BANGLADESH - Pathfinder International

BANGLADESH

B ACKGROUND

HIV was first detected in Bangladesh in the 1980s, but the country has been largely spared from the epidemic thus far, HIV/AIDS Indicators at a Glance with an estimated prevalence rate of less than two percent. Total population (2003) 146.7 mil However, data from the latest round of surveillance show that unless there are changes in high-risk behaviors, the Adult HIV prevalence rate (2003) < 0.2% spread of HIV/AIDS in Bangladesh could mirror that in Estimated number of adults and 2,500-15,000 surrounding countries, such as India and Myanmar.1 children living with HIV/AIDS (2003) Knowledge of HIV/AIDS is extremely low, while riskSource: PRB World Population Data Sheet, UNAIDS, USAID taking behavior is high. Sex workers in Bangladesh report among the highest number of partners per week in Asia (an average of 18 to 44) and their partners report the lowest use of condoms in any Asian country (where data are available).2 Rates of syphilis and other STIs are alarming among vulnerable populations and injecting drug users routinely share equipment.3 Although HIV prevalence is low for the time being, Bangladesh should take advantage of the opportunity to prevent a largescale epidemic in the future.

P ATHFINDER ’ S R ESPONSE

HIV/AIDS IN B ANGLADESH Pathfinder made its first grant to Bangladesh’s nascent family planning association in the early 1950s. Substantial support began in 1972 and Pathfinder opened its office in Dhaka in 1978. Pathfinder paved the way for government recognition of, and response to, the country’s rapid population growth. Currently, Pathfinder supports wide-scale implementation of NGO services to provide men, women, families, newlyweds, and youth with reproductive health information and services, including services related to STI treatment and HIV prevention.

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NGO Service Delivery Project (NSDP) Pathfinder works with seven international partners to implement NSDP. CARE-Bangladesh is one of the partners most actively involved in coordinating NSDP’s HIV/AIDS work. Through the National Integrated Population and Health Program (NIPHP), NSDP mobilizes 41 local and national NGOs to integrate HIV/AIDS prevention activities into their existing family health services. NSDP builds the capacity of NGO service providers to mobilize communities, provide information, diagnose, and treat STIs, promote safer sex, and provide essential health and family planning services. Services are delivered through 288 urban and rural static clinics in over 13,000 monthly satellite clinic sessions and through community-based depotholders. Special satellite sessions are held for vulnerable populations, such as transport workers, street- and brothel-based sex workers, slum dwellers, injecting drug users, and refugees. Pathfinder additionally works with implementing NGOs to provide factory-based health services for garment workers in Bangladesh, an overwhelming majority of whom are young, unmarried women. Pathfinder trains paramedics and clinic aids to provide HIV/AIDS and FP/RH education, counseling, services, and supplies in selected factories.

NGO Service Delivery Project (NSDP), Continued Community meetings and outreach activities are held with men, women, youth, and newlyweds to increase knowledge and encourage people to visit NGO clinics. NSDP also coordinates with other HIV/AIDS efforts, such as those organized by Family Health International, CARE, the Ministry of Health and Family Welfare, and UNAIDS. Seven NSDP partner NGOs are getting additional funds from CARE-Bangladesh to implement STI/HIV prevention programs for vulnerable groups, such as transport workers along the Bangladesh-India borders. NSDP is also leading an effort to improve referrals and linkages between NSDP’s NGO services and other national health programs.

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I NFORMATION , C ONTACT : David Weiler, Acting NSDP Chief of Party ♦ Pathfinder International/Bangladesh “Dhansiri” House, NE (N) 5, Road 88, Gulshan-2, Dhaka 1212 Bangladesh Tel: +880 2 988-6994 ♦ Fax: +880 2 988-3634 ♦ Email: [email protected] Dr. Mohammad Alauddin, Country Representative ♦ Pathfinder International/Bangladesh Tel: +880 2 861-8182 ♦ Email: [email protected]

Tayla Colton ♦ HIV/AIDS Technical Services Associate ♦ Pathfinder International ♦ Email: [email protected] 1 2 3

UNAIDS. 2004. Bangladesh: Epidemiological fact sheets on HIV/AIDS and STIs. www.unaids.org Ministry of Health and Family Welfare, Bangladesh and UNAIDS. 2001. HIV in Bangladesh: Where is it going? Ibid. 2001.

BOTSWANA

B ACKGROUND

Botswana is one of the hardest hit countries by HIV/AIDS. The HIV prevalence rate among women seeking antenatal care has grown dramatically, from 18% in 1992 to over 37% by 2003.1 HIV prevalence rates range from 25.7% in Southern District to 50.2% in Selebi Phikwe District. There is no longer a marked difference between urban and rural areas; and while in two-thirds of the country prevalence is over 30%, in one-third of the country prevalence is over 40%.2 Prevalence among 15 to 25 year-olds is increasing rapidly, although UNAIDS surveillance showed the highest rates among 25 to 29 year-old adults (around 50%),3 with young women showing significantly higher prevalence rates than men in their age range.


