Progress to MDG 6 and 3 (Aug 2010)

Guest moderator: Dr. Noeleen Heyzer
Under-Secretary-General of the United Nations and Executive Secretary of United Nations Economic and Social Commission for Asia and the Pacific (ESCAP)

The numbers of new HIV infections annually in Asia-Pacific have stabilized, yet HIV infections among women are on the increase. Of all HIV positive people in the region, the proportion of women living with HIV rose from 19 percent in 2000 to 35 percent in 2008. Similarly, prenatal transmission continues to rise, accounting for 5.1 percent of new infections in the Pacific in 2005.

The impact of HIV on women and girls is experienced more severely compared to male counterparts. Structural gender inequalities work to the detriment of women and girls, increasing their vulnerability to both the causes and consequences of HIV. A number of reinforcing factors place women in double jeopardy regarding their higher infection rates and greater impact of living with HIV. These include:

Harmful norms and practices affecting women and girls, including stigma and discrimination
Violence against women
Barriers in achieving economic security
Barriers in receiving education
Barriers in access to services and information
The great burden of social care carried by women.

Key to effectively tackling these issues is the translation of global commitments to MDG 3 on Gender Equality and Women’s Empowerment and MDG 6 on HIV, Malaria and other Diseases into real change for women and girls in Asia and the Pacific. The UN system is united in its commitment to this goal and is working with stakeholders across the region to end the gender inequalities which are a key driver of the HIV epidemic and the associated heavy cost to women.

I am delighted to have this opportunity to launch a virtual discussion on these issues and challenges. One key focus for discussion is how gender inequalities in the context of HIV can be addressed through progress on MDG 3 and MDG 6 in Asia-Pacific. Specific practical issues for consideration include the barriers to information, strategic intervention and access to services; how to encourage attitudinal change and effective enforcement of existing laws; and implementing commitments which uphold the rights of women and girls living with HIV.

I look forward to your contributions, including recommendations and best practices from your areas of work that would enrich the findings and provide us all with pointers on the way forward. Together we can make a real difference to the prospects of women and girls living with the threat and effects of HIV across our region.

Process Note:

Wed, 2010-08-11 08:09 — admin

The discussion will be based on findings of consultations conducted with women affected by HIV/AIDS in the Philippines, PNG and India - See Summary Report on key findings

The focus of the discussion will vary each week, as follows:

First week: issues of advocacy, stigma and discrimination;
Second week: access to health, ARV and harm reduction technologies;
Third week: providing a conducive legal environment particularly vis-à-vis Violence Against Women.
Guiding questions will be provided to kick start the discussion each week. We look forward to your contributions!

Comments:

MDG 6 and 3 - E-discussion Part 3
Mon, 2010-08-30 08:26 — admin

[We have now come to the last week of the e-discussion. This week we will focus on what needs to be done to stop violence against women. Please send your feedback to us by 3 September 2010. Contributions can be submitted by replying to this email or via the HIV-APCoP website at www.hivapcop.org]

Gender based violence is associated with higher risks for HIV transmission and is a key driver of the epidemic in many countries. Women’s empowerment is constantly threatened by the frequency of, and the scale on which, violence against women occurs. The fact that violence against women mostly occur within the family and that this violence is perpetrated by an intimate partner further underscores the need for structural and profoundly transformative interventions. Despite clearly articulated laws against gender based violence, consultations hint that the ineffective enforcement of these laws nevertheless contributes to making physical abuse of women endemic.

Question:

What can be done to precipitate more effective enforcement of existing laws against gender based violence?
What other structural interventions can be done besides legislation and law enforcement?
What can be done to foster the social transformation necessary to end gender based violence; and build women’s resilience to violent behaviour originating either within the family or from outside?

HIV APCOP Facilitator
Nashida Sattar

Contribution by: Aparna Basnyat
Tue, 2010-08-31 12:42 — admin

We are pleased to share with the group examples of initiatives implemented under the UNDP Access to Justice programme in Cambodia and Nepal to address Gender Based Violence.

Cambodia

A part of the Access to Justice project in Cambodia focused on access to justice for women including on providing legal aid for women in 3 provinces and also training village facilitators to conduct community conversations on domestic violence to promote dialogue on domestic violence in 89 villages. Please see below for a write up on the handbook developed on the community conversations. For more information, please contact Rany Pen (rany.pen@undp.org), UNDP Cambodia.

Talking about Domestic Violence – A Handbook for Village Facilitators - Download PDF

This handbook is developed as part of the Access to Justice Project, implemented jointly with the Ministry of Justice and the Ministry of Interior with the support of UNDP, for Village Facilitators. Between 2008 and 2010, Village Facilitators in 89 villages conducted Community Conversations on domestic violence in their villages in the provinces of Kampong Chhnang, Kampong Speu, Siem Reap, Rattanakiri and Mondulkiri. Impact surveys show the Community Conversations have increased awareness and understanding of the issue, have been conducive to creating an environment where the taboo of domestic violence is broken and discussed more openly, and the people in villages where the discussions took place even have the perception that prevalence of domestic violence decreased.

This handbook includes information on different aspects of domestic violence as well as guidelines of how to undertake each of the ten topics. We hope that the handbook will assist Village Facilitators to continue to talk about and work to address domestic violence in their villages.

Nepal
In order to increase people’s access to justice UNDP under its Enhancing Access to Justice Project has been implementing paralegal programs in Morang, Banke, Bara, Siraha, Dhanusha, Kailali and Doti districts. The community based paralegal program primarily focuses on addressing gender based violence by raising awareness on rights of women and socially excluded groups, on informing them on who and how to contact to seek redress and what remedies are available. The project also seeks to raise awareness among justice service providers on the rights and grievances faced by women and socially excluded groups.

The project also includes a legal aid component which focuses on establishing legal aid desks to provide free legal aid services to women affected by gender based violence through mobilizing women lawyers in collaboration with Nepal Bar Association and Nepal Police Headquarters

Please see write up (Download PDF) on the initiative shared by Keshab Prasad Dahal (keshab.dahal@supremecourt.gov.np), the National Project Manager for the UNDP Enhancing Access to Justice Project. For more information, please contact Tek Tamata (tek.tamata@undp.org) at UNDP Nepal.

Aparna Basnyat
Human Rights Capacity Development Specialist

Contribution by: Jacob Kupu
Thu, 2010-09-02 07:55 — admin

Hi everyone,

Firstly I take this opportunity to thanked ap-hiv-cop for providing this vital information -not only this but the previous ones too. they all contribute to our refining of HIV, GENDER BASED VIOLENCE Program in PNG. You all have given insights on the very issue which in PNG we can not find solution overnight.

Secondly, I personally like this training especially at the village level. In PNG, Violence against Women is an issue that seems to be perceived as a norm. Its culturally OK for men to use force on women most times and we don't quickly response to a woman's plea in a violent situation where a husband or boy friend is involve. It becomes an ordinary /normal wife-husband affairs and everyone thinks two people not in good teams with each other. Its a private matter -GO home and solve it.

I think, due to this most of PNG mothers in the rural villages are living with pains, sores and broken limbs and bones.Women accept the pain, the truama and the ill-health -She lives in fear of many things, security, shelter, family's comfort, love, food and mainly her own life. She must not provoke the man, I have seen this happen, and still seeing it within my own family, Law enforcers are beginning to provide help in this regard but this is only in the urban towns.

I request one day training for PNG. I recommend this training should also be facilitated by UNDP in Papua New Guinea. This advocacy must be targeted mainly to rural villages of this beautiful country PNG-

Thank you.

Jacob Kupu
Program Officer-HIV/AIDS
Department of National Planning & Monitoring

Contribution by: Lisa Williams-Lahari
Thu, 2010-09-02 12:09 — admin

Hi All,

Sustained and core support for front line services such as Police and law enforcers AND victim support/counselling and refuge centres must be considered a priority for those living with Gender Based Violence (GBV). They are both front-line, first point of contact (along with health professionals) for those stepping out of the silence to escape or report the crime which has taken place. However, only the police and health workers are on the government payroll. We need to ensure that there is support coming from refuge centres, crisis phone lines, trauma and relationship counselling services given by those who also assist with picking up the pieces of the families broken by violence and abuse.

Creating change

One of the big aha moments in this work of combatting GBV in the context of HIV/AIDS is the real need to shift the talking and action around the issue to the bastions of power: Our Men.

Whether we are talking about police and justice officials, high level leaders and front-line policy makers, or doctors/health care providers at the front line of those who make it to the hospitals, the focus on empowering men and boys to understand that talking gender is not women's talk but a discussion on the dynamics of POWER is essential to the process of breaking down attitudes and visioning new approaches.

And always, we need to foster perception and truth on ownership, discussion, and an appreciation that men and boys are needed even more urgently at the table with women and our high level leaders as we work MEANINGFULLY and EFFECTIVELY towards the solutions.

In all regions of the world, its plain to see the imbalance in male -female ratios in the room when the agenda item is on gender, on violence in families, on the inequalities of women and girls which are in fact the inequalities of ALL. This discourse, historically hosted and fostered in spaces for women, and I guess with the best of intents, has a down side.

I often salute the work of Africa's One Man Can initiative by the Sonnke Gender Justice Network.....opening up spaces for evidence-based and proactive campaigns such as the One Man Can initiative which, if I had funds, would definitely provide much food for driving a similar Pacific campaign....

The Stepping Stones approach pioneered by Alice W. of the Salamander Trust in the UK has been a fantastic tool for opening up spaces in Pacific communities to address GBV in non-confronting ways.

Pacific Council of Churches also does faith-based leadership advocacy in this area. It is evidence that for the Pacific region, the entry points into the family environment where the law of the land gives way to the power of the fathers, are via the religious and village leaders who must be included in interventions aimed at addressing this minefield of silence.

in solidarity, lis

WAIGANI, PAPUA NEW GUINEA

Contribution by: Annie McPherson
Fri, 2010-09-03 07:13 — admin

Dear Jacob,

Your call for training, are you talking about training for men or is it for women? I personally think that our attempts to addressing this issue is very much focus on the victim. It is like we are reacting to an action rather than preventing it from happening in the first place. A women who lives with daily violence is so controlled that she loses her physical strength to give voice to the issue. She in most part believes that it must be her fault and that she asked for it through her actions.

Given what I said, I strongly recommend that these training or education should be directed to the men. Men speaking to men about this very serious issue and put real faces to the issue. I am also concerned that not enough homework is done in PNG to see if there are any effective programs that can be better taylored to addressing these issues. Organisations like Peace Foundation Melanesia (PFM) provide training and work in the communities in the Southern Highlands & Bougainville & NCD, these were recognised as the main trouble spots because of conflict and tribal fights in the past. PFM work towards establishing peace and good order committees within each community. Some of these programs are very effective and I believe that these are organisations we should be looking to and supporting programs that bring education to the men citizens.

Certainly we must encourage many women groups continue to provide quality peer support to each other and look at counseling programs to rebuilding their lives.

