survey results from Machaze and Mossurize
Districts showed that only 13 per cent of respondents (aged 1549) had used
a condom during the previous year.
Lessons learned
Lessons learned
HIV and AIDS is perhaps one of the biomedical conditions that, because of the
perception of it as a terminal illness and its association with death, often evokes
mental as well as spiritual anguish among those affected by it. It is therefore not
uncommon for HIV and AIDS patients to turn to traditional healers in the same
way that people with mental illnesses do or those with any other health
problem for which modern medicine has yet to find a cure.
There are a number of herbal remedies that are effective in strengthening the
immune system, increasing appetite, and treating opportunistic infections
associated with HIV, including thrush, skin diseases, sexually transmitted
infections (STIs), and chronic diarrhoea. 16 It is possible to link traditional healers
in a comprehensive HIV care and treatment approach if enough research is done
to identify and educate traditional healers and medical providers about, for
example, interactions between specific traditional treatments and ART.
Theory-U
As part of the adaptation of the project and the space given within it to respond
to changing needs in order to make it meaningful to the communities, key
Lessons learned
Before this programme one of our health facilities in an area where traditional
birth attendants are the norm used to attend to an average of about 12 births per
month. Now that has gone up since this project started to an average of 30 per
month, most of whom are referred by the traditional birth attendants in this
programme.
District Director of Health, Mossurize District Hospital 17
2. Although the project helped to bring traditional healers into the networks,
they still reported challenges in engaging meaningfully in a structured way
that would make the partnership a two-way rather than a one-way
relationship.
We have referred many patients to the health centres, but we never get the
health workers refer any to us, why? We do not even get feedback.
Traditional healer in Chipopopo, Machaze District 18
4. Many traditional healers said that, as a result of the project, they had started
modifying traditional practices, such as avoiding the use of cutting
instruments on more than one patient, and promoting safer sex, including
condoms, as a regular part of their service.
Integration of services
A plan of action on SRHR was put together in the Maputo Plan of Action report
by the African Union Commission (2006), where it was agreed that all African
countries should have SRH and HIV integration in all key national health policy
documents and plans, including health management of GBV in the curriculum of
health workers. However, there are a number of challenges around the definition
and operationalisation of integration that must be ironed out in order for the
concept to work in practice, particularly in resource-poor environments.
Lessons learned
The project operated in a policy vacuum in the sense that local health workers
did not seem to clearly understand how to put integration of services into
practice. They were expected to incorporate new practices into existing
frameworks, with no real understanding of how that would work. There is
currently no existing national framework or document with guidelines for
integrating SHR into HIV programming in Mozambique, 20 and this poses
challenges for health workers on the ground.
Sexual and Reproductive Health and HIV: Linkages Evidence Review and
Recommendations, WHO/UNFPA/IPPF/UNAIDS/USCF (2009). A
literature review of promising practice for linking and integrating SRH and
HIV services, with key recommendations for policy-makers, programme
managers, and researchers. Available at:
http://www.who.int/reproductivehealth/topics/linkages/en/index.html
1. Activities such as the values clarification exercise are useful in assessing the
attitudes and beliefs that exist not only in communities but among those who
are expected to lead change throughout the project (in this case, the DSCs).
3. Innovative tools can help challenge the social norms and purpose of
tradition, but must be adapted to specific local contexts. It is also important
to remember that change will not happen overnight, or as a result of just one
or two workshops or activities.
Both of these events were successful in raising awareness about HIV and AIDS,
as well as generating community dialogue about underlying issues associated
with them. Activities included collaboration with youth and theatre groups in
promoting positive messages about HIV prevention and stigma and
discrimination; STAR circles and participatory methods used to encourage
communities to analyse power relations, identify the underlying causes of
community problems, and come up with their own solutions; public speakers on
issues related to gender-based violence and HIV and AIDS; and dissemination of
anti-violence and safer sex messages through radio, posters, t-shirts, marches,
and music.