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HIV/AIDS Indicators at a Glance Total population (2003) 1.6 mil Adult HIV prevalence rate (2003)

37.3%

Estimated number of adults and children living with HIV/AIDS (2004)

350,000

Estimated number of children orphaned by HIV/AIDS

120,000

Source: PRB World Population Data Sheet, NACA, UNAIDS, U.S. Census Bureau

B OTSWANA

Pathfinder has been working in Botswana since 2001, in partnership with PATH and UNFPA, under the African Youth Alliance (AYA). AYA is a five-year initiative, funded by the Bill and Melinda Gates Foundation, to improve adolescent sexual and reproductive health (ASRH) and reduce the spread of HIV/AIDS in Botswana, Ghana, Tanzania, and Uganda. Through the Alliance, young people are educated about HIV/AIDS prevention and provided with necessary information, skills, services, and support to protect their health. Pathfinder is specifically responsible for increasing access to Youth Friendly Services (YFS) and Institutional Capacity Building (ICB) of implementing organizations within AYA.

African Youth Alliance (AYA)/Botswana

AYA partners selected 10 working districts in Botswana, based on STI/HIV/AIDS prevalence rates and expressed youth needs. Initial activities took place in four districts: Northwest/Maun, Gantsi, Francistown, and Khatleng/ Mochudi. The program is now expanding to additional districts, including Serowe/Palapye, Selibe-Phikwe, Southern, Kgalagadi, and finally to Lobastse and Gaborone Districts. AYA’s implementing partners, both governmental and non-governmental agencies, aim to improve ASRH in project areas by strengthening collaboration efforts, supporting referral services, and facilitating the exchange of information among youth organizations. In Botswana, Pathfinder expands and improves YFS in partnership with the Botswana Family Welfare Association (BOFWA). BOFWA is an IPPF affilliate that, with technical assistance from Pathfinder, is assessing existing youth centers, strengthening five youth centers, and establishing three new centers. Pathfinder provides technical assistance to increase reproductive health outreach through communtiy-based youth service providers. Pathfinder also works with the Ministry of Health’s Family Health Division to establish and expand YFS. Pathfinder worked with health facility staff to assess YFS and develop and implement action plans for eight clinics. Additionally, Pathfinder trained service providers and supervisors in YFS and provided refresher training on reproductive health. YFS are also delivered in schools, sporting events, and other alternative delivery points.

Pathfinder assists other AYA implementing partners to build institutional capacity to design, implement, and monitor ASRH programs, including: Botswana National Youth Council: The Youth Council sets up, strengthens, and supports national- and district- level coordination through youth advisory committees and youth councils. They are active participants in AYA coordination committees and AYA partner meetings. Botswana Young Women’s Christian Association (YWCA): Under AYA, the YWCA scales up peer approaches to teen counseling in schools, provides age-appropriate life skills training through peer education, distributes condoms, and promotes services through referral networks. Botswana Christian Council: The Botswana Christian Council advocates for integration of ASRH issues into the teachings of the church. Under AYA, they also encourage churches to offer their sanctuaries as youth activity centers, as well as offering selected ASRH services in mission schools.

Other AYA implementing partners working with PATH and UNFPA in Botswana include: Botswana National Sports Council: The Sports Council aims to mainstream ASRH issues into sporting events to address the health needs of both athletes and spectators. They are developing a policy on ASRH that advocates for the provision of selected health services in sports facilities and more resources for ASRH and sports programs. Ministry of Education (MOE): The MOE works closely with the YWCA and schools in four districts to develop and strengthen ASRH programs in primary, secondary, and tertiary schools. Population Services International (PSI): PSI promotes YFS and supplies through mass media campaigns focused on adolescents. They work with young people to design, pre-test, produce and disseminate youth-specific RH materials through innovative channels, such as street parties. Ghetto Artists: This AYA implementing partner organizes theater productions in Ghanzi, Maun, Muchudi and Francistown that provide ASRH messages and materials through the “entertainment-education” approach. Women Against Rape: This organization sensitizes lawyers, judges, and the police on issues of sexual violence among young people and helps women’s groups lobby for legislation and policies condemning violence and rape.

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I NFORMATION , C ONTACT :

Sophia Ladha, Country Representative ♦ Pathfinder International/Botswana 6, Sempre La Serena, 30 East Road, Morningside 2057 ♦ South Africa Tel: +27 (11) 726-5666 ♦ Fax: +27 (11) 802-1679 ♦ Email: [email protected]

Tayla Colton ♦ HIV/AIDS Technical Services Associate ♦ Pathfinder International ♦ Email: [email protected] 1 National AIDS Coordinating Project (NACA) in collaboration with AIDS/STD Unit, the BOTUSA Project (CDC), District Health Teams, the Botswana Harvard Partnership and WHO, 2003. 2 Ibid. 2003. 3

UNAIDS. 2004. Botswana: Epidemiological Fact Sheets on HIV/AIDS and STIs. www.unaids.org

BRAZIL

B ACKGROUND

Brazil accounts for over 50% of reported AIDS cases in Latin America and the Caribbean.1 While the HIV/AIDS epidemic in Brazil is showing some signs of stabilization, heterosexual transmission and transmission through injecting drug use are increasing. The Ministry of Health reports that the epidemic in Brazil is becoming “poorer, more feminine, and increasingly in the interior of the country.2” The epidemic is most concentrated in urban areas and about 65% of infections occur in the states of São Paulo and Rio de Janeiro.3 Brazil is one of few developing countries that guarantees universal access to antiretroviral therapy and treatment of opportunistic infections.