It is so sad that a women in this situation has great difficulties in being able to find the strength both physically and mentally to walk away, where is she going to go to, and who is going to provide for her and what if she has children.

Annie McPherson

Contribution by: Emma Fulu
Fri, 2010-09-03 11:35 — admin

Partners for Prevention: Working with Boys and Men to Prevent Gender-based Violence

Dear All

Thank you for this interesting discussion. Some additional thoughts from our programme...

For effective enforcement of existing laws on gender based violence, the larger context and institutional structures in which these laws are developed and implemented need to be understood as gendered. Implementation of GBV laws exists within a gender order of society and in many cases those responsible for implementing such laws are men who may themselves be directly engaged in violence, may have little incentive to end a system which privileges them, or are men who favor ending violence but have limited space, support or incentive to do so. The centrality of violence to the workings of the patriarchal system has long been dissected and documented by feminist scholarship and activism. Violence, or the threat of violence, keeps power hierarchies in place.

To better understand laws on GBV and the gendered context in which they are situated, recent research studies and programme interventions have explored the connections between masculinity and gender-based violence at the individual, institutional and larger societal levels. In recognizing that there is not a singular masculinity, but rather multiple forms of masculine expression and practice that can and do change over time, masculinities work with men has opened up space to look at the ways in which men can choose non-violent, and promote gender justice. But in order to work effectively with men to end gender-based violence, it is essential to understand the ways in which the violence of the gender order is reproduced by the policies and cultures of political, economic and social institutions and legitimated by ideologies that sanction hierarchies based not only on gender but other axes of inequality, including sexuality, class, race/ethnicity, caste, faith and age. This institutional and ideological focus serves to emphasise that violence is not simply the behaviour of individuals, but is structured by and within unequal social relations, as a tool of oppression. The violence of the gender order is one dimension of the violence of oppressive social orders more generally.

Male-dominated institutions and ideologies of male domination fuel gender-based violence and it is essential that more men get involved in allying with women to challenge these expressions of male power. A powerful motivation for men to get so involved is that men too are targeted by other men’s violence, as one look at homicide statistics makes clear. The violence that men do to other men is in part based in the masculine/feminine gender logic of domination and subordination from which women suffer.

As an interesting example, I understand that UNDP in PNG is in the early stages of supporting a Baseline Study of Royal PNG Constabulary’s (RPNGC) Prevention and Response to Gender-Based Violence (GBV), Papua New Guinea. The survey will look at current responses to GBV as well as the institutional approaches and attitudes of individual members of the police force to provide and support the development of a comprehensive package of training curriculum for the RPNGC, as well as a benchmark to measure the performance and effectiveness of the training curriculum. Looking at the institutional structure of the police force, their individual gender perspectives that may prevent them from enforcing the law should help effective enforcement.

In terms of what can be done to foster social transformation, most responses to GBV have tended to focus on women’s rights and empowerment, legal reform, protection and service provision. Whilst these interventions are priorities and need to be continuously sustained and enhanced, they must be complemented by comprehensive approaches to primary prevention. Addressing root causes of GBV through primary prevention with boys and men is part of such a comprehensive approach to create societies where gender-based violence is unacceptable to all.

For example, Partners for Prevention (P4P) is a UNDP, UNFPA, UNIFEM and UNV regional programme for Asia and the Pacific that began in September 2008. The long-term goal of this programme is to prevent gender-based violence in the region by addressing its root causes and transforming the norms and behaviors that perpetuate it. Partners for Prevention is taking a coordinated approach that combines evidence, capacity development and communications for a more comprehensive response to gender-based violence. A key area of P4P’s work includes supporting new research on masculinities and their connections to gender-based violence to inform evidence-based responses to violence prevention, particularly through the engagement of boys and men. P4P is enhancing the knowledge and skills of organizations to engage in effective communications for behavioural and social change through designing campaign messages based on new knowledge about the causes of violence, and what men are willing to do to take action to prevent it. P4P is also working to develop the capacity of local organizations by facilitating sharing of successful approaches, materials, and programmatic insights across countries to involve boys and men in GBV prevention and using new research findings to develop more effective interventions for violence prevention programme plans. For more information on Partners for Prevention, see www.partners4prevention.org or email info@partners4prevention.org.

Thanks

Emma

Partners for Prevention: Working with Boys and Men to Prevent Gender-based Violence
UNDP, UNFPA, UNIFEM & UNV Regional Joint Programme for Asia and the Pacific
3rd Floor, UN Service Building
Rajadamnern Nok Avenue
Bangkok 10200 Thailand
Tel: +66 (0)2 244 8150 / Mobile: +66 (0)8 1409 2763
www.partners4prevention.org

Contribution by: Annie McPherson
Fri, 2010-09-03 11:35 — admin

Shiba,

This would be a great conversation to have….like many countries, issues are just as important in PNG and if anything I think it is more difficult in PNG given the cultural complexities, norms and traditional practices that are quite varied throughout the country. Currently there seems to be much emphasis on the Highlands regions and so there is a focus there but that is also in many ways hindering any understanding in the other parts of the country. For example wrong assumptions were made on the New Guinea Islands and we are now discovering that we do have a problem in the region and therefore there is a lot of catch up work now being undertaken.

PNG is also experiencing very high levels of gender violence and there is not sufficient data of what is being treated as an acceptable behavior and people tend to turn a blind eye on a very real problem……this is also happening within the PLHIV communities and we need to start seriously addressing it.

Annie.

Contribution by: Annie McPherson
Mon, 2010-09-06 14:27 — admin

[Facilitator’s Note: We thank members for the overwhelming responses we received to this 3 part discussion series. We are now in the process of preparing the consolidated reply, and we request you send in your final contributions over the next two days so they may be incorporated. We will shortly be conducting a survey and look forward to your feedback on this discussion series. Thanks!]

Dear Emma,

Excellent contribution to the discussions and right within what I was trying to express….let’s keep up the support programs for the victims AND let us address or prevent it and change the mind set through programs for boy and men.

Annie.

MDG 6 and 3 - E-discussion Part 2
Mon, 2010-08-23 07:18 — admin

[Good Morning! Thank you very much for the substantive responses we had last week. This week the e-discussion will focus on Access to Health, ARV, and Harm Reduction and Prevention Technologies. Please send your feedback to us by 27 August 2010. Contributions can be submitted by replying to this email or via the HIV-APCoP website at www.hivapcop.org]

Part 2: Access to Health, ARVs, and Harm Reduction and Prevention Technologies

Despite the fact that Anti Retro Virals (ARVs) are provided for free, the costs of women’s access to comprehensive HIV treatment is driven up by a variety of other factors, including the costs of diagnostic (CD4) tests, the cost of nutritional supplements, the cost of treatment for Opportunistic Infections (OIs) and the logistical costs of accessing Anti Rretro Viral Treatment (ART) centres.

Our consultations with discussants in Philippines, India and PNG, showed that counseling cover is either non-existent or grossly inadequate, especially in rural areas. This contributes to widespread misinformation about PMTCT and PPTCT. Reports also highlight that, in many instances, healthcare personnel recommend courses of action to positive would-be mothers that increases the risks of the child being born HIV positive. Coupled with this, we also found during consultations that frequency of condom usage remains low on account of women’s dependence on the men for condom procurement and use.

Lack of confidentiality with regards to HIV status is another area of concern. In the Philippines and India our consultations found that confidentiality is often flouted. On the other hand, women from PNG maintain that confidentiality clauses allow their partners/husbands to avoid disclosing their status. This, coupled with low acceptability of condoms are a major cause for concern for HIV transmission within intimate couples in PNG.

Questions:

What has been/can be done to provide gender responsive HIV care and support services that are affordable, keeping in mind that resources – both physical and human are limited, that numerous bottlenecks exist and that stigma and discrimination surrounding HIV are major obstacles?
Given these limitation, how can we improve the coverage and quality of Prevention of Mother to Child Transmission (PMTCT) or Prevention of Parent to Child Transmission (PPTCT)?
How can we improve counselling and testing without compromising confidentiality and the health of spouses and partners?
What strategic interventions can expand the acceptability and usage of harm reduction technologies and prevention methods by women and girls?

HIV APCOP Facilitator
Nashida Sattar

Contribution by: Maura Elaripe
Mon, 2010-08-23 14:06 — admin

[Facilitators note: The following e-mail was sent as a response to the discussion on Part 1: Advocacy, stigma and discrimination. However as the contribution smoothly takes us to the issue of confidentiality raised in Part 2 of the discussion on access to health we are posting it now]

Thank you Ferdinand for your email. I want to again emphasis on Provider Initiated Counselling and Testing (PICT); In PN, health workers implementing PICT need to ensure that NO HARM is caused to people accessing it. Also it’s suppose to be voluntary NOT MANDATORY.

PICT is at times misinterpreted at ground levels by staff as mandatory and people are not given the choice to opt out. In the case of women and girls; once they are confirmed positive then the drama starts. How to tell their partners is a real dilemma as it ends up in violence and being thrown out of their homes. I have watched a number of incidents that have happened already here in PNG and am really concerned.

Again coming back to the aim of PICT if it is to ensure people have early access to treatments then for PNG this may be a challenge with the current treatments (ART) issues that we are faced with. We all need to be very careful of what we do in the name of saving lives. Some programs are dealing with sensitive issues and where possible we need to ensure NO HARM IS CAUSED…..

Thank you and I hope others have something to add on…..

Maura Elaripe
GIPA Advocacy Officer
PNG-Australia HIV & AIDS Program
AusAID
Locked Bag 129
Waigani,
Papua New Guinea
Ph: +675 323 8585
fax: +675 3237364

Contribution by: Shiba Phurailatpam
Thu, 2010-08-26 13:35 — admin

Dear All,

In contribution to the ongoing discussion, I am pleased to share with you research conducted by The Asia Positive Network of Positive people (APN+) in 2009 on challenges faced by positive women in accessing HIV services in the region. Field research was conducted in Cambodia, China, India, Indonesia, Thailand and Vietnam. The participants of the study were identified through existing positive groups or network so they are likely to have better information or access, this though brought to light the difficulties faced by positive women face who are not in touch with existing positive or community groups. The study was part of a series of studies done on access to treatment, that included access to treatment for IDUs and MSM in addition to positive women.

A short summary of the findings and key recommendations made are highlighted below. You will find the full report titled A long Walk… Challenges to women’s access to HIV services in Asia on our website www.apnplus.org

Key Findings:

HIV information and counseling: The study found out that the majority of women in all countries except China were informed they were going to be tested for HIV before the test and had post-test counseling; women 40 years and older were significantly less likely than younger women to have received information before their HIV test or counseling afterwards. Many migrant workers said they had mandatory testing in the host country without counseling. The majority of respondents in all countries except China received post-test counseling.