I was weaned off from my mother at a very young age and sent to live with
another family. I grew up thinking that I was being cared for by my mother and
father. When I was 13, the family built a hut and told me to go and sleep in it. I
remember the man, who I thought to be my father, coming in and forcing himself
on me sexually. It was so painful and I was devastated. I had heard stories of
fathers raping their daughters, and thought I was a victim of incest. The next
day my real parents came to see me. They had not been allowed to see me until I
lost my virginity. I was the last wife of this man, and the senior wives were
unkind to me. I am now miserable living in this household.
Cecilia from Mossurize District
Cecilia shared her story in a session on early and forced marriage during the 16
Days of Activism. She had been sold off as a child to become a wife of an older
man at a very young age and raped when she reached puberty. She had been
denied an education and wanted more than anything to build her skills so that
she could make her own money and not have to remain economically dependent
on her abusive husband, with whom she now had three children, and she asked
how the programme could help her.
This is just one example of gender inequality and rights violations that was
drawn out through the use of participatory methods and awareness-raising
forums. It buttresses the argument for overall systems change through legal
protection and enforcing legislation related to SRHR and HIV, as well as change
Lessons learned
Communication
It is important that prevention approaches go beyond ABC. Many of the issues
drawn out of surveys and focus group discussions related to gender inequality and
the inability of women and girls to control their own sexual and reproductive health.
For example, abstaining from sex was not an option for girls who had been married
off to older men; women in polygamous marriages might be faithful to their husbands,
while the behaviours of their husbands put them at risk; women who are expected to
have children require a new technology that will prevent the transmission of HIV but
not prevent pregnancy; and violence against women and girls was a common
response to them even suggesting that their partners use a condom.
Community engagement
Working with communities requires a strong relationship built on trust. Agreement to
carry out surveys and regular activities (e.g. the implementation of STAR
methodology) from community leaders is an essential first step in getting their buy-in
from the beginning. This will also help in the development of stronger leadership,
ownership, and longer-term sustainability of the project.
Exit strategy
A clear exit strategy was lacking but one is necessary for a successful phase-out of the
project. Continuity and sustainability of the project requires a well thought out and
articulated strategy that enforces the commitment and responsibilities of all stakeholders
after the departure of Oxfam.
This type of dialogue points to the difficult position that women find themselves
in trying to support themselves and their families, abide by culturally defined
values, and protect themselves and their children from HIV and AIDS, all at the
same time. It also demonstrates the challenges involved in breaking down these
deeply rooted attitudes that are so entrenched in many societies, and why it
takes time, innovation, and persistence to overcome these attitudes and beliefs as
a first step towards behaviour change.
Women in many parts of the world have limited power to negotiate condom use
with their husbands. This has to do with expectations of having many children,
fear of domestic violence, and economic dependency on the man to provide basic
needs. In fact, in some societies married women in monogamous, heterosexual
relationships are at the highest risk of HIV infection. 24
Married women and women in long-term relationships have typically not been
listed as a risk group for contracting HIV, and therefore have not benefited as
much from public education and sensitisation campaigns such as the ABC
approach.
Can a girl who has been forced to marry refuse sex with her husband who
has paid lobolo (bride price)?
What happens if a married woman insists that her husband wear a condom?
The Manica project was able to reach young people with messages about safer
sex, stigma and discrimination, and preventing unwanted pregnancy, as well as
rights issues, including sexual exploitation and abuse and cross-generational
relationships a frequent situation where sex in exchange for commodities is
practised. 26 This was done through theatre and drama and through quiz and
poster contests organised during World AIDS Day.
However, SRH and HIV services at clinic level still need to be designed in a way
that is user-friendly for young people. In focus group discussions, for example,
young people talked about not wanting to go to the clinic for condoms, STI
treatment, or other SRH issues, out of fear that their confidentiality would not be
maintained or that they would be denied services. Furthermore, focus group
discussions with young people showed that sexual exploitation and abuse by
teachers is common in schools. Girls talked about a common practice of teachers
requesting sex in exchange for good grades. This highlights the need for more
sexual education both in and out of schools.
