Our Commitment: We are committed to addressing the HIV pandemic and reducing people s vulnerabilities to HIV. A visual aid on Gender based violence used for awareness raising and training in communities, South Kivu, DRC 81
The issues The last chapter, Standard 7: Gender, highlighted the ways in which women and children are vulnerable to sexual violence, intimidation and abuse. Sadly, such behaviour in some societies is common, but abuse often escalates in situations of poverty, conflict and disaster. There may be large-scale population displacement, leading to a break down in family and social structures, moral norms and a lack of traditional protection systems. Commercial sex work and coercive sex (giving sex in order to receive assistance) will often increase. All of these factors directly relate to HIV. People are vulnerable towards HIV when they are involved in risky behaviour. In addition, social, economic, political and environmental factors can increase people s vulnerability towards HIV. Emergency settings often mean that these vulnerabilities are even greater than normal as communities cope with the physical and psychological trauma of the emergency. Extreme and prolonged poverty may also push women into prostitution, as a way of earning income and feeding their families. These underlying factors need to be addressed to try and change the root causes or structures that affect individual risk and vulnerability to HIV. If we do not consider HIV in our projects, then the impact of our work may be reduced. Meeting basic needs such as water, sanitation and food security is not enough if vulnerabilities to HIV are not addressed and HIV is allowed to spread. Poorly designed projects may even increase people s vulnerabilities. Vulnerabilities that could fuel the HIV epidemic include: Political upheaval with high numbers of refugees and displaced people Deepening poverty Gender inequality and low status of women Men separated from their wives and families due to recruitment into the armed forces, or in search of work Sexual gender-based violence, endemic in some cultures. High levels of illiteracy Lack of infrastructure and timely response by health system e.g. lack of testing kits, counselling services and provision of triple ARVs for everyone with CD4 count<350 and for all HIV positive pregnant women. Lack of antenatal care and sexual and reproductive health services Prevalence of, and lack of access to treatment for, sexually transmitted infections, e.g. syphilis. Lack of treatment of other diseases such as TB, Malaria Injecting drug use Competing health priorities Traditional patterns of sexual union 82
Lack of culturally appropriate preventative tools Vertical transmission from mother to child The importance given to reducing vulnerability to HIV may depend upon the overall prevalence of the virus in the population; if the disease is hardly known, then it may receive a lower priority, but where prevalence is high, every project must take this into account for beneficiaries and for staff. In a low HIV prevalence country, the emphasis will be on addressing people s understanding of the disease and any underlying vulnerability factors such as gender inequality. In a medium or high HIV prevalence country, more emphasis might be given to advocating for access to HIV services, prevention of risky behaviour and addressing stigma and discrimination. Measures to increase the availability of testing and ARV (anti-retroviral) drugs will be particularly important. Biblical foundations Tearfund s response to HIV is shaped by biblical principles of compassion, justice, accountability, leadership and participation. Jesus showed compassion and justice, especially towards those who were broken and rejected, and challenged stigma and marginalisation. In his culture, leprosy sufferers were stigmatised and rejected. Today, people living with HIV (PLHIV) and affected by HIV are often treated in a similar way. Misconceptions about how HIV can spread can affect people s attitude towards HIV. Stigma and discrimination can cause marginalisation of PLHIV and make it more difficult for them to access services. The Bible calls us to serve PLHIV and their families so that they may discover their value to God, gain access to proper treatment and be able to live meaningful lives with dignity. Good Practice commitments HIV is a priority concern for Tearfund because it is a major cause of poverty. Families affected by the disease are less able to engage in hard physical work and carry a higher financial burden for medical care. These families are more vulnerable and are less able to cope in times of crisis. Addressing the HIV pandemic and people s vulnerability to HIV involves the following: Internally for staff: Ensuring that staff working for your organisation are fully aware of the facts about HIV, addressing issues of stigma and putting in place policies to provide a positive environment for staff living with HIV or affected by HIV Externally for beneficiaries: Designing all projects to ensure that these do not increase people s vulnerability to HIV, in addition to specific projects to raise awareness and prevent the spread of HIV, to address underlying attitudes and beliefs, and to advocate on key policy issues. Those with the 83
disease should be supported in gaining access to testing and treatment, with advocacy for such services if they are not available. Close links to other Quality Standards Our commitment on HIV has close links with: Values, in our commitment to combat stigma; Impartiality, as our commitment is to the most vulnerable, including vulnerability to HIV and people living with HIV; Disaster Risk, in recognising the particular considerations of HIV and vulnerability; Children, recognising the impact that HIV is having on children; Gender, recognising the close connection between HIV and gender; Conflict, recognising the vulnerability of women and girls in conflict situations; and Advocacy, recognising that policy issues need to be addressed where HIV is of high prevalence but given low priority by Governments. Where to look for further information: Tearfund s HIV Corporate Strategy to 2015 Tearfund Good Practice Guidelines on HIV The inter-agency standing committee (IASC) guidelines for HIV in emergencies Tearfund s Think Livelihoods! Guide for HIV-affected families 84
Practical steps for carrying out our HIV Commitment Identification Step 1: Ensure staff understand the HIV epidemic and address stigma Step 2: Understand your project context in relation to HIV Design Step 3: Design projects to make people & their children less vulnerable towards HIV Step 4: Design projects to help save lives & make life easier for people living with HIV (PLHIV) and their families Implementation Step 5: Undertake awareness and prevention activities with communities & increase access to testing & treatment for PLWHA. Step 6: Advocate and address issues relating to HIV where they are a priority Step 7: Address underlying attitudes and help to shape positive values Step 8: Monitor and evaluate the impact of your HIV approach 85