Quality of HIV Services: Most women (63.3%) were satisfied with HIV services available in their area. Only in China was the majority of respondents (63.0%) dissatisfied with available services. There was a significant difference in satisfaction depending on where women lived: capital city 81.7% were satisfied, other city 66.6%, town 74.3%, village 58.3. Indian women said most doctors are unable to give quality personal time to women with HIV and the situation in some district hospitals is “deplorable” because many of the doctors are not trained or equipped to deal with HIV in general and women in particular. Other women spoke of breaches of confidentiality by health care providers which act to discourage access to treatment and care. FGD participants in both Cambodia and China said services in hospitals are not integrated. This causes problems in terms of travel, time spent waiting for doctors, and discrimination from health care workers in services that are not used to and comfortable to treat people with HIV. Women who are HIV-positive and who also want reproductive health services or treatment for TB or Hepatitis must visit several different clinics or hospitals.

Accessibility of ARVs: The majority of women (65.1%) were currently taking ARVs (range: India 50.2% to Cambodia 86.1%); women 40 years and older were significantly more likely to be on ARVs than younger women (84.6% vs 59.0%). Most (85.9%) get them from a public health facility; 30.0% of women said they had not started ARVs. Just over half of the women (53.6%) said access to ARVs in their area is easy, 12.9% said they did not know, and one in three women (33.5%) said access was difficult or very difficult. Women who lived in the capital cities were significantly more likely to have easy access to ARVs than women in rural areas (61.5% vs 50.8%). Many HIV services for women and children living with HIV are available only in large urban centres. In Vietnam free ARVs and treatments for opportunistic infections (OIs) are available in some hospitals or clinics, but these are usually in large urban centres or in provinces that have PEPFAR11 funding, so the number of people able to receive ARV treatment is restricted and the number of people needing ARVs and treatment for opportunistic infections (OIs) is much higher than the resources available. Some Vietnamese respondents said that some health care workers assume that it is a waste of money buying drugs for people whom they see as having no hope of surviving. Some women complained that the drug supply system does not function adequately to ensure the availability of all needed drugs so stocks of drugs running out are common. ARVs are free in many government facilities but some health care providers are unethical because they request money from them. In Thailand women said they get free ARVs and CD4 tests as well as TB tests and pap smears. These are available at particular hospitals,
but if you do not live close by, travel expenses can be high.

Distance from services: On average, the time it takes for women to travel to their nearest HIV service provider was 1.5 hours (range 0 to 30 hours). Twenty women in the survey said they regularly travel vast distances (100-280 kilometres) resulting in high transportation cost. In most countries, ARVs are provided only on a monthly basis, which means a journey to the clinic at least once per month if not more (mean 1.2 times per month); sometimes when there have been drug stockouts, clients have had to return to the clinic every few days for their next supplies of ARVs.. Women rarely receive support for transport costs. Some Cambodian women said they had resorted to selling property to pay for travel costs to get to health services. Several women from different countries said they frequently borrow money in order to get to the hospital. Some women choose to travel to large urban centres to get services because they are afraid of a breach of confidentiality if they use services close to home.

Income: Most women (78.7%) said they do not have adequate financial resources to access HIV services, including transport and most women (59.7%) said they do not have sufficient income to maintain their health needs (range: 40.8% in Indonesia to 75.2% in China); 28.7% said their income was barely adequate; only 11.5% of women said they had sufficient income to maintain their health (4.5% in China to 23.5% in Indonesia). Women in several countries said finding money for the next meal is most women’s top priority. Women in Indonesia said they often face a dilemma as to whether to spend their money for transport to get ARVs or to buy food. Most women in India said they got no income support from anybody; many have faced rejection from home, the community and society. Only 23.1% of women said they knew of any programs that provide financial support for women living with HIV. Women who lived in rural areas had significantly greater likelihood of inadequate financial resources to maintain their health and get access to HIV services. Few peer support groups have income-generating activities. Some women complained that where such projects exist, they generate very little income and the cost of transportation to the project can be more than the amount the woman earns in a day.

Other services: Most women (69.3%) said they needed access to counseling in the past six months; significantly more women who are on ARVs needed counseling than women who were not on ARVs - 71.1% vs 64.6%; women over 40 years old had a significantly higher need for counseling than younger women (84.0% vs 64.9%). Most women (86.7%) said they needed CD-4 testing and 47.1% said they needed viral load testing; the majority of women over 40 said they needed access to viral load testing, a significantly higher proportion than women under 40 (71.7% vs 40.0%), because older women are more likely to have been on ARVs longer. Only 21.9% of women were able to get access to all the services they needed. Women got needed services from a government facility (43.1%), peer support group (34.9%), NGO (32.5%), or the private sector (5.2%); 15.2% were unable to access any of the services they needed; place of residence was related to availability of services; only 6.8% of women living in the capital cities said they were unable to get access to any of the services they needed compared to 24.0% of women living in villages, women 40 years and older were significantly more likely to say they were unable to get access to any of the services they need in the past six months compared to younger women (23.5% vs 12.%). In 50.1% of cases services were free; 46.3% of women said they had to pay for some or all of the services they received (in Thailand 83.9% of women said they paid for some or all of these services). Lack of money was the major reason respondents cited for not being able to get access to services they needed (28.6%); other reasons were fear of discrimination (15.6%), not knowing where to go (12.2%) and services not being available (10.2%). The availability of CD4 counts varies greatly. In India it is free in government hospitals but at times staff members try to charge clients or ask them to go to private clinics (where the staff member has connections). Some women in Vietnam said they do not know their CD4 count and the only monitoring they have ever had is a blood test measuring their lymphocyte count, which is a less sophisticated measure of one’s immune system. Most FGD participants said that if they need to change their ARV regime due to drug resistance, alternatives are often prohibitively expensive, Viral load testing is also usually unavailable or when it is available it is too expensive for most women; most women said they did not get viral load tests. Several participants said they would rather use their money for living expenses. Most women said they had never had viral load tests. No women said they had access to drug resistance testing.

Prevention of vertical transmission: One in ten women (10.5%) said no ARV regimes are available to prevent vertical HIV transmission among pregnant women (Thailand 0% to Vietnam 17.3%), 34.7% said they know that preventive ARV regimes were available and 54.8% of women did not know (Vietnam 44.5% to Indonesia 68.8%); Indian women were most likely to say that one-off dose Nevirapine is still used (41.5%), while Cambodian respondents were more likely to have access to more complex WHO-recommended ARV regimes (34.9%). Many Chinese FGD participants said there is no referral system in Beijing, so HIV-positive women do not know where they can go to deliver their baby. In Thailand women said there is an “ever-changing policy” on migrant workers so migrant women who are pregnant are not certain how they will be treated by Thai authorities; therefore a considerable number of migrant women do not attend the antenatal clinic because they are afraid they will be sent back to their homeland.

Discrimination within health care sector: About one in two women (47.0%) said they had faced discrimination within the public health system in the previous two years. Women who lived in rural villages experienced significantly more discrimination than women in urban areas (52.7% vs 43.3%). Of the 53 women who said they had been tested as a result of donating blood, 43 said they had experienced discrimination in the health sector in the past two years. Women who were not informed they were going to be tested for HIV subsequently experienced significantly more discrimination than women who knew they were being tested for HIV (58.9% vs 39.4%). A significantly higher proportion of women who identified as migrants and/or refugees said they faced discrimination compared to other women (62.0% vs 42.2%); among 444 women who lived in rural villages, a significantly higher proportion of over 40 year-olds said they faced discrimination in the health sector within the past two years than did younger women (68.7% vs 45.5%). Women who identified as sex workers did not face more discrimination within the health system than other women. A higher proportion of women who identified as injecting drug users said they experienced discrimination in the health system compared to other women but the difference was not significant (52.7% vs 46.1%). Marital status had no correlation with levels of discrimination. Stigma and discrimination happens in most hospitals at different levels, often in subtle ways. In some facilities doctors are reluctant to treat people with HIV. Women in FGDs in Vietnam said that some doctors postpone health checks or delay treatment; some said they have to wait a long time before receiving attention, and sometimes women are referred to other hospitals.

Based on the findings the study made these recommendations:

This study found that the major constraints on women’s access to HIV services and treatments are: where women live, having sufficient income to sustain one’s health and information available; the study also found that overall, older women had more unmet needs and greater levels of dissatisfaction with HIV services than younger women.

The findings of this study can be used to advocate for the following recommendations:

Governments act responsibly to address discrimination and breaches of confidentiality within the public health system and engage women living with HIV to train health care workers on issues of HIV-related stigma.
Governments and NGOs promote the concept that HIV is a chronic but treatable condition, and provide resources for increased treatment literacy and treatment adherence.
Counseling services are expanded and women living with HIV are trained and employed as counselors within the public health system.
Governments and NGOs support HIV-positive women’s income generation, provide micro-credit schemes and assist women to build small businesses.
HIV-friendly reproductive health services are integrated with HIV services to improve accessibility of services; accurate information about reproductive and sexual health is provided and regular cervical pap smears for HIV-positive women are promoted; no woman is coerced into sterilization.
Women living with HIV are assisted to understand their rights and advocate for them

Thanks

Shiba Phurailatpam
Regional Coordinator
APN+

Contribution by: Annie McPherson
Fri, 2010-08-27 13:07 — admin

Dear Shiba,

Thank you for the brief on the research conducted. After reading through it I felt disappointed that similar research has not being undertaken in the Pacific especially when PNG is the epicenter of HIV prevalence in the Asia/Pacific.

Just yesterday and the day before The Executive Director for UNAIDS Mr Michel Sidibe was in PNG on his official visit and he spoke very strong about the issue of Gender, Violence against women, Discrimination & Stigma and the great urgent need to engage better with women. Provide access of services for women so that women can have better understanding and make informed decisions for themselves. He also spoken very strongly on mother to child transmission and so through better access for mothers will mean better protection for children/babies. Every year in PNG we have approximately 400 babies born are tested positive, these I strongly believe we can be control but it can only happen if there is a better baseline information available through such research.

I sincerely that APN+ will in the future consider undertaking similar research in the pacific.

Sincerely,

Annie McPherson

Contribution by: Shiba Phurailatpam
Fri, 2010-08-27 13:07 — admin

Dear Annie,

Thanks for your interest on the study and on conducting a similar research in PNG.

The study was conducted as part of our women's working group (WAPN) activities. Similarly the other two (MSM and IDU) were also conducted through our pos MSM and IDU working groups. The study on women was supported by Ford Foundation, UNDP and UNAIDS.

We have received many expressions of interest from other countries that weren't part of our initial study. The steering committee is interested in discussing with those countries not included in the first round for a second study. We are happy to discuss further with Igat Hope as we move forward the discussion.

Thanks.

Shiba

Director. IHI.

Contribution by: Priya Nanda
Fri, 2010-08-27 07:36 — admin

Universal Access for Women and Girls Now! – India

Dear All,

For women and girls in many countries, access to both HIV prevention and treatment programs remains limited. Barriers to prevention programs, testing, and treatment come from multiple sources and frequently differ among populations. While there is greater acknowledgement now that gender inequality and unequal power relations between and among women and men is central to the issue of access, there is a greater need to bring women and girls to the forefront in the global and national response to AIDS. In fact, meeting the goals of universal access to HIV prevention, treatment and care by 2010 and the Millennium Development Goals by 2015, will not be possible unless the needs of women and girls are addressed as a central element and urgent priority of the AIDS responses (UNAIDS 2008, UNDP 2009).