Normally, safer sex messages target unmarried and younger populations. Post-
menopausal women and married couples, as discussed above, are often
erroneously considered to be at low risk of HIV infection. In fact, doctors at the
Radcliffe Hospitals Trust in Oxford, UK reported that older people are actually
more susceptible to STIs, including HIV. 28
The African Protocol for Womens Rights was ratified in 2005. However, a recent
study in Mozambique showed that 54 per cent of women interviewed had
experienced physical or sexual violence at some point in their lives. 29 There has
been progress in some areas but, in general, application of these international
commitments has been weak and often does not reach local community levels. 30
Discriminatory legal frameworks often fail to uphold equal rights and protection.
Inequitable divorce and property laws make it difficult for a woman to leave an
abusive relationship. However, even when protection laws are written, they are
often not enforced due to insufficient resources, discriminatory practices by
police and courts, and weak institutional support. 31 For example, in
Mozambique, girls access to school is constitutionally guaranteed. However,
sexual exploitation and abuse in the schools is often not condemned, while
teenage pregnancy is. This leads to girls getting pregnant (often by teachers) and
dropping out of school early, reinforcing gender inequality and discrimination
and increasing HIV risk and vulnerability.
Despite this important step in the direction of gender equality, most people still
do not know anything about the law or how it can protect their rights. As
pointed out through focus group discussions, household surveys, STAR circles,
and workshops in communities of Machaze and Mossurize Districts, customary
laws tend to prevail over constitutional laws when it comes to the rights of
women and girls in Mozambique. Members of the girls or womans family
traditionally decide whether or not a girl is to wed. Marriage brings money and
gifts to the brides family in the form of lobolo (bride price), so a family desperate
for money may often marry off a daughter despite her young age.
Knowledge about the protection of women under the Family Law is low,
suggesting that more efforts are needed to disseminate information and
aggressively promote such laws. Surprisingly, this lack of awareness is found not
only in rural communities, but also among change agents involved in
programmes aimed at tackling inequality and HIV.
VAW is a global human rights and public health problem. It increases HIV
vulnerability among females. There is evidence that women who have been
forced to have sex are at greater risk of HIV infection due to injuries to the
vaginal or anal tissue, 35 which creates viable entry points for HIV into the
bloodstream. Worldwide, up to one in three women and girls have experienced
domestic violence, sexual assault, or sexual abuse. Particularly in areas where
HIV-related stigma is high, fear of violence prevents women from being tested
for HIV, disclosing HIV status, accessing prevention services for infants, or
receiving counselling and treatment, even in cases where they know they have
been infected. When women and girls lack economic means, there is a higher
incidence of non-consensual sex, fear of abandonment or eviction from homes or
communities, and an inability to negotiate safer sex.
The cost implications of HIV prevention are much lower than the treatment costs
for HIV and AIDS. 36 However, interventions that focus solely on HIV prevention
are not effective in cases where women suffer from abuse and violence and are
unable to negotiate condom use. There is a recognised need to combine efforts
focusing on rights, empowerment, and education through a gender perspective
on eliminating VAW. The Manica project addressed the intersections of VAW
and HIV in a number of ways, including active participation in the 16 Days of
Activism, STAR circles addressing VAW, and lobbying the government for
stronger monitoring and enforcement of SRH- and HIV-related policies and
laws.
Empower civil society to demand that the state provides equitable resources,
services, and opportunities for women.
Provide continuing education to public servants on laws around VAW and monitor
and evaluate their performance accordingly.
Establish whistle-blowing systems and enforce zero tolerance policies against all
forms of SGBV by public servants, including sexual exploitation and abuse in
schools.
