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One of the phrases repeated in a number of forums at the Durban Conference in July was “prevention works”. It is a thought-provoking phrase. In some places, at some time, with some groups of people, prevention has worked. Senegal, Uganda and Thailand are often quoted as examples of this. There is also new evidence that rates of infection have dropped in some populations in Cambodia. Nevertheless, we know that the HIV epidemic continues to flourish globally and that we are not succeeding in stopping it. Maintaining safe behaviour, and protecting young people who are becoming sexually active continue to be challenges. There are some real successes, though mainly limited to particular populations. We need to learn from these and translate the lessons they illustrate into everyday work to prevent infections in the different countries where we work.

The Alliance experience, in common with others, shows that information and high levels of awareness of HIV, though essential, are often not enough to enable people to avoid the risk of becoming infected. Moving beyond awareness means making it possible for individuals within communities to change, which in turn means communities have to assess their own vulnerability and have to have the means to do something about it. We know that this is more likely to happen if there is political leadership and acknowledgement of the need to address the epidemic, an understanding of what drives the epidemic socially, and resources to ensure that people have the means to protect themselves.

Experience has also shown that at different stages of the epidemic, different approaches are appropriate. At an early stage, there may be a concentration of infection in a few especially vulnerable groups such as sex workers or injecting drug users. This is an opportunity to prevent further spread so long as we can identify the right approaches. But whatever community is affected, and whatever activity is risky, the principle of active participation by those affected in identifying risks and finding their own solutions remains the same. In later stages, especially when more than 10% of the sexually active population is infected, approaches have to be broader and have to reach even more people. With limited resources, this means making difficult choices about how to identify the most effective approaches.

The Alliance has developed and is developing tools to help communities and NGOs assess their needs in a participatory way. This is the Alliance’s particular strength. But there are other essential pieces to the jigsaw of prevention. Partnerships need to be fostered to ensure that there are facilities for treatment of STDs, access to treatment for HIV related illness, and provision of condoms. NGOs can influence governments to try and create a policy environment and legal framework which facilitates HIV prevention. Access to care and treatment help to reduce the fear of HIV and the stigma which fear engenders.

But even though we can identify what needs to be done, prevention isn’t easy, and the need for it isn’t going to go away.

Linking prevention and care in Zambia

By Simon Mutonyi

The tradition in NGO action on HIV in Zambia has been mostly care rather than prevention. Home care programmes, which are well developed, were generated from a religious background because the church was already involved in care. At the time these programmes started, it seemed that the only message for prevention was the use of condoms, which had some problems for the religious sectors. So the churches began to concentrate on care and support and the government concentrated on prevention. But lately it’s been discovered that doing one without the other does not work very well.

I think that high visibility of HIV in the community has brought a realisation that caring and supporting people does not stop the infection. There is a need to look back at the source of the problems and engage the community in finding solutions. And within the government sector, where a lot of money was spent on prevention, we have not seen evidence of a translation of HIV awareness into specific action. So the churches have begun looking at how they could provide prevention messages as well as care. From this has come the thinking that linking prevention to care and support would strengthen the message. Care and support provide the visibility of HIV and AIDS, and prevention creates the awareness. When these are linked together, people begin to see the relationship and this may lead to more behaviour change.

We are working with a number of NGOs and CBOs who are doing care and support work and who have integrated prevention, looking at specific groups of people that they have identified as the most vulnerable. They are developing peer education programmes and prevention education within the community and relating these to their care and support work.

The Kabwe Adventist Development Aid Programme is an example. They have been providing community support to people with HIV but discovered that youth are being affected by HIV and AIDS. As these young people cannot be accessed through home care programmes, they have shifted to getting resources into targeting youth in schools, outside school and in the churches. They are developing peer education programmes that actively involve youth in giving HIV/AIDS education to other youth. They’ve started to mobilise the church leaders to begin to talk about how to prevent HIV among the youth. They have also made links with health facilities to create youth friendly services and “youth corners”. They have also made links to voluntary testing and counselling services so that when people know what HIV is, they can go for testing – and when that happens there are those who may be positive who can then make a link back to the original home care programme. In this way, they are working towards providing a continuum of care.

Zambia Integrated Health Program (ZIHP) is building capacities in these NGOs/CBOs in 12 districts in strategic planning and HIV/AIDS. Part of this is aimed at enabling partners to establish prevention projects that are proven to work – increasingly by ensuring links to care and support are in place.

Strategies for behaviour change: Cambodia and Ecuador
It is now widely agreed that effective prevention needs more than information and awareness, though these are essential as a starting point. Individuals exist within a community and society and there are many factors which affect a person’s ability to change. A prevention framework being used by the Alliance to guide programme design and implementation looks at prevention at three levels: individual needs, social context, and access to services. Another common perspective differentiates amongst:

• information (giving information and raising awareness);

• empowerment (facilitating participatory activities which give people the ability to act on the information through developing, for example, negotiation skills or understanding and challenging the gender roles which lead to vulnerability); and

• change in the environment (for example, through changing laws and societal responses, or by providing access to services such as STD treatment or resources such as condoms).

Projects supported by linking organisations in Ecuador and Cambodia illustrate how these three elements can be combined effectively:

Cambodia
KHANA, supported by the Alliance, funded the Indradevi Association (IDA) from 1997-9. A needs assessment carried out in 1997 with sex workers led to the decision to work with their clients - the police, military and airforce personnel - as well as the sex workers themselves.

Information and awareness, for example

• Peer group discussions using participatory techniques to share information on STDs/HIV/AIDS and prevention.