In response to this the Global Initiative Universal Access for Women and Girls Now! was launched to reinvigorate progress towards achieving universal access to HIV prevention, treatment, care and support (universal access) and Millennium Development Goals (MDGs) focusing on women and girls and their access to HIV services. The aim of the initiative is to significantly accelerate progress towards meeting the specific universal access targets for women and girls by ensuring full integration of key gender actions into national AIDS strategies and plans, and the integration of key HIV actions into national gender strategies and plans. The initiative uses country led, country focused and multi-stakeholder process to concretely address challenges and bottlenecks to scaling up HIV responses for women and girls and promoting gender equality in national AIDS responses. In India the initiative is implemented by ICRW with support from UNDP.

Although researchers in India have investigated and identified many of the socio cultural factors that make women vulnerable to HIV, what is still not adequately understood is a comprehensive understanding of barriers (perceived and actual) to HIV prevention, testing and treatment services for women and girls in different settings of risk and vulnerability.

As a first step toward addressing the issue on access to treatment for women in the country, there needs to be greater understanding of the issue based on evidence from the ground. As such, ICRW plans to conduct a study to assess the barriers that impede women’s access to HIV services in particular for female sex workers and wives of migrant men. The two populations identified here are both based on review of the literature that suggests that there are very few studies on wives of migrant men who are at risk of infection in source settings. The findings from the study will be shared at regional and national meetings.

The findings of the study with be shared at regional and national consultations meetings with key stakeholders who will help identify priority focus areas for research and action. ICRW in consultation with UNDP will develop an action plan for addressing girl’s and women’s barriers to HIV services. The proposed action plan will be informed by documents that have already been developed such as the Mid Term Review Report of NACO and the Gender Mainstreaming document of NACO, building on them further by developing short term and long-term strategies.

Priya Nanda,
Director - Social & Economic Development Group
International Center for Research on Women (ICRW)
Asia Regional Office
C-139, Defence Colony, New Delhi-110024
www.icrw.org

MDG 6 and 3 - Query
Fri, 2010-08-13 08:23 — admin

I would like to know where/whether I can access a Report cited in the Summary Report - Lewis, I. (2008) “Report on Links Between Violence Against Women and the Transmission of HIV in 4 Provinces of PNG” University of Canberra, Australia & National HIV/AIDS Support Program, Papua New Guinea.

Thank you
Christine Stewart
Australian National University

Contribution by: Monica Smith
Mon, 2010-08-16 09:14 — admin

[Facilitator’s note: The issue of HIV and Gender Based Violence will be discussed in more depth in Part 3 of the e-discussion on HIV and MDG 6 and 3 www.hivapcop.org. Thanks to Chris Bradley for also replying to the query and providing the location of the report online.]

Dear Ms. Stewart,

The report that you are referring, FINAL Report on Links Between Violence Against Women and the Transmission of HIV in 4 Provinces of PNG by Lewis, I., Maruia, B., Mills, D. & Walker, S. November 2007 Revised September 2008, University of Canberra, Australia & National HIV/AIDS Support Program, Papua New Guinea, Funded by the National AIDS Council, PNG with the support of the Australian Government, is available on the Papua New Guinea, National AIDS Council Secretariat website: http://www.nacs.org.pg/www/html/201-research.asp. The Papua New Guinea, National AIDS Council Secretariat website shares publicly key publication on issues relating to HIV in PNG.

The study argues that the spread of HIV in Papua New Guinea is influenced by the social and cultural context and aims to develop knowledge about the relationship between violence against women and HIV transmission, and to give women a voice by asking them about their experiences of violence and their recommendations for services and community responses for women experiencing violence. Physical abuse in relationships was reported by 58.2% of the sample, emotional abuse was reported by 56.4%, financial abuse were reported by 45.5%, sexual abuse was reported by 44.6%, and social isolation by 36.4%. Women who reported violence in their relationships were, on average, at least two years older than women who said they had not been abused. Women spoke about the negative impact of violence on their lives. Women’s attitude towards the violence included acceptance because of financial dependence on husbands and partners, and cultural customs such as payment of bride price and polygamy. 75% of the sample had never accessed support services. Participants in the study called for changes to legislation to protect women’s rights, more informed responses to violence against women by police, strengthening of court responses to offenders, empowerment of women, employment opportunities to reduce financial dependence on men, and education of men in the need to care for women. There was also a strong recommendation for making community and counselling services available and accessible for women who are victims of violence. The study concludes that programs which are concerned with the prevention of HIV in PNG must include interventions to counter child sexual abuse and domestic violence and should aim to increase the financial independence of women through greater access to education and employment.

Monica Smith – Consultant, UNDP

Peterson Magoola – HIV Programme Specialist, UNDP PNG.

MDG 6 and 3 - E-discussion Part 1
Wed, 2010-08-11 12:32 — admin

[Facilitator’s note: This week we will focus on issues relating to advocacy, stigma, and discrimination. Please send us your feedback by 17 August 2010. Contributions can be submitted by replying to this email or via the HIV-APCoP website at www.hivapcop.org]

Part 1: Advocacy, stigma and discrimination

Discrimination on the basis of HIV positive status continues to impede the capacity of positive women to function normally and effectively in society. Not only does it contribute to mental trauma, it also deprives women’s access to the social amenities and institutions that are necessary for a dignified existence.

Our consultations with women affected by HIV in India, Philippines and PNG brought to light many examples of stigma and discrimination against people living with HIV, women in particular. Participants from India complained that doctors and nurses refrain from providing positive women with medical (and, even, dental) treatment. In the Philippines, disclosure of HIV status has been found to compromise the employability of women in the non-NGO, non-positive network sector as well as their ability to rent premises for accommodation. In the rural areas of PNG, almost complete ostracism of positive women continues unabated.

Also, in many Asian communities, including but not limited to those discussed above, adolescent and young women are not educated about sex and HIV, for various gendered social, cultural and religious norms and expectations that require girls to be “ignorant about such issues. Instead, their primary sources of information – often, inaccurate and misunderstood – are peer groups and the media. In many instances, as the findings from the consultations show – media portrayal of HIV related issues is negative and biased.

Questions:

What can we do to encourage attitudinal changes in attitudes and practices that will lead to treat positive women as equal participants in social life?
How can we formulate and deliver culturally appropriate knowledge to women and girls that is not misunderstood?

Nashida Sattar

HIV-APCoP Facilitator

Contribution by: Susana
Fri, 2010-08-13 07:23 — admin

Contribution by: Susana Fried, Mandeep Dhaliwal, Deena Patel, Julia Kim, Brianna Harrison and Brian Lutz, HIV/AIDS Practice, UNDP.

Dear colleagues:

Congratulations on the launch of this e-discussion. We welcome this opportunity to expand the conversation about women, girls, gender equality and HIV. This is an especially opportune moment, given the recent launch of the UNAIDS Agenda for Accelerated Country Action for Women, Girls, Gender Equality and HIV, the conclusion of the 2010 International AIDS Conference and preparations for the upcoming High-Level Summit on the MDGs this September well underway. In the following note, we focus on two inter-related themes: first, we stress the importance of structural interventions to effectively addressing gender inequality and HIV, in a cross-MDG context – for example, looking at the intersections of gender equality (MDG 3), maternal health (MDG 5) and HIV (MDG 6); and second, we highlight the critical role that women living with HIV can play in this process (expanding upon the foundational principle in the AIDS response of GIPA – greater participation of people living with AIDS). UNDP is working towards achieving the MDGs in a coordinated fashion under the guidance of Administrator Helen Clark and the recently released MDG Breakthrough Strategy, which clarifies the role of UNDP in the broader context of the UN system in advancing the MDGs worldwide, and provides an operational framework for implementing enhanced MDG support work at the country, regional and global levels.[i]

The last five to ten years have borne witness to unprecedented achievements in improving access to HIV treatment. Today, more than 5 million people are currently receiving treatment.[ii] Some strides have also been made in the prevention of new infections.[iii] According to the recent 2009 AIDS Epidemic Update, “the annual number of new HIV infections globally has declined, and HIV prevalence among young people has fallen in many countries.[iv] Globally, coverage for services to prevent mother-to-child HIV transmission rose from 10% in 2004 to 45% in 2008,[v] and the drop in new HIV infections among children in 2008 suggests that these efforts are saving lives.”[vi] This International AIDS Conference also heard the announcement of the “CAPRISA” trial, in which for the first time, a microbicide containing the HIV drug Tenofir was found to reduce infection risk in women by 39%.[vii]

According to UNAIDS, the total number of people living with HIV in 2008 reached an estimated 33.4 million. Of these, around half were women and girls (although women and girls constitute almost 60% of all those living with AIDS in southern Africa). While sub-Saharan Africa remains the most hard-hit by AIDS, worrying trends are being observed in other global regions, notably Central Asia and Eastern Europe where the rate of new infections continues to be high. In Asia Pacific, UNAIDS estimates that around 4.7 million adults are living with HIV in Asia, approximately 35 percent of whom are women.[viii] Many countries in the region are already experiencing severe epidemics among typically marginalized groups such as sex workers, injecting drug users, men who have sex with men and transgender people.

There is also alarming significant increase in the number of new infections through intimate partner transmission. According to the report of the Commission on AIDS in Asia, at least 75 million men in the region buy sex regularly from women, men and transgender people, and many are either married or likely to get married.[ix] In India, It has been estimated that 90% of women living with HIV in Asia were infected by their husband or long-term partner.[x] Thus, while much has been achieved globally, nationally and locally against AIDS, much remains to be done if MDG 6 is to be reached in the foreseeable future.[xi]

In the Secretary General’s 2010 Report on the Implementation of the Declaration of Commitment on HIV/AIDS and the Political Declaration on HIV/AIDS, he emphasizes that universal access to HIV prevention, treatment, care and support represents an essential bridge towards achieving the full range of Millennium Development Goals. He also stresses the need for the international community to “redouble its commitment to achieve results in the response” and to “capture and maximize the synergies between the response and the broader Millennium Development Goal agenda.”[xii] The UNDP Breakthrough Strategy aligns with UN Secretary General Ban Ki-moon’s call for increased commitment to delivering on the MDGs. We address the cross-linkages and importance of achieving the MDGs in the subsequent discussion.

1. Structural interventions

More than 25 years into the AIDS epidemic, gender inequality and unequal power relations between and among women and men continue to be major drivers of HIV transmission.[xiii] Gender inequality and harmful gender norms are not only associated with the spread of HIV but also with its consequences, such as violence targeted toward women living with HIV. Intimate partner violence, challenges in negotiating safer sex, unequal access to primary and secondary education, unequal access to income and control over household assets and other manifestations of gender inequality are closely associated with the risk of women becoming infected with HIV and with the challenges they face in managing the impact of HIV on themselves, their families and their communities.