Step 1: Ensure staff understand the HIV epidemic and address stigma We can only address the HIV pandemic if we have the facts right ourselves and our attitudes and behaviours are correct. Make sure that staff have a full understanding of the basic facts about HIV: What is HIV? What is the cause? How is it transmitted? How does it spread? What is the prevalence globally and for your country of work? Is it a concentrated or a generalised epidemic? Who are the most at risk groups? Do PLHIV have access to testing and treatment? What support is there within the team/organisation for people who are infected or affected by HIV? How do you personally feel about PLHIV? There is often stigma attached to people affected by HIV and misinformation can increase this. We need to ensure that staff have a correct understanding of HIV and that stigma is reduced. Organisations need to have policies in place to support staff in all these areas. Tearfund has an HIV Work Place Policy (WPP) for this reason. 86
Step 2: Understand your project context in relation to HIV The following questions will help: i) What is the situation that you see, what are the vulnerabilities? (examples might be: conflict, drought, poverty, displacement, poor infrastructure, gender inequalities) ii) What are the effects of the vulnerabilities that you see? (examples might be lack of education and health services, particularly absence of HIV testing & ARV treatment, sexual violence, lack of human rights, increase in disease, unemployment, migration, drug and alcohol abuse, unprotected sex, no positive role models, etc.). iii) What are the underlying causes? (gender issues, cultural practices, war, environment, issues in power, trade, religion, economic) iv) Who are those groups most at risk of HIV? Using participatory tools such as the crunch model or a problem tree will help you analyse the community and context where you are working and get the answers to these questions. 87
Step 3: Design projects to make people & their children less vulnerable towards HIV When designing your project, use the information obtained from step 2 above to design activities that help to reduce the vulnerabilities identified. There should be measures to both reduce horizontal transmission and the passing on of infection from mother to child. Reducing both the individual and community s risk is essential. Underlying causes such as gender inequality and protection should be considered (see also the Practical Steps listed under Gender and Conflict). Funding needs should be identified at the design stage and included in project budgets to ensure any extra activities can be supported. Step 4: Design projects to help save lives & make life easier for people living with HIV (PLHIV) and their families This will be especially important in countries of medium or high prevalence. In these situations, it is important to ensure that PLHIV and their carers (who are sometimes children) have access to all available community services. In particular they need to have access to testing and treatment for HIV and coinfections (e.g. TB, Malaria) For example water pump handles should be easy to use for those people who have muscle wasting and/or for children. PLHIV may need more water than others and food fortified with vitamins and minerals. These activities should not necessarily be targeted at only PLHIV as it may not be known who has HIV and who does not. Instead these measures can be considered for the whole community if there is high prevalence and this will also avoid stigma and discrimination. 88
Step 5: Undertake awareness and prevention activities with beneficiaries and communities Project staff are able to interact with many different groups to share messages on HIV awareness, treatment and prevention ; these may include refugees, beneficiary groups, families, and women and children. These messages should be a core part of any health promotion curriculum and need to use creative methods of communication, such as video and drama. But in addition, awareness, treatment and prevention messages can be integrated within all project sectors and included for example in any training with Village Development Committees. Staff can also be in a unique position to become equipped to work to encourage perpetrators of sexual violence and abuse to understand and address the impacts of their actions and work towards genuine behaviour change - whether rebel groups, the military or youth. There is opportunity in these situations to disseminate HIV messages amongst the perpetrators of violence and to urge a change in behaviour. Step 6: Advocate and address issues relating to HIV where they are a priority There may be major policy issues in the context which need to be addressed in collaboration with others. These could relate to the lack of access to HIV services, particularly HIV testing and ARV treatment (and treatment for TB and opportunistic infections), or to a lack of safety and high levels of gender based violence. See also the Practical Steps listed under Standard 12: Advocacy. 89
Step 7: Address underlying attitudes and help to shape positive values There are often underlying attitudes in a culture which are highlighting gender disparities and therefore heightening vulnerability to HIV. Where there are local churches in a community, these churches are a key shaper of values. The same applies in settings where there are other local faith based organisations (FBOs) shaping values. Project staff can work with these leaders to not only disseminate appropriate HIV awareness and prevention messages but to begin to tackle unhelpful traditional attitudes, discrimination and stigma. One of the local church s greatest strengths is the importance it gives to relationships. This makes it well-placed to provide relational support. This can be through prayer, pastoral care and hospitality, acknowledging and caring for people s inner hurts and grief. This can include setting an example in loving and caring for people living with HIV. Step 8: Monitor and evaluate the impact of your HIV approach Ongoing monitoring and lesson learning is needed to assess the appropriateness of the project design and take account of any changes in the community or the context. Are vulnerabilities changing, are the HIV awareness, treatment and prevention messages having an impact, and are any changes needed in the project approach? 90
Project Examples In Darfur a project took steps to make people less vulnerable to HIV in a variety of ways: by locating activity centres and health clubs throughout the community in order to limit the distance women needed to travel; by introducing an income-generating project to provide income for women and reduce the likelihood of them resorting to high risk behaviours to earn income; by locating latrines and water points in appropriate locations where these is less likelihood of attack. In DR Congo HIV prevention messages were integrated into a one week farmers training workshop. In South Sudan a network was set up, called Sudan Christian AIDS Network (SCAN), to help church leaders and other faith-based organisations share resources and discuss their beliefs, attitudes and theology when responding to HIV. In Zimbabwe, a project which promotes conservation farming methods uses an approach which spreads the farming workload over the year in a less intensive way, as opposed to short bursts of intensive farming. This makes it more suitable for those who are weakened by chronic diseases such as HIV, enabling them to be productive and restoring their dignity. In many countries the local church is playing an active role in ensuring people have access to testing, ARV treatment and antenatal care for pregnant women to ensure not only that people with HIV live longer, but also that transmission of HIV is reduced both horizontally (between adults) and vertically (from mother to child). 91