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0.7%


660,000

Number of adults and children receiving ARV therapy (2004)

140,000

Source: PRB World Population Data Sheet, UNAIDS, WHO, National STD/HIV/AIDS Program

B RAZIL

Pathfinder has been working in Brazil since the 1970s, supporting both public and private sector family planning and reproductive health efforts throughout the country. Currently, Pathfinder activities in Brazil support national efforts in the fight against HIV/AIDS, particularly in capacity building of national NGOs, with a special focus on community development, behavior change communication, and advocacy. The overall goal is to decrease vulnerability to HIV/AIDS, with particular emphasis on the most vulnerable populations such as men who have sex with men (MSM), transvestites, commercial sex workers (CSWs), and drug users. In addition to a number of local NGOs in the States of Bahia, Paraná, and Mato Grosso do Sul, Pathfinder has also initiated collaborations with national networks of civil society that represent vulnerable populations. Pathfinder collaborates with the National Association of Gays, Lesbians, and Transvestites (ABGLT), the National Articulation of Transvestites (ANTRA), the Brazilian Network of Commercial Sex Workers (RBPS), the Brazilian Association of Harm Reduction Agents (ABORDA), and the National Association for Harm Reduction (REDUC). These networks are pivotal partners in the National HIV/AIDS Program and play fundamental roles in the definition of HIV/AIDS policies and action plans. Interventions with Men Who Have Sex with Men After assisting ABGLT in the definition of its strategic plan, Pathfinder is now supporting the Association to implement its workplan, mainly focused on institutional communication and advocacy for human rights. ABGLT recently awarded Pathfinder a medal in recognition for its outstanding support of the gay movement in Brazil. At the local level, Pathfinder is continuing its successful partnership with the Gay Group of Bahia (GGB), one of the most respected gay organizations in Brazil. Interventions focus on implementation of community development activities with young gay men in poor communities of Salvador.

Interventions with Transvestites Pathfinder is assisting ANTRA in the institutional development of six regional training centers to support the establishment of AIDS-competent transvestite associations throughout Brazil, aiming to fight discrimination and stigma and implement HIV/AIDS prevention interventions focusing on community development and behavior change. At the local level, Pathfinder is supporting HIV/AIDS prevention interventions with ACOGLET, the Association of Transvestites of Corumbá, a town bordering Bolivia, in close collaboration with the activities conducted with sex workers in the same city. Interventions with Commercial Sex Workers Pathfinder collaborates with the RBPS, by supporting the publication of newsletters and booklets addressing issues related to sexual and human rights and HIV/AIDS prevention. The network is planning to conduct a strategic planning exercise in collaboration with Pathfinder. In Bahia, Pathfinder aims to increase the capacity of APROSBA, an association of CSWs, to address the vulnerability of CSWs to HIV/AIDS. Activities include training CSWs as peer educators, developing HIV/ AIDS educational materials prioritizing issues such as safe sex, negotiation skills, condom use, and sexual violence, and establishing referral networks with health, legal, and social systems. The program covers about 1,500 CSWs in eight areas of Bahia. Pathfinder more recently began another program for CSWs in the border towns of Foz do Iguaçú (Paraná) and Corumbá (Mato Grosso do Sul). Activities conducted with local NGOs include formation of CSW associations, training for CSW associations’ staff, development of HIV/AIDS educational materials, linkages to VCT and other health services, provision of condoms, and advocacy. Interventions with Drug Users At the national level, Pathfinder is currently supporting ABORDA and REDUC in the definition and implementation of their respective strategic plans. In Bahia, Pathfinder coordinates with a local NGO, CETAD, to improve STI/HIV prevention among drug users in Salvador City. Activities include the development of training and monitoring tools and HIV/AIDS educational materials, training community harm reduction agents in counseling, establishing a referral system for legal, social, and psychological services, and outreach activities that emphasize prevention and condom use. The program serves about 800 drug users and their partners. Increased HIV/AIDS Awareness among Leaders and Followers of Afro-Brazilian Faiths In collaboration with implementing partner CBAA, Pathfinder seeks to increase HIV/AIDS awareness among African religious leaders and followers, particularly related to HIV transmission risks during ritual ceremonies, such as the collective use of blades to shave hair. Activities include identification of religious temples in poor communities in the cities of Salvador and Feira de Santana, participatory workshops with religious leaders on HIV/AIDS, safer sex and condom promotion, reproductive health, gender-based violence, and social mobilization. Pathfinder also works with CBAA to develop appropriate educational materials, including specific messages for MSM. The project is currently funded by the Elton John AIDS Foundation.