If gender inequality is a driver of HIV, it is also true that HIV contributes to perpetuating gender inequality. For example, as girls are increasingly kept out of school to stay home and care for affected relatives, their disadvantage vis á vis their male counterparts escalates. Likewise women tend to suffer more than men from HIV-related stigma, which can lead to loss of employment and/or housing, thereby placing women at a greater disadvantage than men in their communities. In addition to disadvantage, women living with HIV may be targeted for violence.[xiv]

Evidence of the link between HIV and gender-based violence is becoming much more robust. For example, a report from South Africa makes the point unequivocally: intimate partner violence, and “relationship power inequity” more generally, increase the risk of HIV infection in young South African women.[xv] The recent publication “Addressing violence against women and HIV/AIDS: What works?” documents the growing body of well-evaluated, promising programmes that can inform work on violence against women and HIV, and notes that “locally relevant ways of achieving gender and structural transformation need to be developed and evaluated.”[xvi]

Addressing inequitable relationships and reducing gender-based violence require multi-pronged strategies that focus on scaling up human rights-based health and community systems to empower women to secure their sexual and reproductive health, and to address root causes of vulnerability to HIV through fostering gender equality and securing human rights. For example, in India, knowledge of and access to sexual and reproductive health services in rural areas is low, and HIV-related stigma and discrimination lead to low levels of demand. UNDP is supporting a public-private partnership to establish small hospitals providing low-income clients with access to maternal and child healthcare services – such services can help make societies more crisis-resilient over the longer term, and contribute to more sustainable and equitable growth.[xvii]

Efforts can have even greater impact on HIV and other MDGs when combined with programming that strengthens women’s legal and economic empowerment, such as microfinance projects combined with HIV and gender-based violence prevention or community mobilization and challenges to traditional gender norms. In some cases, multi-sectoral approaches have catalyzed changes in key policies. For instance, a widow pension scheme in India is now helping reduce impact in AIDS-affected households, especially for women and girls. The UNDP Women and Wealth Project for the socioeconomic empowerment of women living with HIV in Cambodia and India enables groups of women living with HIV to develop small business enterprises. In turn, these enterprises help cultivate lasting economic and social growth for women and their families, while reducing HIV-associated stigma and discrimination at the community-level.[xviii] Studies on the correlation between property rights and women’s roles in the household and community show that women who have rights over land and housing, independent from those of their husbands or fathers, are more respected in the community, have fewer instances of domestic violence and are better able to improve their own lives as well as those of their children.[xix] UNDP, in collaboration with the International Association of Women Judges (IAWJ), worked with the Nepalese judiciary on women’s inheritance and property rights in the context of HIV. Building upon the work that the UNDP Regional Programme on HIV in the Asia Pacific Region, in partnership with UNIFEM and UNAIDS, undertook in 2008 to increase women’s access to land and property in the context of HIV, this process contributed to the enhanced awareness of judges about the link between women’s rights to property and inheritance and their ability to manage the impact of HIV on themselves, their families and their communities. At the same this, it strengthened cross constituency dialogue on issues of access to justice, women’s inheritance and property rights and HIV.

Significantly, structural interventions can lead to sustained progress across MDGs, particularly where those who were disempowered by the existing structures are directly involved in determining the changes needed for equal enjoyment of rights. This is embodied in the hallmark of the AIDS response – the principle and practice of the greater involvement of people living with HIV.[xx] Such a commitment to participatory methodologies can have a positive impact on other MDGs.

2. The role of women living with HIV

The purpose of participation reaches beyond an ethical commitment: women living with and affected by HIV are uniquely placed to assess and analyze their region’s response to gender inequality and AIDS, or indeed, progress toward achieving all of the MDGs. In many cases these are women with first-hand experience of gender inequality’s impact on HIV vulnerability, and vice versa. While statistical assessments conducted can provide a broad overview of a country’s progress, it cannot reveal what that progress (or lack of) means in terms of the lives of women and men in communities. In addition to adding value to the veracity and impact of such assessments, involving networks of women living with and affected by HIV directly in national and global responses to AIDS can contribute to the development of social capital amongst these groups and between these groups, other civil society organizations and the national government. For instance, the Sonagachi project in India, started in 1992 with the aim of helping sex workers to address HIV on their own terms,[xxi] has resulted in greater empowerment of sex workers, mostly women, and increased condom use. By training sex workers to act as peer-educators, by addressing social and practical barriers that prevent sex workers from using a condom, and by about increasing awareness about the economic benefits of enforcing condom use in their brothels, condom use among sex workers rose from 27% to 82% from 1992 to 1995.[xxii] HIV prevalence among sex workers in the area fell from 11% in 2001 to less than 4% by 2004.[xxiii]

Effectively addressing the full range of issues related to needs and rights of women and girls in the context of HIV requires a comprehensive response that is grounded in the experiences of women, girls and key populations; informed by evidence; and based on the promotion and protection of the human rights of all women and girls. Efforts should address the specific issues faced by women living with and affected by HIV. The UNAIDS Agenda for Accelerated Country Action for Women, Girls, Gender Equality and HIV and Joint Action for Results: UNAIDS Outcome Framework, 2009-2011 sets an action agenda with priority results identified for achieving universal access and the MDGs, including for women and girls. As noted in UNDP’s Essential Actions on Gender and AIDS,[xxiv] HIV-positive women’s organizations, women’s organizations and individual women, in partnership with governments, are essential actors in HIV responses. In most countries, civil society remains at the forefront of HIV prevention, treatment, care, support, and especially in reaching out to people in key populations including the most marginalized.

Promoting and facilitating the meaningful participation of groups of HIV-positive women and groups that work on women’s human rights―including sexual and reproductive health and human rights, gender-based violence, rights of sex workers, rights of women who have sex with women, and transgender persons―as a core part of national HIV responses, will contribute to the effectiveness of these strategies, policies and programmes. UNDP has recently launched a Leadership Development Programme (LDP) focusing on developing capacity and leadership of HIV-positive women and girls and directly addresses their needs and rights as defined by them. The project is currently being rolled out in at least 10 countries across regions.[xxv] Additionally, UNDP is leading an initiative to empower national networks or organizations of women living with HIV to advocate on and contribute to achieving MDG targets. The project is supporting at least two national-level networks or organizations of women living with HIV in six key global regions[xxvi] to map and assess progress on gender equality and women’s and girls’ human rights commitments and achievements on HIV, as input to the 2010 UN Millennium Development Goals Summit. As stated in the UNDP Breakthrough Strategy, “gender equality and women’s empowerment not only constitute a development goal in their own right (MDG 3), but also are essential if countries are to achieve the other MDGs.”[xxvii]

Through this e-discussion, we look forward to learning about innovative approaches in this area of work and to sharing more about some of the work already mentioned in this reply.

[i] UNDP, UNDP’s MDG Breakthrough Strategy, 2010.
[ii] WHO, 2010.
[iii] UNAIDS, 2009.
[iv] UNAIDS, 2008.
[v] World Health Organization, United Nations Children’s Fund, UNAIDS, 2009.
[vi] UNAIDS and WHO, 2009. AIDS Epidemic Update, p. 9.
[vii] See Kaiser Daily Global Health report at http://globalhealth.kff.org/Daily-Reports/2010/July/20/GH-072010-AIDS-20...
[viii] UNAIDS, 2008.
[ix] Report of the Commission on AIDS in Asia, Redefining AIDS in Asia – Crafting an Effective Response, 2008.
[x] UNAIDS, HIV Transmission in Intimate Partner Relationships in Asia, 2009.
[xi] See www.aids2031.org for a series of discussions on what the world needs to do NOW in order to reverse the course of the epidemic by the year 2031, 50 years after the discovery of the virus that causes AIDS.
[xii] Report of the Secretary-General, Progress made in the implementation of the Declaration of Commitment on HIV/AIDS and the Political Declaration, 2010.
[xiii] UNDP, 2008.
[xiv] See for example, S Maman, J. Mbwambo, N. Hogan, G. Kilonzo, “HIV-positive women report more lifetime partner violence: findings from a voluntary counseling and testing clinic in Dar es Salaam, Tanzania.” American Journal of Public Health, 2002. Accessible at: http://www.popcouncil.org/pdfs/horizons/VCTarticle.pdf.
[xv] Rachel Jewkes, Kristin Dunkle, Mzikazi Nduna, Nwabisa Shai, “Intimate partner violence, relationship power inequity, and incidence of HIV infection among young women in South Africa: a cohort study.” The Lancet, vol. 376, July 3, 2010.
[xvi] WHO, 2010.
[xvii] UNDP Press Release 8 April 2010. Available at: http://content.undp.org/go/newsroom/2010/april/indian-hospital-chain-to-....
[xviii] http://content.undp.org/go/newsroom/2010/june/women-weavers-in-india-wal...
[xix] ICRW, 2006.
[xx] See, for example, The World Bank, Public Health at a Glance, at http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTHEALTHNUTRITIONANDPOP...
[xxi] http://www.avert.org/sex-workers.htm.
[xxii] http://www.avert.org/sex-workers.htm.
[xxiii] UNAIDS, 2005.
[xxiv] UNDP, Essential Actions on Gender and AIDS, 2008.
[xxv] Participating regions include: 1) Latin America and the Caribbean, 2) the Arab States, 3) Asia-Pacific, 4) Eastern Europe/CIS, 5) Eastern and Southern Africa, and 6) Western and Central Africa.
[xxvi] The six participating regions include: 1) Latin America and the Caribbean, 2) the Arab States, 3) Asia-Pacific, 4) Eastern Europe/CIS, 5) Eastern and Southern Africa, and 6) Western and Central Africa.
[xxvii] UNDP, UNDP’s MDG Breakthrough Strategy, 2010.

Contribution by: Karabi Baruah
Mon, 2010-08-16 12:48 — admin

Congratulations on the launch of this e-discussion. As Edward Camedon, Constitutional Court Justice in South America remarked: “AIDS is probably the most stigmatized disease in history…If we do not appreciate the nature and impact of stigma, none of our interventions can begin to be successful”.

In the previous contribution Susana Fried and colleagues highlighted the mutually reinforcing nature of the relationship between gender inequality and HIV perpetuating gender inequality, and on the participation of HIV positive women in AIDS responses. There is indeed international consensus on the need for women’s participation as well as donor and civil society calls for enhanced focus and resources on gender equality and women’s human rights, women’s full participation in the AIDS response – yet we are far from realization of this.

Data and analyses of women’s representation and participation, including networks of women living with HIV, women’s rights organizations or grassroots women, are not readily available at the country, regional or global level. With very little consistent monitoring of involvement by key stakeholders, obtaining information on who is participating where, in the formal and informal AIDS response is challenging. The deeper question of meaningful participation by those most impacted by the epidemic is even more difficult to assess.