Carry out specific campaigns on HIV prevention illustrating how violence makes
women and girls vulnerable to the transmission of HIV (e.g. 16 Days of Activism).
Provide trainings for journalists, communication officers, and other media personnel
about avoiding communications that promote, reinforce, or reproduce violence
towards women.
Strive for active involvement of people affected by HIV in decision-making and policy
design that address the causes and consequences of VAW.
Train police to counsel and refer victims of sexual violence to medical centres and
consider training on administering emergency contraceptives.
Ensure that emergency contraception and post-exposure prophylaxis (PEP) for HIV
prevention are available and accessible to victims of sexual violence.
Virginity testing can actually put young women and girls at higher risk of
pregnancy, STIs, and HIV when they are also denied the right to education and
information about SRH, including HIV and pregnancy prevention. Young
women in cultures where virginity testing takes place have been known to
practise more anal sex, in order to preserve their hymens, which increases the
risk of HIV even further. 38 This is why advocacy around traditionally accepted
practices such as virginity testing and other human rights violations related to
SRHR and HIV and AIDS must be a strong component of integrated SRH and
HIV programmes.
Reproductive rights 39
The right to life
The right to bodily integrity and security of the person (against sexual violence,
assault, forced sterilisation or abortion, denial of family planning services)
The right to privacy (in relation to sexuality)
The right to the benefits of scientific progress (e.g. control of reproduction)
The right to seek, receive, and impart information (informed choices)
The right to education (to allow full development of sexuality and self)
The right to health (occupational, environmental)
The right to equality in marriage and divorce
The right to non-discrimination (recognition of gender biases).
Most of these same men also reported not using condoms with their partners for
a number of reasons, including:
Fears of the woman that the condom would get stuck inside her womb and
harm her;
Studies have shown that in the long term increased multiple partners reduce the
likelihood of condom use 40 and that the pattern of concurrent partnerships can
result in much higher rates of HIV transmission across communities. 41
Sexual networks and bridging patterns should also be analysed to determine the
level of HIV risk in different contexts. For example, the number of persons in a
sexual network, number of persons with HIV, number of persons engaged in risk
behaviours, number of persons in monogamous relationships, and the number of
links each has to others are all factors in assessing how rapidly HIV can be
transmitted within and across sexual networks. 42
Segregation of HIV and AIDS services from mainstream primary health care
services fuels stigma;
Those who stigmatise others are most likely to be those who are vulnerable to
HIV, are suspicious of being HIV-positive, and mostly likely want to deflect
attention from their own behaviour.
The Manica project worked to overcome stigmatisation associated with HIV and
AIDS by collaborating with local associations of PLHIV, such as local partner
organisation Rudo Kubatana, and local theatre groups to address HIV
stigmatisation during World AIDS Day. PLHIV said that community
sensitisation about HIV and AIDS had helped them feel less discriminated
against and more empowered as community change agents to encourage people
to get tested, know their status, practise positive living, and prevent new and
secondary infections. Training of health workers in treating and counselling
PLHIV based on their particular needs is also a step towards reducing
discrimination associated with the virus.
Overall, there is a call for increasing access to HIV and AIDS services as a way of
fighting stigma. At the same time, PLHIV can serve as champions to help
normalise HIV and AIDS and overcome the barrier of stigma and discrimination
in HIV prevention, care, and treatment.