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Dr. Carlos Laudari, Country Representative ♦ Pathfinder International/Brazil Praca 15 de Novembro, 13 ♦ Edificio Bouzas, salas 202/207 Terreiro de Jesus–Centro 40025-010 ♦ Salvador (Bahia), Brazil Tel: +55 (71) 321-0791 ♦ Fax: +55 (71) 341-3022 ♦ Email: [email protected]


UNAIDS. 2004. Brazil: Epidemiological Fact Sheets on HIV/AIDS and STIs. www.unaids.org National STD/HIV/AIDS Coordination. www.aids.gov.br USAID. 2001. Leading the way: USAID responds to HIV/AIDS. www.usaid.gov

ETHIOPIA

B ACKGROUND

While Ethiopia is home to one percent of the world’s HIV/AIDS Indicators at a Glance population, it hosts nine percent of the world’s HIV/AIDS Total population (2003) 70.7 mil cases. HIV prevalence is increasing at an alarming rate, Adult HIV prevalence rate (2003) 4.4% impacting all sectors of society. HIV/AIDS prevalence rate 1 estimates vary, from 4.4% reported by UNAIDS, to 6.6% Estimated number of adults and reported by the Ministry of Health,2 to as high as 10-18% children living with HIV/AIDS (2003) 1.5 mil quoted by the National Intelligence Council.3 The U.S. Census Estimated number of children orphaned Bureau estimates that by 2010, life expectancy will drop to 42 by HIV/AIDS 720,000 years, compared to 55 years without the impact of AIDS.4 Contributing factors to the growing epidemic include high Source: PRB World Population Data Sheet, Ministry of Health, UNAIDS, U.S. Census Bureau internal migration (largely due to drought), a large population of displaced people, many demobilized soldiers, low education levels, and minimal condom use. HIV prevalence among pregnant women in Addis Ababa rose from 4.6% percent in 1989 to 15.6% end of 2001.5 Most HIV infections occur among youth, with young women being particularly vulnerable. According to the Ministry of Health, an estimated 1.2 million Ethiopian children have been orphaned due to AIDS.6


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E THIOPIA

Pathfinder was one of the first international organizations to use private funds to support family planning (FP) and reproductive health (RH) activities in Ethiopia during the years when U.S. government funding was suspended for political reasons. In 1964, Pathfinder gave a small grant to a group of Ethiopians to carry out FP activities. This group evolved into what is now the Family Guidance Association of Ethiopia (FGAE), the largest FP provider in the country. Pathfinder’s HIV/AIDS projects in Ethiopia aim to prevent the spread of the virus and to care for those who are infected or affected. Pathfinder’s programs aim to build local partners’ capacity to integrate HIV/AIDS efforts into existing FP/RH services and seek to strengthen community-based HIV/ AIDS activities, especially with vulnerable groups.

Family Planning and Reproductive Health Project Pathfinder was awarded a five-year USAID agreement to support FP and RH activities in three focus regions of Ethiopia (Amhara, Oromia, and SNNPR). This is an expansion of its former USAID-funded project to increase access to, and use of, FP and RH services. The project’s primary emphasis is on providing integrated services through traditional and alternative service-delivery mechanisms. This includes the provision of integrated, community-based HIV/AIDS services, such as behavior change communication, condom promotion, and referrals for voluntary counseling and testing (VCT) and prevention of mother-to-child transmission (PMTCT) services. Pathfinder currently works with 19 implementing partner organizations (IPOs) to carry out project activities in the three focus regions.

Comprehensive Reproductive Health Program This six-year program, funded by the Packard Foundation, is designed to increase the accessibility and availability of FP and RH services through the private sector in three major regions of Ethiopia (Addis Ababa, Amhara, and Oromia). Pathfinder trains private sector physicians, nurses, midwives, and community health workers to offer a range of preventive and clinical services. The goals of the program are to reduce fertility and maternal and infant mortality, as well as to increase knowledge of, and access to, STI and HIV/AIDS counseling and preventive services. Phase II of the program, which began in January 2002, includes the implementation of an adolescent RH component in selected areas. Pathfinder supports youth groups, the media, and faith-based organizations to provide information and services to Ethiopian youth, particularly on STI and HIV/AIDS prevention. Phase II also includes expansion of outreach efforts to all major marketplaces in the ten target woredas. With the help of public address systems, marketplace agents spread the word about FP, STIs, and HIV/AIDS, and then make referrals to nearby clinics.