In the absence of relevant data and to establish a foundation for further research, UNIFEM in partnership with the Athena network, commissioned a review of women’s leadership and participation in the AIDS response at the national and global level. The outcome “Transforming the National AIDS Response: Advancing Women’s Leadership and Participation”[i] was launched at the recently concluded 2010 International Conference on AIDS in Vienna. In addition to understanding where and in what ways women particularly those affected by the epidemic, participate, the study also assesses the opportunities for and challenges to their participation in the responses.

In depth interviews and consultations with more than 100 key informants, including institutional leaders and decision-makers were held in Southern Africa, South and Southeast Asia, Latin America, and elsewhere. The analysis was also informed by an extensive literature review, documentation of country case studies, and the responses to and results of a survey disseminated to global and regional networks. Additionally the review benefitted from and drew on a series of in-depth interviews of 25 women leaders from around the world conducted by the International Center for Research on women (ICRW).

One of the five key findings from the review relevant to this E-discussion is on the barriers faced by affected women and their participation in AIDS responses: these are gender norms (79%), Stigma (58%), lack of access to information (46%) and resources (58%), the burden of care and women’s multiple responsibilities in the home (46%), illiteracy (46%) and low self esteem (25%) as key constraints to their meaningful participation. Moreover, women’s participation is treated as a privilege rather than as a right. Respondents consistently reported that even when women do hold a ‘seat at the table’ – whether it be in formal decision making forums such as the Country Coordinating Mechanism (CCM) or at a meeting of NGOs – their presence is frequently contested or their expertise is looked to as only relevant to ‘women’s issues’ instead of as having a critical role to play as both speaking to issues of particular importance to women and stigma, lack of access to resources and information, the burden of care-giving, illiteracy and low self-esteem as central barriers to the full involvement and meaningful participation of women, particularly of those most affected by HIV and AIDS

There is an urgent need for dedicated commitment to developing women as agents of change and active partners in defining and implementing solutions from the community to the global levels. Advancing women’s leadership and participation in the AIDS response requires concrete steps to address the various systematic obstacles they face. There is also a need to foster longer term commitments to increase resources.

Of the ten actionable recommendations outlined in the report, I would like to emphasize the following: While increasing women’s awareness and understanding of human rights, including the right to full and meaningful participation, it is imperative to develop definitions and standards for what constitute as meaningful participation through consultation with women, particularly HIV-positive women and their networks.

To realize the power of participation also necessitates significant investment in those who are most affected by HIV. Thus it is critical to strengthen the capacity of affected women, particularly HIV-positive women and young women, to participate fully in the HIV and AIDS response through leadership training, sustained technical support and mentorship in order to promote a new cadre of women leaders at local and national levels. At the same time, gender expertise within formal decision-making bodies and funding mechanisms involved in the response to HIV and AIDS should be strengthened to ensure that national plans and programmes on HIV and AIDS prioritize women’s needs as identified by women themselves through consultation and engagement, and respond to the immediate needs of women, including increased access to HIV prevention, testing, treatment, care and support services.

In terms of progress made in achieving the MDG goals, the Asia-pacific Region is noted to have achieved amongst others the indicator “stopping the spread of HIV’[ii]. Two countries in the region have seen a reversed trend of the HIV epidemic, namely Cambodia and Thailand: In Cambodia from 1998 to 2007 the prevalence among the population decreased from 2.0% to 0.8%.[iii] While in Thailand with a peak of 143 000 in 1991 the estimated number of new infections had reached 13 936 in 2007.[iv] Yet there is another emerging picture: An estimated 1.6 million women (aged 15 years and above) are currently living with HIV in the Asia –Pacific Region, an increase from 19% in 2001 to 35% in 2008.[v] Besides, the epidemic in Asia that has been concentrated in the specific populations is gradually expanding among women whose partners have unprotected sex, with other men or whose partners are IDUs. For instance: The proportion of women among reported AIDS cases has increased in Thailand from 14% in 1990 to 39% in 2008. A third of the new infections are now among low-risk women who are infected by their husbands, of whom a vast majority have acquired HIV through paid sex.[vi]

UNIFEM in partnership with UNAIDS , UNDP and civil society organization including networks of People Living with HIV (PLHIV), researchers facilitated regional studies for strengthening the evidence informed knowledge base on HIV transmission in intimate partner relationships. Since 2008 UNIFEM has initiated the project “Empowerment and Positive Women’s Leadership in the Asia –Pacific Region”. One of the community initiatives supported under the project is entitled “Diamonds- Stories of Women from the Asia Pacific Network of People Living with HIV”[vii] on HIV positive women exercising their leadership, comprising of a publication and a documentary. On women’s participation, Mony Pen, Coordinator from Cambodia Community of Women Living with HIV remarked: “First we need to raise awareness on human rights, and also create an environment where women can come and talk freely and openly about their needs and rights…”[viii] The publication narrates the lives of ten women and a girl who overcome the challenges ascribed by their status to become leaders in their communities. The documentary on the other hand is of four extraordinary women from the region (Cambodia, Philippines, Malaysia and Vietnam) who disclose their HIV positive status and share their stories- in a society where stigma and discrimination still abounds. Their objectives and as shown by their own lived experience holds tremendous potential for shaping change whether through empowerment, eliminating isolation, fear and stigma or advancing research, policies and programmes.

An indicator of real progress in the region (as also elsewhere in the world) lies not only in the reversal of the overall epidemic but also that of women. For progress to be more meaningful the issues of stigma and discrimination and human rights abuses constantly taking place in this region need to be addressed.

Further action is needed that provides evidence how reducing stigma could result in fewer infections. To achieve greater intensity and scale of response to stigma, donors, researchers, programmers and advocates need to standardize approaches and guidance to support scale-up efforts, increase testing and translation of intervention tools, mobilize support for “best practice” field programming; prioritize the health sector for expansion and institutionalization of stigma reduction.

Work already being done requires enhanced communication and advocacy on multiple levels to scale up and mainstream better practices; Collaboration and expanded inclusion of human rights groups to counter discriminatory laws and policies. And finally strengthen capacity and equip networks of people living with HIV and other vulnerable groups to intensify stigma reduction efforts and expand training to drive expansion. [ix]

We hope to receive feedbacks on further refining our work and look forward to a continued fruitful discussion on these issues.

Karabi Baruah,
Gender and HIV Programme Specialist
UNIFEM (part of UN Women) ESEARO, Thailand

[i] Transforming the National AIDS Responses: Advancing Women’s Leadership and Participation. UNIFEM and ATHENA Network. 2009; http://www.unifem.org/materials/item_detail.php?ProductID=177

[ii] UNESCAP, ADB, and UNDP (2010) Achieving the Millennium Development Goals in an Era of global uncertainty: Asia/pacific Regional Report. http://www.mdgasiapacipic.org/files/shared_folder/documents/Regional_MDG...

[iii] http://unaids.org/en/CountryResponses/Countries/cambodia.asp

[iv] HIV/AIDS & Mobility in South-East Asia, Rapid Assessment 2008, p.30

[v] UNAIDS and WHO estimate, 2009. AIDS Epidemic update, p. 39

[vi] HIV/AIDS in the South-East Asia Region 2009, p. 10

[vii] http://unifem-eseasia.org/docs/2009_Diamonds.pdf; Trailer of Diamonds –the documentary: http://vimeo.com/7391512

[viii] Transforming the National AIDS Response: Advancing Women’s Leadership and Participation. P. 5

[ix] Scaling Up the Response to HIV Stigma and Discrimination

Contribution by: Maura Elaripe
Tue, 2010-08-17 07:46 — admin

[Facilitator’s note: With request from members, we have extended Part 1: Advocacy, stigma and discrimination of the e-discussion on MDG 6 and 3, until Friday 20 August. Contributions can be submitted by replying to this email or via the HIV-APCoP website at www.hivapcop.org]

Women and girls living with HIV in PNG face a lot of stigma, discrimination, violence and breach of confidentiality. Stigma faced in PNG is different in different settings. In urban centres women are mainly stigmatised verbally and their status revealed to others by their neighbours and families. They are left to care for the children and it’s a challenge when a woman does not have financial security. In the rural settings verbal stigma leads to some violence and abuse of human rights.

Therefore; we need to build the skills of positive women themselves and equip them with facts, skills and information on HIV and they can be the agents of change. As most stigma and discrimination starts from the families and the communities these women live in. Helping them to bring correct information to their families and communities will help to address these misconceptions and this should be made a priority. Lots of positive women I have met and worked with always say that it is because of myths and misconceptions; our families and communities stigmatise us. Some even share that because they have made it their business to learn the facts of HIV and how its spread they have educated their own families and communities who have accepted them and they live as part of the community. Also building the skills of these women to advocate for policies and laws that will support them and their children.

Maura Elaripe
GIPA Advocacy Officer
PNG-Australia HIV and AIDS Program
AusAID
Locked Bag 129
Waigani,
Papua New Guinea
Ph: +675 323 8585
fax: +675 3237364

Contribution by: Christine Stewart
Wed, 2010-08-18 08:40 — admin

I agree, Maura, and this is where the argument against maintenance of confidentiality breaks down. So many women are terrified of the possibility of stigmatization and worse. And so many other women actually suffer terrible effects when confidentiality is breached. Your plea for the building of advocacy skills to counter stigmatization and abuse, to promote condom acceptance, to counter the 'double standards' applying to men and women, generally to tear down any barriers to acceptance of the equal rights and value of all women, is so important. We hope everybody will hear it.

I am currently doing my PhD on the effects of criminalization of sex work and sodomy in PNG, and am a strong supporter for change in the legal environment. I would like to share with the group a couple of articles I have written on the subject.

Towards a climate of tolerance and respect legislation for HIV/AIDS and human rights http://www.paclii.org/journals/fJSPL/vol08no1/2.shtml
Prostitution and homosexuality in Papua New Guinea: legal ethical and human rights issues http://rspas.anu.edu.au/grc/publications/pdfs/WP_19_Stewart.pdf

More recently, I have given two seminar presentations which may be of interest to some members, regarding the WHO policy of Provider-Initiated Testing and Counselling (PITC) at ante-natal clinics in PNG, and the potential of this for stigma and abuse. Members of this group who would like copies are welcome to contact me directly.

Christine Stewart
Australian National University

Contribution by: Peterson Magoola
Wed, 2010-08-18 11:45 — admin

First, I would like to thank you for getting all this together and engaging the APCOP members to comment on this issue.
In response to the discussion questions, this is to share with you experiences from Papua New Guinea on key structural factors that have created the ‘attitude syndrome’ for positive women.