As Dr. Joel Rakwar of AMKENI argues, 47 when dealing with human beings, it
does not make sense to separate their needs into different boxes, forcing them to
seek different types of care for their problems, which require a holistic approach
to individualised care. 48 However, each context must be considered when
deciding on which level of integration would be most cost-effective. For example,
prevention of mother-to-child transmission (PMTCT) is currently integrated into
MCH services in Mozambique, but problems exist with the capacity of health
personnel and limited resources. 49
44 Integrated HIV and AIDS Response in Manica Province, Mozambique
Oxfam GB, August 2009
One-stop-shop model
A holistic approach to responding to sexual violence is being tested in Kenya
through a one-stop-shop teaching hospital. After realising the obstacles that
vulnerable women and children face in accessing care, treatment, psychosocial
support, and legal aid for cases of SGBV, Kenyatta National Hospital established
a partnership with Liverpool VCT in 2006 to address the barriers to care and
treatment. The hospital was set up to respond to cases of sexual violence by
providing essential services, including medical surgery; emergency services such
as STI treatment, emergency contraception (EC), and post-exposure prophylaxis
(PEP); psychosocial support; legal aid; referral to shelters; and outreach. The
approach is still being evaluated, but results are showing that women are more
likely to receive comprehensive care for sexual violence due to a reduction in
referral points and with access to all of their needs at one location.
An interesting study done in Zambia looked at addressing care and support for
survivors of sexual violence by training local police officers to administer
emergency contraceptives as well as increase referrals to health centres.
According to a Demographic and Health Survey, 53 per cent of women in
Zambia had experienced beatings or physical abuse since the age of 15 and close
to one in four had experienced violence in the previous year. Low reporting rates
suggested that GBV survivors did not seek medical care or legal redress due to
the poor quality of care available in public health facilities and police stations. In
2006, the Population Council developed a programme aimed at increasing access
to emergency contraceptives and appropriate referrals at first points of contact. It
found that almost all survivors first reported the assault to police, but very few
continued to seek medical care. The study indicated that police officers were in a
unique position to help survivors avoid unwanted pregnancy due to sexual
assault. 50
Approach
Remember that global strategies need to be adapted to local contexts.
Focus on combination prevention strategies i.e. multi-pronged prevention
programmes including behaviour change, biomedical strategies (e.g. PMTCT,
treatment of HIV and STIs), social justice, and human rights.
During the initial assessment, look for entry points for men, women, and
young people and identify most-at-risk populations (e.g. married women,
young and elderly people, sex workers, men who have sex with men).
Carry out a context analysis and identify first ports of call for SRH and HIV
services, and involve these service providers in the programme (in rural
areas of sub-Saharan Africa these are often family members, traditional
healers, traditional birth attendants, and others, rather than health centres).
Use participatory empowerment approaches such as Stepping Stones and
STAR that address issues such as healthy relationships, communication, and
unequal power relations, which can lead to increased safer sex behaviours
and reduced incidence of violence against women and girls.
Advocacy
Ensure that the linkages between SRH and HIV and AIDS are addressed in a
countrys national development plans and budgets, including in
decentralisation processes, poverty reduction strategy papers (PRSPs), and
sector-wide approaches.
Encourage ministries of health to amalgamate separate policy papers on
maternal, child, and infant health, PMTCT, family planning, VCT, and STIs
into one coherent policy paper.
Advocate for SGBV services to be exempt in cost-sharing or cost-recovery
systems.
Invest in building the capacity of civil society at local and national levels to
empower citizens to demand their rights to essential SRH and HIV services
from their governments.
Health services
Consider the needs of people of all ages, genders, sexualities, and
professions. Furthermore, ensure that health workers are trained to deal with
most-at-risk populations (men who have sex with men, injection drug users,
sex workers) in a sensitive, non-judgmental, non-discriminatory manner.
Train health workers to be aware of and to be able to respond to the specific
health needs of sex workers, providing e.g. regular counselling and testing,
Gender
Engage boys and men from the outset in both community activities and
clinical services and outreach. Avoid integrating services into existing
female-friendly services only.
Develop strategies to provide essential SRH services for men and boys of all
sexual orientations, and not just in relation to women.
Pilot initiatives in conjunction with heath service providers and the ministry
of health to train first points of contact in responding to sexual and gender-
based violence, administering emergency contraceptives, post-exposure
prophylaxis, conducting rapid HIV testing and counselling, and referrals to
legal protection services
Conduct power and gender analyses with communities to identify and
address factors that fuel HIV and AIDS, including gender inequality and
violence against women and girls as both a cause and consequence of HIV.