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Tilahun Giday, Country Representative ♦ Pathfinder International/Ethiopia P.O. Box 12655 ♦ Addis Ababa, Ethiopia ♦ Tel:+251 (1) 613-330 ♦ Fax:+251 (1) 614-209 ♦ Email: [email protected] Tayla Colton ♦ HIV/AIDS Technical Services Associate ♦ Pathfinder International ♦ Email: [email protected]

1 2 3 4 5 6

UNAIDS. 2004. Ethiopia: Epidemiological Fact Sheets on HIV/AIDS and STIs. www.unaids.org Ministry of Health, Ethiopia. Disease Prevention and Control Department. 2002. AIDS in Ethiopia. National Intelligence Council. 2002. The next wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India and China. www.odci.gov/nic U.S. Census Bureau, UNAIDS. 2002. HIV/AIDS Country Profiles: Ethiopia. www.census.gov Ibid. 2002. Ministry of Health, Ethiopia. Disease Prevention and Control Department. 2002. AIDS in Ethiopia.

GHANA

B ACKGROUND

HIV/AIDS spread more slowly in Ghana than in other African countries, although it has now reached the general population, with no signs of slowing down.1 While the national prevalence rate reported by UNAIDS is 3.1%, surveillance reveals a range of prevalence rates, some as high as 5%, in pregnant women across the 18 testing sites.2 Over two-thirds of HIV/AIDS cases in Ghana occur among women. Commercial sex workers in Ghana are extremely vulnerable to HIV/AIDS, as many are forced to travel to neighboring countries for work – often countries with high HIV/AIDS prevalence, such as Cote d’Ivoire.3


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3.1%


350,000

Estimated number of children orphaned by HIV/AIDS (2003)

170,000

Source: PRB World Population Data Sheet, UNAIDS, Ghana MOH 2002 HIV Surveillance Survey

G HANA

Pathfinder has been working in Ghana since 2001, in partnership with PATH and UNFPA, under the African Youth Alliance (AYA). AYA is a five-year initiative, funded by the Bill and Melinda Gates Foundation, to improve adolescent sexual and reproductive health (ASRH) and reduce the spread of HIV/AIDS in Botswana, Ghana, Tanzania, and Uganda. Through the Alliance, young people are educated about HIV/AIDS prevention and provided with necessary information, skills, services, and support to protect their health. Pathfinder is specifically responsible for increasing access to Youth Friendly Services (YFS) and Institutional Capacity Building (ICB) of implementing partners.

African Youth Alliance (AYA)/Ghana The AYA partners initially selected five project regions in Ghana, and then chose 20 districts from those regions in which to focus activities. The five project regions include: Greater Accra, Ashanti, Upper West, Central, and the Eastern Regions. Ghana’s supportive ASRH policy and program environment bodes well for AYA activities. There has been great success in integrating YFS into faith-based service delivery organizations, as well as openness to nontraditional outreach and condom distribution strategies, such as through tailors, hairdressers, and at sporting events. Pathfinder works with the following AYA implementing partners to establish or expand YFS and build institutional capacity to support ASRH programs: Planned Parenthood Association of Ghana (PPAG): PPAG is expanding and strengthening the range and availability of YFS in four facilities and in schools. PPAG selects, trains, and supervises ASRH providers, including peer providers and non-traditional distributors. They conduct a range of behavior change communication (BCC) activities in 16 districts and integrate ASRH and life-planning skills into livelihood development programs for youth in three districts. Through AYA, PPAG aims to provide HIV/AIDS counseling to 10,000 young people, encourage 2,000 young people to access voluntary counseling and testing (VCT), increase condom use among 50,000 youth, and increase youth participation in planning, implementation, and evaluation of ASRH programs.

Ministry of Health/Reproductive Health Unit: The Ministry of Health has facilities in all AYA working districts and is well-positioned to reach significant numbers of young people with YFS. The RH Unit is strengthening its referral system, integrating YFS into existing clinical services, and implementing a comprehensive YFS training program for service providers. YFS activities are planned for at least 50 MOH facilities. National Youth Council: The National Youth Council is a statuatory government body charged with implementing the government’s policy on youth. As an AYA implementing partner, the Council promotes the government’s adolescent policy, as well as promoting ASRH outreach through condom distribution at sporting events, parks, and other venues where young people congregate. Condoms are promoted by peer distributors, who encourage young people to seek reproductive health services. Through AYA, the Council aims to serve 240,000 young people with YFS and outreach services in six districts. Other AYA/Ghana implementing partners responsible for behavior change communication (with PATH) and policy and advocacy (with UNFPA) include: Center for the Development of People (CEDEP): CEDEP works in Ashanti and the Upper West Regions to mobilize out-of-school youth to become peer educators. CEDEP provides life-planning skills education, peer outreach and advocacy, as well as linkages to YFS, such as those provided by PPAG clinics. FIDA Ghana: FIDA Ghana is an affiliate of the International Federation of Women Lawyers, who work with AYA to advocate for reform of traditional laws and customs that negatively impact ASRH. Ministry of Education/Ghana Education Service: The Ministry provides in-school youth with information and skills related to ASRH through co-curricula activities, counseling, and life-planning skills education. National Population Council: The Council advises the government on population and population-related issues, and under AYA, will coordinate implementation at the national, regional, and district levels. Population Impact Project: This project, based at the University of Ghana, conducts ASRH surveys under AYA. The data will be used for program planning and to lobby national policy makers. Voluntary Services Organization (VSO): VSO implements BCC activities for in-school youth in Wa, Nadoli, Akuapim North, and Cape Coast. Their goal is to increase knowledge on STIs and HIV/AIDS, condom negotiation skills, and safer sex practices through capacity building, peer education, mass media, and extra-curricular activities.