First, we would like to highlight that new infections among women in Papua New Guinea are increasing at a faster rate than new infections among men. There is a total number of adults (aged 15-49) living with HIV in 2009 was estimated to be 35,800 and by the end of 2009, a cumulative total of 11,520 people were estimated to have died because of HIV-related illnesses[i]. From 1987 to 2009, females accounted for 56% of all reported cases of HIV infection (excluding cases where sex was not reported), and males for 43%[ii]

Analysis of key driving factors of the epidemic among women in Papua New Guinea has (to a greater extent) been attributed to gender imbalances and power relations between men and women. These general imbalances and lack of power among women in the community, family, intimate relationship, workforce, political representation, etc has increased women’s vulnerability to poverty and HIV risk. For positive women, the already existing power imbalances between men and women and the limited knowledge on HIV especially in the rural areas has worsened the ability for them to enjoy full human rights resulting into more stigma and discrimination from within society.

Similarly, there is still lack of/implementation of laws and policies that specifically protect positive woman against stigmatization and discrimination. The HAMP Act[iii] has clauses that could be used to address this but it is outdated and needs review. Besides, the police and judicial system have not been properly sensitized on the issue and hence are not providing adequate/any legal protection. In some instance, HIV positive people have complained that they do not get proper protection from law enforcement agencies on cases relating to discrimination. Further, little has been done on communication and advocacy strategies that address HIV related attitudinal issues. The previous National Strategic Plan on HIV/AIDS (2006-10) for Papua New Guinea hardly highlighted any advocacy/communication strategy on this pertinent issue. Some current communication strategies being developed, focus on messages that address HIV general issues such as; transmission, prevention, treatment/ ART.

In addressing the above root causes and gaps in the region, importantly and as highlighted recently by the IRG group in PNG, there is a need to have full engagement of communities and families in the response. This needs to be viewed not only as a means of providing care and support but also as a means of normalizing ‘personalising’ and de-stigmatising[iv] for the positive women. In addition, active engagement on men and boys in advocacy on positive living and gender related imbalances will significantly pave way to change in community attitudes towards positive women.

Micro credit facilities for positive women have proved to be an effective tool in particularly to empower them to participate in economic prosperity where they had been excluded in the past. In African models, microfinance schemes have become more self-sustaining. They have been considered to be an effective anti-poverty tool in giving ‘power’ and recognition to positive women i.e. ‘When the poorest specially positive women receive credit, they become economic actors with power to improve not only their lives but also lives of their families, their communities. Perhaps these models could be tried in especially in Papua New Guinea where this kind of economic empowerment for positive women still lacks.

Likewise, the economic empowerment could be sustained with strong leadership capacity for women. Research has showed that countries where women have been represented at various levels, significantly contributed to increased advocacy on issues that affected women including education, protective laws against stigma and discrimination and policies that promote women’s rights including positive women. Perhaps, there is more need to invest resources in leadership capacity development for positive women as a means of enhancing their ‘bargaining power...’ within their communities on issues related to attitudes.

Happy to read from other APCOP members,

Carol Flore and Peterson Magoola,
UNDP, Papua New Guinea

[i] PNG National consensus workshop on HIV estimation - June 2010
[ii] NDoH (2010) THE 2009 STI, HIV AND AIDS DRAFT Annual Surveillance Report 2009. National Department of Health STI, HIV and AIDS Surveillance Unit May 2010. Port Moresby

[iii] HIV/AIDS Management and Prevention Act, PNG 2003

[iv] Independent Review Group(IRG) on HIV, PNG 2010

Contribution by: Malu Marin
Thu, 2010-08-19 07:25 — admin

The HIV vulnerabilities of migrant women and the dual stigma and discrimination faced by HIV positive migrant returnees is a special issue of concern for the Philippines. The Action for Health Initiatives (ACHIEVE), Inc. works on a number of fronts to address the issue in the country.

Through our project “Reducing Stigma and Building an Enabling Environment for Migrant Workers Living with HIV” funded by Levi Strauss Foundation, Inc., 2007-2009, we worked in partnership with migrant workers and spouses living with HIV to design a capacity development plan that would respond to their capacity building needs as HIV activists and educators. We conducted a series of workshops to deepen their perspective on issues of migration, HIV-related stigma and discrimination, gender and sexuality and build their skills in communication, peer education, public speaking and advocacy. Also activities were implemented on mentoring activities and fielding of the trained migrant and spouses educators and advocates in various practicum activities such as conducting HIV orientation seminars for OFWs, speaking at HIV conferences locally and internationally, and participating in ACHIEVE’s projects and activities.

Monthly community meetings were conducted in 2008 as a venue for the migrants and spouses to share their knowledge and insights related to their involvement in various local and regional activities. In order to assess their performance and determine their additional learning needs, the project conducted two annual assessments, which included soliciting feedback from the community on ACHIEVE’s programmes and activities. The project also supported the training of medical practitioners to enhance their capacity in reducing HIV-stigma and discrimination in handling HIV cases in the hospital setting.

Under our current project, Reducing HIV-Related Stigma and Discrimination through Policy Review and Advocacy and Building Media Competency (November 2009-November 2010), we are reviewing relevant laws and policies including: 1) The Philippine AIDS Prevention and Control Act of 1998 (RA 8504) and its utilization of PLHIVs who have experienced discrimination; 2) The Anti-Trafficking Act (RA 9208), which is invoked by police authorities to arrest and prosecute entertainment establishment owners found with condoms in their premises; and 3) the Anti-Vagrancy Act (Article 202 of the Revised Penal Code), which is used to arrest and round up sex workers and MSM, thereby affecting effective outreach prevention activities.

The results of the policy reviews will be used in organizing multi-stakeholder forums and dialogues between and among relevant agencies and communities, in order to resolve these policy conflicts that affect the implementation of effective HIV prevention programmes, particularly among sex workers. It will also guide the development of appropriate policy and programmatic responses.

Another component of this project is the production of a situation analysis report on the state of HIV-related media reporting in the years covering 2006-early 2010. This report will be utilized in the development of capacity building activities for media practitioners on responsible and sensitive HIV-related reporting. The activities will entail participation of PLHIV, thus, two trainings have been incorporated in the project, namely, basic research and advocacy. The PLHIVs that underwent research training have already participated in the conduct of the policy reviews, while those who underwent the advocacy training are applying it in their own organizations and support groups.

Contact Information

Action for Health Initiatives (ACHIEVE), Inc.
Street Address: 162-A Sct. Fuentebella Ext., Quezon City 1103, Philippines
Telephone/Fax: 632-426-6147
Telephone: 632-414-6130
Email: achieve_caram@yahoo.com
Website: www.achieve.org.ph

Contribution by: David Bridger
Thu, 2010-08-19 07:31 — admin

Sri Lankan Stigma Index reports powerful findings around internalised stigma

At the heart of human rights is human dignity. And central to human dignity is a life free from stigma and discrimination. This means honouring the Declaration of Commitment on HIV/AIDS promulgated by the General Assembly of the United Nations. The Declaration recognises that people living with HIV must enjoy the same rights as everyone else in society including: the highest attainable standard of physical and mental health, including sexual and reproductive health; sexual relationships with the person of their choosing; emotional well-being; the provision of goods and services, including appropriate healthcare professional services and treatments; access to education, and, non discriminatory employment conditions with a view to economic security. In reference to their work, the authors of the Stigma Index Report summarise such a collective spirit of justice when they assert: “If the Stigma Index points to anything, it points to the need for positive living - how to live positive, productive and full lives with HIV – in Sri Lanka”.[1]

The Stigma Index Report provides, for the first time, an important insight into the manner of injustice found against people who are HIV positive in Sri Lanka. It not only reveals that direct and visible injustice occurs, such as verbal harassment, domestic abuse, intimate partner violence[2] as well as lost employment opportunities[3], but also finds significant levels of invisible or structural injustice exists, impacting upon HIV positive people’s abilities to confidently live the same full and rewarding lives that people without HIV do.

Key amongst the many findings of the Sri Lankan Stigma Index Report are the high levels of “internalised stigma” experienced by respondents and the “corresponding decisions” they make in the face of the many structural or invisible societal barriers in Sri Lankan society. The report finds that unfair stereotyping of people living with HIV sanctions prejudicial attitudes held by people not HIV positive. Holding such attitudes is conducive to discriminatory and unjust conduct. When benchmarked against notions of morality and culture such attitudes directed towards people with HIV translate into feelings of low self esteem and internalised stigma. “It is clear that respondents were not comfortable with friends, neighbours, co-workers, employers, and children finding out their [HIV] status”, the report reveals.[4] Reports of health care workers “gossiping” and breaching professional codes of confidentiality with respect to the handling of medical records instilled fear into people with HIV of “ostracization (sic), physical assault and damage to property” from village or community peers.[5]

Shame, guilt and self-blame characterises the feelings expressed by many people with HIV and which shaped the decisions they make about their lives.[6] The lives of a significant number of people with HIV in Sri Lanka are being restricted by the invisible barriers being presented to them. As many as 77% will not have children, 45% will not marry and 37% will not enjoy sexual relations again in their lives as a result of the barriers being presented to them by society.

These decisions and the feelings of frustration that many people with HIV reported to discuss basic issues of sexual and reproductive health or their emotional well being with appropriate healthcare professionals[7] because many professionals, the Report states, do not appear, on the face of their actions, to support approaches to positive living in Sri Lanka[8] and leading the Stigma Index Report to conclude that “the continuum of care is incomplete” in Sri Lanka.

David Bridger
Country Coordinator
UNAIDS Sri Lanka and the Maldives

[1] Stigma Index Report p. 20

[2] Stigma Index Report p. 17

[3] Stigma Index Report p. 18

[4] Stigma Index Report p. 16

[5] Stigma Index Report p. 23 Of the respondents interviewed, 65% believed health care workers would gossip and 23% alleged they “have actual knowledge of healthcare workers disclosing their status without consent”.

[6] Stigma Index Report p. 28

[7] Stigma Index Report p. 25

[8] Stigma Index Report p. 27

Contribution by: Ferdinand Strobel
Fri, 2010-08-20 11:52 — admin

More stigma reduction action is needed in the health care system

I would like to argue that the response to stigma has long equated to avoidance because stigma is often poorly understood and it’s hard to figure out where to start. Enacted stigma or discrimination, on the other hand is arguably easier to address. It is dealt with by the Law, as long as laws exist and are enforced. Unfortunately if the law provides protection and redress for the consequences of stigma, the law only addresses behaviors and not the attitudes that produce the behavior. As a famous (rather cynical) example illustrates “if a company fires a saleswomen because she is HIV positive, that is discrimination under the law. But if customers refuse to deal with her, it is called choice”...

Confidentiality and privacy are highly necessary and effective solutions but they are only quick fixes and short term ones because they do not actually confront stigma. In tightly knit communities where any deviation from the norm is prone to suspicion i.e a woman not breastfeeding, a married man carrying condoms, and where everybody knows everybody; this is particularly hard to achieve and maintain. In addition to what others suggested about better understanding and measuring stigma (stigma indexes), about providing more accurate and culturally understood information and empowering women to be agent of change; and about improving the Law, I’d like to argue that we need much more efforts to address stigma at the health care facility level. After all it is often where it all starts.