Communications
Train and involve media in multi-sectoral collaboration efforts to promote
community-developed, gender-sensitive HIV prevention messages, and use
them for advocacy purposes around rights issues.
Rights-based approach 53
Multi-sectoral collaboration
Advocacy protocols for linking local issues to national and global policy
Bilevich de Gastrn, L. (2008) HIV and violence: implications for older women,
in The Multiple Faces of The Intersections Between HIV and Violence Against
Women, Development Connections, UNIFEM, Pan American Health
Organization, Inter-American Commission of Women, and the Latin American
and Caribbean Womens Health Network (2008).
Cooper, S.L. (2003) HIV Counselling and Testing Programs Strive Through the
Use of Incentives, National HIV Prevention Conference, 2730 July 2003,
Atlanta, GA. Abstract no. MP-028. Family and Medical Counselling Service, Inc,
Washington, DC.
Erulkar, A.S., Mekbib, T.A., Amedemikael, H., and Conille, G. (2007) Leave No
Woman Behind, Ethiopia(baseline report), Population Council.
The Global Coalition on Women and AIDS (2005) Violence Against Women and
HIV and AIDS. Backgrounder. A UNAIDS Initiative.
IRIN News (2009) Rwanda: Sugar daddies and mummies have bitter
consequences, Kigali, 2 July 2009. Available at:
http://www.irinnews.org/Report.Aspx?ReportID=85113. Last accessed 7 July
2009.
Jewkes, R., Nduna, M., Levin, J., Jama, N., Dunkle, K., Wood, K., Koss, M., Puren,
A., and Duvvury, N. (2007). Evaluation of Stepping Stones: A Gender
52 Integrated HIV and AIDS Response in Manica Province, Mozambique
Oxfam GB, August 2009
Transformative HIV Prevention Intervention (policy brief), Medical Research
Council, March 2007.
Kelly, R., Gray, R.H., Valente, T.W., Sewankambo, N.K., Serwadda, D., Wabwire-
Mangen, F., Lutalo, T., Li, C., and Wawer, M.J. (2000) Concurrent and Non-
Concurrent Sexual Partnerships and Risk of Prevalent and Incident HIV,
International Conference on AIDS, 914 July; 13: Abstract No. MoPpC1027.
Makanyengo, M., Violet, C., Okech, A., Kanyanya, I., and Mukhisa, E. (2008)
Setting Up a Model Comprehensive One Stop Centre for Gender Based Violence
Recovery Services: The Kenyatta National Teaching And Referral Hospital
(KNH) Experience: Successes and Challenges (abstract), 1st Conference on
Strengthening Linkages between Sexual and Reproductive Health and
HIV/AIDS Services: The Sexual Violence Nexus, 29 September1 October 2008,
Nairobi, Kenya.
McNeil, M. (2008) Integration of HIV and AIDS with Sexual and Reproductive
Health and Rights (SRHR), XVII International AIDS Conference, Mexico City,
AIDS and Reproductive Health Team, DFID, 3 August 2008, p.6.
Mullick S., Askew I., Maluka T., et al. (2006) Integrating Counselling and Testing
into Family Planning Services: What happens to the existing quality of family
planning when HIV services are integrated in South Africa? paper presented at
Linking Reproductive Health and Family Planning with HIV/AIDS Programs in
Africa, Addis Ababa, Ethiopia, 910 October 2006.
PATH (2003) Promoting Gender Equity. Paths Gender, Violence and Rights
Strategic Program (brochure). Available at:
Population Services International (PSI) (2005) Milking the Cow: Young Womens
Constructions of Identity, Gender, Power and Risk in Transactional and Cross-
Generational Sexual Relationships, First Report.
Romo, F., Mabunda, L., Buque, C., Samo, G., and Ondina da Barca, V. (2007)
Violence Against Women in Mozambique, United National Development Fund
for Women (UNIFEM).