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Dr. Andrew Arkutu, Country Representative ♦ Pathfinder International/Ghana 7 Orphan Crescent, Labone, ♦ Accra, Ghana Tel: +233 21 781-216/214 ♦ Fax: +233 21 781-215 ♦ Email: [email protected]

Tayla Colton ♦ HIV/AIDS Technical Services Associate ♦ Pathfinder International ♦ Email: [email protected] 1

USAID. 2002. HIV/AIDS in Ghana: A USAID Brief. www.usaid.gov

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UNAIDS. 2004. Ghana: Epidemiological Fact Sheets on HIV/AIDS and STIs. www.unaids.org

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Ibid. 2004

INDIA

B ACKGROUND

With a population of over one billion, and half of the HIV/AIDS Indicators at a Glance population between ages 15 and 49, HIV/AIDS in India has a strong impact on the pandemic, both in Asia and globally. Total population (2003) 1.068 bil India is home to the largest number of people living with HIV/AIDS second only to South Africa.1 80% of reported Adult HIV prevalence rate (2003) 0.9% AIDS cases occur in the southern States of Maharashtra, Tamil Estimated number of adults and Nadu, Andrha Pradesh, and Karnataka, and in the northeastern children living with HIV/AIDS (2003) 5.1 mil States of Nagaland and Manipur.2 In the southern States, HIV is mainly heterosexually transmitted (with prevalence rates Source: PRB World Population Data Sheet, NACO, UNAIDS among sex workers as high as 50%), although HIV transmission through men having unprotected sex with men is also a cause for concern, as many men who have sex with men also have sex with women. In the northeastern States of Manipur and Nagaland, transmission is mainly through intravenous drug use (with prevalence rates among injecting drug users as high as 70%).3 In the six States with generalized epidemics, prevalence among pregnant women has remained stable at just above 1%, which some experts suggest indicates that the epidemic may have stabilized.4 High rates of tuberculosis in India exacerbate the growing number of HIV infections.


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Pathfinder has been working in India since 1999, primarily focusing on adolescents and postabortion and post-partum care, with an expanding focus on HIV/AIDS.

Targeted Interventions for Groups at Risk (TIGRIS) in Maharashtra Pathfinder, with the support of the Bill and Melinda Gates Foundation’s Avahan initiative in India, is implementing the five-year Targeted Interventions for Groups at Risk (TIGRIS) Project. The Project operates in Pune metropolitan area, as well as 10 other high HIV prevalence districts of Maharashtra, where 96% of HIV infections occur through sexual transmission. The epidemic in Maharashtra is fuelled by a flourishing commercial sex trade, migration to and from rural areas, a large highway network, and the continued marginalization of vulnerable groups such as sex workers, men who have sex with men, and drug users. Pathfinder’s goal is to decrease the spread of HIV among vulnerable groups. The project seeks to achieve the following outcomes: • Decrease ulcerative and non-ulcerative STI prevalence rates among sex workers and other vulnerable groups. • Increase STI/HIV/AIDS awareness and treatment seeking behavior, including regular STI screening, among brothel and non-brothel based sex workers. • Increase consistent condom use among brothel and non-brothel based sex workers with both paying and non-paying partners. • Improve enabling environments for risk reduction, behavior change, and the protection of human rights for vulnerable groups, especially sex workers.