The stigmatization of patients with STIs -and in fact to some extent to any disease perceived to be related to “avoidable” behavior, or for which the patient should bear some responsibility, or for which there is a fear of transmission to the health care provider- has long been institutionalized in the health care system.

This needs to be addressed urgently, in particular because Provider Initiated opt-out HIV testing is becoming the norm and some evidence already suggests that PIT can have adverse effects on women in particular, including avoidance to use health care facilities altogether and the fear of intimate partner violence. This has been highlighted in the PNG context in particular. It is critical because these negative consequences are defeating the very purpose of PIT which is to scale up access to treatment, itself very effective to reduce stigma.

A number of recommendations have been made to combat HIV stigma in health care settings. For those interested, a recent (2009) paper by the International Centre for Research on Women published in the Journal of the International AIDS Society provides an exhaustive review: http://www.jiasociety.org/content/pdf/1758-2652-12-15.pdf

It concludes:

“To combat stigma in health facilities, interventions must focus on the individual, environmental and policy levels. The paper argues that reducing stigma by working at all three levels is feasible and will likely result in long-lasting benefits for both health workers and HIV-positive patients. The existence of tested stigma-reduction tools and approaches has moved the field forward. What is needed now is the political will and resources to support and scale up stigma-reduction activities throughout health care settings globally.”

Ferdinand Strobel
Regional HIV Practice team for Asia Pacific
Pacific Centre
Suva, Fiji Islands

Contribution by: Alka Narang, Shashi Sudhir, Ernest Noronha and Caitlin Wiesen
Mon, 2010-08-23 12:31 — admin

[Facilitator’s note: We are posting a final contribution to the first part of this e-discussion series which highlights efforts in India towards addressing stigma & discrimination. We like to now bring members’ attention to the second part and request you to share your experiences on promoting access to health, ARVs, and harm reduction & prevention technologies. Thanks.]

Contributions by –Alka Narang, Shashi Sudhir, Ernest Noronha and Caitlin Wiesen -UNDP India

UNDP India’s work on HIV and the resultant stigma has been informed and shaped through generation of the much needed strategic information and balanced through the community voices from the field. Stigma and discrimination have always topped the list of PLHIV priority issues; this stigma is encountered just about everywhere – in the family, workplace, community, health care setting... everywhere. UNDP tried to address some of the development challenges faced by PLHIV through a three pronged approach - to generate more evidence for advocacy, support to community led action to address stigma and initiate initiatives that could contribute towards creating an enabling environment by addressing some of the vital structural issues. Some highlights of our work are given below

Gathering and Generating Evidence: Social-Economic Impact Study[1] : This 2006 study showed that AIDS widows face stigma on three counts – as women, as people living with HIV, and as widows. 90% were forced to leave marital home; 79% denied share in husband’s property; 43% live alone and are economically worse off than other HIV affected households. These echoed findings from a much smaller state specific UNDP supported need assessment study of and by PLHIV[2] in Gujarat (2007).Denial of property rights, maintenance, custody of children, fighting stigma and discrimination continued to be major challenges for positive women. In the recently concluded UNDP-India study on levels of stigma, the first in the country, 55% of the respondents from general population believed that PLHIV were promiscuous and 66% believed that HIV was punishment for bad behaviour. Same study also shows that levels of self stigma were significant especially among the most at risk populations who are also living with HIV.

Needless to state here that such negative perceptions not only make it more difficult for people trying to come to terms with HIV and manage their illness on a personal level, but also interfere with attempts to fight the AIDS epidemic as a whole. Women living with HIV, especially widows bear the brunt of such discriminatory attitudes and behaviours. Studies like the ones mentioned above provide excellent ammunition for advocacy for policy level and programmatic interventions and contribute to enhanced understanding of the law makers. UNDP has contributed to formulation of the HIV legislation to specifically strengthen redressal mechanisms. The draft[3] is now awaiting approval from the Parliament.

Creating an Enabling Environment- helping make structural changes:

a) Police Training was identified as one of the key strategies to address stigma towards the marginalized communities. In the state of Delhi 11,000 (or ¼ of the total police force in the state) were trained on both- ways to protect themselves from infection and also on issues of rights of those living with HIV. The training in the state of Tamil Nadu was implemented mainly through master trainers from members of marginalized communities and PLHIV, first hand exposure and interactions with transgender and positive sex workers have proved to be more efficacious.

b) Working closely with the State AIDS Control Societies in 2 states (Tamil Nadu and Andhra Pradesh), the State Legal Services Authority and the networks of people living with HIV and AIDS, UNDP set up seven Legal Aid Clinics (LACs)[4] for people living with HIV in seven high prevalence districts of the 2 states. Legal services are provided by lawyers trained on rights-based approach to HIV. An analysis of LAC beneficiaries showed that almost 70% of HIV positive people seeking legal aid services were women, many of whom were widows. Most of the disputes were related to property rights, maintenance, and custody of children, divorce & separation. Based on the success of these clinics, the state Government of Tamil Nadu[5] has already set up similar clinics in 16 districts in the state. UNDP is now helping the National AIDS Control Organisation (NACO) to draw up a strategy so as to replicate the initiative in 200[6] districts in the country.

c) As part of UNDP support for mainstreaming HIV for social protection, UNDP supports NACO to engage with different government ministries and department[7]. As a result of intensive engagement 35 government schemes[8] have been amended. One such amendment is the widow pension scheme. The Central Government provides a small sum of money to reach State for a monthly pension to all widows aged 60 and above. The State Governments are encouraged to top up the central contribution. Different states add different amounts. Evidence shows that HIV widows are in their 20s and most might not live to reach 60 years and would therefore not be able to access this provision. As a result of active advocacy, Rajasthan[9] State Government was one of the first states to modify the scheme to cover all HIV positive widows irrespective of their age. This is being replicated in other states in the country. In the state of Tamil Nadu, all widows are eligible to get either a monthly pension or a onetime grant if they are 35 years of age or above. However, as a result of active advocacy, the age conditionality has been waived for all HIV positive widows and they now get both the monthly pension plus the one time grant. This very positive amendment is also helping the non HIV widows. The State Government has directed the district administration to consider waiver of age conditionality on a case by case basis.

d) Engaging with Faith Based Organisations, essentially different denominations of churches in the north-east India, to address stigma and impact mitigation activities. Churches are actively collaborating with positive networks extending care and support, impact mitigation and using PLHIV as positive speakers in church congregations.

Support community action in order to bring in the much needed community intelligence and action at work to combat stigma.

a) Innovations Fund was set up with the India network of positive people as fund managers. The grant encouraged community led innovative action to address stigma at a localized scale, Some of the small grants initiatives are - Counselling and supporting the care taker in the family of PLHA by local network of people living with HIV, PLHIV contesting municipal elections with a purpose to create awareness and `normalizing’ HIV, placing positive `buddy’ at the hospital to ensure that the positive people are not denied health care, training sex workers to drive taxis as an alternate profession are a few examples of the 24 innovations supported. UNDP is currently supporting 12 NGO initiatives to address stigma at community level.

b) Options and Opportunities for sustained livelihoods: Interactions with the positive communities reiterated that economic empowerment not only boosts morale of the people and helps sustain health care, it also helps reduce stigma. In this regard, UNDP has supported individuals, households and collectives with livelihood support. In Bellary district of Karnataka, with UNDP support the district administration and local network of positive persons partnered with local banks to seek micro-credit for setting up small enterprises at individual level. In the north-eastern part of India, women’s groups including trafficked survivors and WLHIV have successfully been engaged in handloom textile-based livelihood programme for the past three years. This unique enterprise has just last week been honoured as a model initiative by the Chief Minister of the state of Assam.

c) Setting up and strengthening state/district level networks of positive people to help them articulate their needs, better understand the social welfare and protection programmes of government as well as civil society and then demand inclusive policies and programmes. One the most critical role played by these groups is to provide support to the positive people and report instances of violation to the appropriate authorities for action. In the current 5 year programme cycle UNDP has helped set up/ strengthen 29 district level networks. There is great demand to replicate UNDP supported 2007 initiative. As part of this initiative, 92 PLHA leaders (of state/ district level networks) graduated from Xavier Institute of Management leading Management School and received a certificate for Leadership and Management Proficiency. This initiative not only helped strengthen capacities of PHIV but it contributed to sensitizing the faculty and fellow students of the school.

d) It is evident that positive environment for inclusion of women living with HIV in social contexts needs to be created to help them assimilate better with the communities they are living in. Community structures such as Self-help groups (SHGs) have been used to address stigma in the community. Women’s groups have received technical and financial support from government and non-government agencies for undertaking livelihood programmes. In Bellary, Karnataka the SHGs are not only addressing issues of stigma but have also become a strong voice against violence against women. In Tamil Nadu a positive women collective has been able to source funds from the state government to set up small dairy selling milk.

Our focus so far has been on people infected and affected by HIV especially the women and girls. Given that transgender people (the most visible and yet marginalized) also face stigma arising from gender infrastructs and need focused attention, our work is increasingly becoming inclusive of this segment of the marginalized community.

In October 2009, UNDP hosted the first national consultation on Hijras and Transgenders in India. This brought the community and various policy makers together on the same forum. The National Legal Services Authority (NALSA), the state chapter of which is the partner providing free legal counsel at the legal clinics in Tamil Nadu, was charged through participation in this session and is now looking at broadening the scope of the legal aid for the marginalized including transgender.

The above are some highlights but these plus several others are not enough. Those infected and affected by HIV especially the marginalized and women still fear stigma and face discrimination.

We are currently helping the National AIDS Control Programme to draw up its strategy for addressing stigma which will include work towards structural changes and effective mechanisms for redressal and social protection and strengthening community capacities to advocate for rights of those infected and affected.

[1] Gender Impact of HIV and AIDS in India, UNDP India, 2006, http://data.undp.org.in/hivreport/Gender.pdf
[2] Need Assessment Study of and by PHIV in Gujarat, 2007, http://data.undp.org.in/hiv/GSACS_NAIL.pdf
[3] The latest draft of the HIV/AIDS bill can be accessed at http://www.lawyerscollective.org/hiv-aids/draft-law
[4] The legal aid assessment report can be accessed at -http://www.undp.org.in/sites/default/files/reports_publication/Documentation-and Assessment-report-on-UNDP-supported-Legal-Aid-Services.pdf
[5] Tamil Nadu, with a population of 65M, is comparable to Thailand and France
[6] 200 out of the total 606 districts in the country have been identified as high HIV prevalence districts
[7] It is important to note that the Government functions through more than 70 ministries and departments with each having number of schemes
[8]These include schemes for provision of free transport, nutritional support, legal aid, redressal, micro grants, short stay homes, livelihoods, education, pension etc.
[9] Rajasthan has a population of 62M comparable to Thailand, France and Italy

Alka Narang, Shashi Sudhir, Ernest Noronha and Caitlin Wiesen
UNDP India

Created: 07/02/2011 16:33:50
Updated: 10/02/2011 16:00:48

Progress to MDG 6 and 3 (Aug 2010)

Process Note:

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