Safreed-Harmon, K., and Daly, M.F. (2008) Mobilising for RH/HIV Integration
(shadow report). Review of Country Coordinating Mechanism Proposals with
SRH-HIV/AIDS Integration. Submitted to the Global Fund Round 8, 22 August
2008.
Samson, A. (2008) Lack of empowerment: a driving force behind the HIV and
violence against women epidemics, in The Multiple Faces of The Intersections
Between HIV and Violence Against Women, Development Connections,
UNIFEM, Pan American Health Organization, Inter-American Commission of
Women, and the Latin American and Caribbean Womens Health Network.
Sexuality Information and Education Council of the United States (SIECUS) (no
date) Virginity Testing: Increasing Health Risks and Violating Human Rights in
the Name of HIV-Prevention. Available at:
http://www.siecus.org/index.cfm?fuseaction=Feature.showFeature&featureID=
1199. Last accessed 28 July 2009.
Smart, T. (2005) Traditional Healers Being Integrated Into HIV Care and
Treatment in Kwazulu-Natal, AIDSMAP. Available at:
http://www.aidsmap.com/en/news. Last accessed 13 June 2009.
Appendices
Baseline Survey
Capacity analysis
8.
8. Try
Try out
out small
small experimental
experimental 2.
2. Select
Select Communities
Communities (DSC)
(DSC)
campaigns
campaigns that
that will
will lead
lead to
to
wider
wider national
national and
and regional
regional
campaigns
campaigns
7.
7. Systems
Systems analysis
analysis (DSC):
(DSC): 3.
3. Create
Create Awareness
Awareness about
about
How
How are the deeper-rooted
are the deeper-rooted project
project in Communities
in Communities
issues
issues entangled
entangled with
with each
each (OGB
(OGB and
and partners)
partners)
other
other and
and where
where is
is the
the
leverage? Focus group
leverage? discussions
Regular monitoring
IEC
World AIDS Day
& 16 Days of
6. Activism Against
6. Information
Information and
and key
key Gender Violence
4.
4. Recruit
Recruit peer
peer workers
workers from
from
messages
messages spread
spread into
into selected
selected communities
communities
communities
communities
Training
Training and
and refresher
refresher
Informing 5. Training of peer workers training
Informing training for
for health
health
communities
communitiesabout and implementation of STAR workers,
about workers,traditional
traditional
existence
existence of
of quality
quality in selected communities healers,
healers, and
and traditional
traditional
SRH
SRHand birth
and birth attendants
attendants to to
HIV&AIDS
HIV&AIDSservices improve
and
services improve quality
quality of
of SRH
SRH
and how
howto
to use
use and HIV and AIDS
and HIV and AIDS
them service
them service (MoH)
(MoH)
WHO/UNFPA/UNAIDS/IPPF
Communication
Behavioural Decision
Choices Making
REFLECTION
Liter ion
pat
N
acy family i
D IA
ic
TIO
t
Par
LOG
ILIT A
t
HIV/AIDS
en
UE
c om
GENDER
FAC
rnm
RIGHTS
Solidarity &
m un
AC G
TI IN
ON ARN
LE
is
M for
s
ob A
aly
ili ct
An
za io
ti n
r
on
we
Po
(3) After the learning journey, the group retreats in silence in order to allow inner
knowing to emerge deliberate time for reflection and processing what was
learnt through observation, deep listening, and dialogue.
(4) The two or three most creative insights that emerge from the inner knowing
are then prototyped in order to learn by doing.
MEASURE Evaluation
Website: http://www.cpc.unc.edu/measure
Provides technical support to build the sustainable capacity of individuals and
organisations to identify data needs, collect and analyse technically sound data,
and use those data for decision-making on health-related issues.
David Patient
Website: http://www.davidpatient.com
A free interactive resource for those living with or affected by HIV/AIDS,
written and hosted by David Patient, one of the longest-documented people
living with HIV/AIDS in the world.