TIGRIS will achieve these objectives through a combination of clinic and community-based STI diagnosis and treatment, HIV education and prevention, and behavior change programs. A network of static and satellite clinics will be established or upgraded in brothel and non-brothel areas in Pune and the project will train, supervise, and support facility upgrades for existing preferred providers working with vulnerable groups in the 10 districts. Clinic-based activities are complemented by communitybased outreach activities with sex workers, clients of sex workers, police, and madams. Outreach activities include interpersonal communication through peer educators, group activities, and mobilization through outreach workers identified and trained by implementing NGOs. The project also seeks to create enabling environments for behavior change to occur, as well as creating and building the capacity of associations of sex workers to advocate for their rights and demand quality health and social services. Expanding Access to Reproductive Health Services for Migrant & Mobile Populations in Karnataka The Flora Family Foundation awarded Pathfinder a grant to expand HIV/AIDS services for mobile populations in Karnataka. The project seeks to expand access to reproductive health services for vulnerable populations and the general community, mainly along major transport routes. Pathfinder provides assistance to clinics so that they can offer comprehensive reproductive health services. These services address HIV/AIDS prevention efforts in selected districts of Northern Karnataka. Promoting Change in Reproductive Behavior in Bihar The objectives of this three-year, Packard Foundation-sponsored project are to facilitate changes in reproductive health behavior among adolescents and young married couples in Bihar and to build the capacity of local NGOs to develop and implement these projects. The project combines behavior change communication initiatives with improved access to family planning and reproductive health services, including STI and HIV/AIDS prevention, for married and unmarried adolescents. A network of 30 Indian NGO partners intervene in 600 villages spread across three districts of Bihar. To date, the project has reached over 180,000 young people with information and services on reproductive health, including child spacing, family planning, and HIV prevention. Adolescent Reproductive Health in India The primary objective of this seven-year project, funded by the Bill and Melinda Gates Foundation, is to improve the reproductive health of adolescents served by NGOs in India, through school- and community-based interventions. Pathfinder increases awareness about reproductive health services for adolescents and improves the capacity of NGOs to deliver such services. Four implementing NGOs conduct activities in Delhi slum areas, as well as in Tamil Nadu, Rajasthan, and Madha Pradesh. Although the primary focus of the project is delaying first births and child spacing, STI and HIV/AIDS activities are integrated by training NGO staff in STI and HIV/AIDS counseling, providing referrals for testing and STI treatment, and through BCC activities.

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Ms. Rekha Masilamani, Country Representative ♦ Pathfinder International/India 3 Link Road, 1st Floor, Jangpura Extension ♦ New Delhi, India 110014 Tel: +91 11 2432-9032 ♦ Fax: +91 11 2432-9037 ♦ Email: [email protected]

Tayla Colton ♦ HIV/AIDS Technical Services Associate ♦ Pathfinder International ♦ Email: [email protected] 1 2 3 4

UNAIDS. 2004. Report on the global AIDS epidemic. www.unaids.org UNAIDS. 2004. India: Epidemiological fact sheets on HIV/AIDS and STIs. www.unaids.org UNAIDS. 2004. Report on the global AIDS epidemic. www.unaids.org UNAIDS. 2004. India: Epidemiological fact sheets on HIV/AIDS and STIs. www.unaids.org

KENYA B ACKGROUND

UNAIDS reports that Kenya is one of the hardest hit countries HIV/AIDS Indicators at a Glance by HIV/AIDS, with an estimated 1.2 million people living with Total population (2003) 31.6 mil 1 HIV/AIDS (PLWHA). The HIV prevalence rate in Kenya is estimated to have dropped from 13-15% to 10% as of 2003, Adult HIV prevalence rate (2003) 6.7% according to Ministry of Health surveillance data.2 Recent Estimated number of adults and UNAIDS data3 indicates that the prevalence rate dropped from children living with HIV/AIDS (2004) 1.2 mil 8% in 2001 to 6.7% at the end of 2003. Despite these reported decreases, the magnitude of the epidemic in Kenya is even Estimated number of children orphaned by HIV/AIDS (2004) 650,000 more evident when considering that half of the country’s population is under age 15. Due in large part to the AIDS Source: PRB World Population Data Sheet, USAID, UNAIDS epidemic, life expectancy in Kenya has dramatically decreased from 60 years in 1990 to 50 years in 2002.4 U.S. Census Bureau, UNAIDS, and UNICEF estimates suggest that by 2010, there will be 1.5 million orphans due to AIDS in Kenya.5 The AIDS epidemic is fueled by the age differences between male and female partners, high rates of STI and TB infections, limited health facilities, and a falling GDP.


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Pathfinder has been working in Kenya since the mid-1960s, and has partnered with over 60 nongovernmental and community-based organizations, government agencies, and public and private sector institutions. Pathfinder provides technical and material resources to develop the organizational capacity of these groups to improve their management systems, create more sustainable programs, and become more technically responsive to their communities’ needs.

The Community-Based HIV/AIDS Care, Support and Prevention (COPHIA) Program COPHIA improves the ability of local communities to manage and implement HIV/AIDS prevention, care, and support activities for PLWHA, their families, and orphans and vulnerable children. The COPHIA program was initially a three-year, USAID-funded initiative, but program successes resulted in a three-year extension and commitment of additional funds, including funding from the President’s Emergency Plan for AIDS Relief (PEPFAR) to expand services for orphans and vulnerable children within the community home-based care context. COPHIA mobilizes local communities to identify their needs and develop and carry out prevention, care, and support activities. COPHIA builds the capacity of communities, local implementing partners, volunteers, PLWHA, and members of vulnerable households to develop appropriate coping strategies. To date, COPHIA has trained over 36,000 family members to provide CHBC and has proven to be a cost-effective use of resources at US$2.00 per client, per month. The COPHIA program serves as a model for other home-based care programs in Kenya, as well as in other Pathfinder countries, such as in Tanzania, Ethiopia, and Uganda.

