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Strategies and Responses
To the extent that the participatory assessment process in Bangladesh, Cambodia and Sri Lanka stimulated a dialogue within communities about HIV prevention and other sexual health issues, it served to mobilise the beginnings of a community response. Many NGOs commented on people’s initial reluctance to discuss issues of gender and sexuality, sex and sexual health and the transformation that took place during the assessment itself to the point where community members were actively engaged and participating in exploring not only problems, but also solutions. The sense of agency that the participatory process of the assessment generates can make a significant contribution to both the effectiveness and sustainability of community HIV prevention activities.
The participatory community assessments produced a wealth of information and analysis that helped to inform the design of strategies and projects to make them more responsive to the needs and aspirations of the communities that they were intended to serve. In this regard, it is noteworthy that the most commonly identified strategy continued to be HIV/AIDS education, partly because people’s lack of adequate information on HIV/AIDs and sexual health more generally was frequently reported as a problem. For example, 90% of community members who took part in Cambodia Women’s League for Development’s assessment in Kandal province requested more education. But education strategies may also have been favoured because most NGOs are familiar with a health education response to health problems (although many of them lacked experience in sexual health work).
Some NGOs used the assessment process to determine the type of educational approaches that would be most effective. Pairwise ranking by IVH in Sri Lanka found that video shows and group discussions would be preferred by the factory workers whom they were targeting in their project. Others continued the work begun during the assessments by continuing with their participatory group discussion format, and used assessment findings to guide the selection of topics to be discussed. For example, the Khmer Buddhist Association (KBA), working in Banteay Meanchey province on the Cambodian -Thai border, found low levels of condom use and a high degree of discrimination towards people living with HIV/AIDS and thus focused on condom promotion, alleviating people’s fears and exploring people’s attitudes during their group work. Some, like Kasekor Thmey in Kompong Cham province, emphasised the importance of targeting their education work at men, given findings about their greater decision-making control over the potential safety of sexual situations.
Many NGOs, especially in Bangladesh and Sri Lanka, identified the need for STD education, referral and treatment. Strategies ranged from production of information materials on and discussion of STD prevention and management to outreach STD testing and treatment, for example at truck stops in Bangladesh and factories in Sri Lanka. Some NGOs stressed the importance of improving maternal/child health services, for instance by increasing the number of trained birth attendants.
There was also a significant emphasis on expanding condom promotion and distribution, though there was less detailed discussion of how the barriers to condom use identified during the assessment would be addressed. Some NGOs stressed the importance of targeting men with their condom promotion, especially through all-male occupational environments such as the police or military. Others, like the Battambang Women’s AIDS Project in Cambodia, focused on marital relationships and strengthening the ability of partners to negotiate their sexual safety, including condom use. KBA in Cambodia has developed a strategy to increase condom use in brothels, through working with sex workers and brothel owners to increase the availability and acceptability of condoms.
Addressing issues of gender inequality and violence against women was a priority for some NGOs. The Community Development Centre, in Bagherat, Bangladesh, noted that: “Violence and abuse against women is rampant in the target area. So, the CDC consider a programme aimed at raising awareness of women rights and human rights is a vital necessity.” Job creation, income generation and vocational training were noted as significant strategies to enhance women’s economic independence, and thus it is hoped their sexual autonomy. Working with men to explore their role in maintaining gender inequalities was recognised as a priority, but specific strategies, beyond the need for more “education”, were not described. The lack of sexual knowledge among young people, and its consequences for their current and future sexual health, had been noted as a concern in some assessments. As CDF in Bangladesh reported: “The participants observed that they would benefit if they and their children were educated about safe sex.”
Many NGOs recognised the importance of meeting some of their communities’ basic needs around water and sanitation, shelter and housing, and literacy. Community development NGOs, like DAC in Cambodia, envisaged combining their HIV education work with poverty alleviation strategies. Several NGOs in Bangladesh responded to the community’s felt need for entertainment facilities, both in order to strengthen a credible relationship with their communities and to provide an alternative to drinking and visiting brothels.
The integration of prevention and care strategies was specified by several NGOs in Cambodia. CDRCP and CWLD both stressed the importance of care activities and providing “Emotional support, money and medicine to people who are living with HIV if it is possible.” Kasekor Thmey identified counselling as an important service to be provided to people living with HIV/AIDS and CCDO targeted their counselling and care activities at the families of people living with HIV/AIDS.
One NGO in Bangladesh identified strategies for harm reduction among injecting drug users as a priority. SHEASS addressed this through involvement in outreach work and awareness raising on issues such as risk reduction, sexuality and STDs, and HIV/AIDS. Local leaders and members of the broader community were mobilised to help fight discrimination within the community. A drop-in centre providing a wide range of services for injecting drug users and their families - including needle exchange, condom distribution and education about general health, HIV/AIDS and harm reduction - was also established.