Empowerment Concepts
Website: http://www.empow.co.za/
Resources around HIV, wellness programmes, articles, and downloadable
toolkits are available.
Advancing the Sexual and Reproductive Health and Human Rights of People
Living with HIV. UNAIDS (2009)
A tool for policy-makers, programme managers, health professionals, donors,
and advocates to better support the sexual and reproductive health and rights of
people living with HIV. See:
http://www.aegis.org/news/unaids/2009/UN090812.html
1 Essential services are services required to protect the life, personal safety, or health of
the whole or any part of a population. These include, but are not limited to, services for
health care, HIV and AIDS, education, and safe water.
2 The Millennium Development Goals are eight international development goals, agreed
by UN member states and various international organisations, to achieve by 2015. They
include reducing extreme poverty, achieving universal primary education, ensuring
environmental sustainability, promoting gender equality, reducing maternal and child
mortality, combating HIV and AIDS, TB, malaria, and other diseases, and developing a
global partnership for development. http://www.un.org/millenniumgoals/bkgd.shtml
3 UNICEF (2009).
4 CIA Factbook (2009).
5 UNICEF (2009).
6 Ibid.
7 UNAIDS (2008).
8 An international campaign started by the Centre for Womens Global Leadership
(CWGL) in 1991, running from 25 November (International Day Against Violence
Against Women) to 10 December (International Human Rights Day) to symbolically link
VAW and human rights. For more information on the 16 Days of Activism Against
Gender Violence, visit: http://www.cwgl.rutgers.edu/16days/about.html.
9 A tradition whereby the wife of a deceased man is inherited by a male relative
10 Welbourn (1995).
11 Jewkes et al. (2007).
12 For more information on Reflect, see:
http://www.actionaid.org/main.aspx?PageID=128.
13 Pamoja Africa Reflect Network is an Africa-wide, non-profit, participatory and
educational development initiative established in 2002 to facilitate learning, sharing, and
continuing evolution of Reflect practices in Africa.
14 Bukali (2002).
15 Oxfam (2006) p.32.
16 Smart (2005).
17 Nanjakululu (2008).
18 Ibid.
19 Ibid.
20 Interact Worldwide et al. (2008).
21 A practice where newly widowed women are made to have sex with one of her
husbands relatives in order to purify his spirit.
22 UNAIDS, 2008 Report on the Global AIDS Epidemic, August 2008.
23 Remenyi (2008).
24 Boonstra (2004).
25 Global Coalition on Women and AIDS (2005).
26 PSI (2005).
27 Bilevich de Gastrn (2008).
28 Ibid.
29 Romao et al. (2007).
30 IPPF (2006).
31 Global Coalition on Women and AIDS (2005).
32 IPPF (2006).
33 US Department of State (2008).
34 Oxfam (2006); US Department of State (2008); UNIFEM (2008).
35 Remenyi (2008).
36 Ibid.
37 SIECUS (no date).
38 Ibid.
39 Sundari Ravindran (2001), cited by Allanson et al. (2009).
40 Medical Research Council (2003).
41 UNAIDS.
42 UCSF (2003).
43 2008 estimate.
44 FHI (2007) p.5.
45 As suggested by Safreed-Harmon and Daly (2008).
46 Tullock (2008).
47 AMKENI is a consortium led by EngenderHealth and composed of the following
partners: Family Health International, IntraHealth International, the Carolina Population
Centre, and the Program for Appropriate Technology in Health (PATH).
48 Fischer (2006).
49 Safreed-Harmon and Daly (2008).
50 Zama and Keesbury (2008).
51 FHI (2007).
52 Caucus for Evidence-Based Prevention.
53 Based on human rights principles of equality, non-discrimination, accountability, and
participation. For more information on the human rights-based approach, see:
http://www.unicef.org/sowc04/files/AnnexB.pdf.