• Leaflets, posters, flipcharts and t-shirts.

Empowerment and mobilisation, for example

• Intensified group work exploring barriers to treatment and underlying factors of vulnerability, especially the sexual and peer culture of men in uniform, and building the men's skills and motivation to use condoms.

• Group work with wives of airforce personnel to help them understand how they might be vulnerable.

Environmental, for example

• Improved access to STD clinics especially accessing subsidised treatment.

• Provision of condoms to the wives of airforce personnel.

• Clear policies and support from the medical authorities within the armed services.

Ecuador
The Alliance supports work in Ecuador through Kimirina. One of the groups receiving technical and financial support from Kimirina is Foro permanente de la Mujer en Esmeraldas. Their work in sexual health, STD and HIV/AIDS prevention with women from a black community started in 1997.

Information and awareness, for example

• Training young people to be facilitators in their own community.

• Peer education among young people through workshops, educational sessions and one-to one talks

• Developing songs and poems using local cultural traditions

• Working with local radio.

Empowerment and mobilisation, for example

• Encouraging facilitators to use group work to establish a shared understanding, responsibility and response.

• Using participatory methodologies to help individuals make decisions.

• Involving young people in the design of projects to make these more appropriate to the needs of their peers.

• Workshops on correct condom use and negotiation skills.

• Using gender analysis to help determine the different vulnerabilities of men and women and understand how to take action.

Environmental, for example

• Improving access to STD services through a guide for service providers based on an assessment of the services available locally.

• Involving young people in training he NGO’s professional staff, which influenced the culture of the organisation.

News Update
Central Europe and Eurasia Programme
The Alliance has launched a new regional programme in Central Europe and Eurasia. Beginning in Ukraine, the Alliance will support NGOs working on HIV/AIDS/STI prevention and community support and will establish a national information centre on HIV/AIDS and STI in Kiev. Vyasheslav Koshokov has been appointed the Alliance’s Programme Officer for Central Europe and Eurasia.

World AIDS Conference
The Alliance and its partners were well represented at the Durban conference. As well as giving plenary and oral presentations, presenting posters, holding satellite meetings and being involved in the rapporteuring, the conference was an opportunity to meet each other and to gain experience of the international arena.

Community Lessons, Global Learning Programme
The main Alliance event at the Durban Conference was a satellite meeting rounding off the second year of the Community Lessons, Global Learning Programme at which Alliance partners from Ecuador, Cambodia and Zambia presented their lessons learned on care and support. This Programme is a three-year partnership between the Alliance and Glaxo Wellcome's Positive Action Programme to share experiences and lessons learned in three programmatic areas. Coverage, impact and sustainability - "scaling up" - is the theme of the third and final year of this Programme. Alliance partners and members of other organisations shared their experiences in this area and explored the issues that arose in workshops held in Zambia, Morocco and India.

First partners' forum in Morocco
In June, AMSED, the Alliance’s linking organisation in Morocco, organised a forum enabling 21 representatives from partners organisations of the PASA/IST-SIDA programme to share the lessons they had learned in their work on the theme of "How to reach more people while maintaining the quality of community HIV/AIDS programmes". A report of the forum in French, and a summary report in English, are available from the Alliance secretariat.

Prevention Evaluation
The Alliance is carrying out an evaluation of the prevention activities of linking organisations in Bangladesh, Ecuador, the Philippines and Senegal. The recently completed evaluation in Senegal concluded that the work of ANCS is respected at national as well as community levels and that it fitted well into the national response.

New Country Office in India
The Alliance has established a country office in Delhi, called the India HIV/AIDS Alliance. Its primary function is to assist in the management of a programme which will mobilise and strengthen community care and support for people living with HIV/AIDS and children affected by AIDS in Andhra Pradesh, Tamil Nadu and Delhi. Bhaskaran Menon has been appointed the administrator and Genevieve Maria Dutta the finance and administrative assistant. A programme officer will soon join the team and more appointments may follow later in the year.

Alliance/Horizons Seminar
The Alliance and Horizons held a five-day seminar in the UK on the scaling up successful HIV/AIDS programmes. Thirty-five participants from Alliance and non-Alliance organisations from all over the world brought a wealth of experience which enabled a deep exploration of the complex issues involved. A "state of the art" paper, which will include the experiences shared, is currently being prepared and will be available from the Alliance secretariat early next year.


Supporters

The Gates Foundation has granted the Alliance $5 million to support ongoing activities and to develop a proposal for a new, larger initiative focused on prevention in countries on the frontiers of the epidemic.

Abbott Laboratories Fund is supporting the Alliance and its partners in India and Burkina Faso for work with children affected by AIDS.

The Alliance and Kimirina have received a three-year grant from DFID’s Civil Society Challenge Fund for work in Ecuador.

The Alliance and the National AIDS Foundation in Mongolia have received approval for a three-year prevention programme for work with marginalised children.

Publications and resources

• ‘An Evaluation of the MoH/NGO Home Care Programme for People with HIV/AIDS in Cambodia’. A report evaluating the impact and cost of the home care programme with recommendations for its expansion is available in English from the secretariat.

• ‘Children Affected by HIV/AIDS – Appraisal of Needs and Resources in Cambodia’. A report highlighting the main issues, resources and gaps for children affected by AIDS is available in English from the secretariat.

• 'Mobilizing Community Action Against AIDS'. A monograph produced by PHANSuP, the Alliance linking organisation in the Philippines, showcasing their work.

Alliance News

Volume 4 No 4, November 2000 (no 10)

• Prevention - what makes it work