COPHIA provides community home-based care and support for PLWHA and their families in nine districts: Nairobi, Mombasa, Malindi, Thika, Busia, Siaya, Butere-Mumias, Bungoma, and Kakamega, with a total catchment area of over 10 million people. Key program strategies and activities include: CHBC through community health workers Strong linkages to health facilities Basic nursing training for caregivers Two-way referrals (community ↔ medical facilities) Support initiatives and linkages to emotional, spiritual, and economic support services Community mobilization and prevention Stakeholder participation and advocacy Income generation activities and safety nets Institutional capacity building and sustainability Support for orphans and vulnerable children Prevention of Mother-to-Child Transmission (PMTCT) of HIV Project In April 2002, Pathfinder began a three-year CDC and PEPFAR-funded project to expand PMTCT activities in Kenya. The program extends PMTCT services to eight districts in Kenya: Trans Nzoia and Nandi, Nairobi, Uasin Gishu, Meru North, Meru South, Meru Central, and Tharaka. In order to increase knowledge of HIV/AIDS among the general public and decrease stigma and discrimination, Pathfinder facilitates the implementation of integrated and comprehensive PMTCT services on two levels: In health care facilities (including optimal antenatal care, voluntary and confidential counseling and testing, optimal obstetric care, the use of anti-retroviral drugs, and appropriate infant feeding recommendations) In the community (where Pathfinder organizes, trains, and supports community-based organizations and health workers to identify and provide support to women who need PMTCT services during pregnancy, labor and delivery, and the postnatal period, including support for optimal infant feeding practices) University-Based Adolescent Peer Education Project This project is based at the Kenyatta University and Egerton University campuses, which serve more than 20,000 students and 4,000 staff. Youth-focused initiatives include peer counseling, family life education, human sexuality education, and the provision of integrated reproductive health (RH) services (including family planning, treatment of STIs, condom distribution and emergency contraception). Through these initiatives, Pathfinder aims to improve youth access to services, reduce student pregnancy and the incidence of STIs and HIV/AIDS, and increase student knowledge about RH, and especially HIV/AIDS. Pathfinder involves youth at all levels of program design and implementation and equips students with basic computer and other skills necessary to compete in the job market.

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Charles Thube, Country Representative ♦ Pathfinder International/Kenya P.O. Box 4814 ♦ Nairobi, Kenya ♦ Tel: +254(2) 224-154 ♦ Fax: +254(2) 214-890 ♦ Email: [email protected] Tayla Colton ♦ HIV/AIDS Technical Services Associate ♦ Pathfinder International ♦ Email: [email protected]

1 2 3 4 5

UNAIDS. 2004. Kenya: Epidemiological Fact Sheets on HIV/AIDS and STIs. www.unaids.org HIV/AIDS Surveillance in Kenya, Ministry of Health, January 2003. UNAIDS. 2004. Kenya: Epidemiological Fact Sheets on HIV/AIDS and STIs. www.unaids.org Ibid. 2004. UNAIDS. 2000. AIDS epidemic update: December 2000. www.unaids.org

MOZAMBIQUE

B ACKGROUND

Mozambique is one of the African countries hardest hit by HIV/AIDS Indicators at a Glance HIV/AIDS.1 Extreme poverty, urban and cross-border Total population (2003) migration, unequal distribution of power between men and Adult HIV prevalence rate (2003) women, stigma, and low literacy levels fuel the epidemic. The scale and future impact of HIV/AIDS in Mozambique can Estimated number of adults and only be understood by examining it in relation to its young children living with HIV/AIDS (2004) population. Youth, aged 10-24, comprise 34% of Estimated number of children orphaned Mozambique’s population, and youth aged 15-24 account for by HIV/AIDS (2004) 60% of new HIV infections in a country estimated to have a HIV prevalence rate of over 12%. Half of the people living Source: PRB World Population Data Sheet, UNAIDS, U.S. Census Bureau with HIV/AIDS (PLWHA) in Mozambique are between the ages of 15 and 29. Girls and women are at especially high risk and are being infected at a ratio of two to one over men. Currently, there are 470,000 orphans due to HIV/AIDS in Mozambique, which will increase to over one million orphans by 2010.2


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17.5 mil 12.2% 1.3 mil 470,000

M OZAMBIQUE

Since 1997, Pathfinder’s programs in Mozambique have increased the availability and use of reproductive and sexual health services, including family planning. Pathfinder’s programs have a special focus on adolescent sexual and reproductive health (ASRH), aimed at strengthening the institutional capacity of governmental organizations to develop policies, services, and strategies for improved ASRH. Widely recognized for its technical capacity in ASRH, Pathfinder also works with local NGOs to strengthen their management capability to provide comprehensive services. The pace of the HIV/AIDS epidemic in Mozambique and its impact on young people requires comprehensive programs that offer prevention, care, and support to meet the needs of the many youth who are vulnerable to, or living with, HIV/AIDS in Mozambique. As essential antiretroviral therapy (ART) and diagnostics become more available, Pathfinder will play a leading role in expanding much-needed HIV/AIDS support and treatment services to young Mozambicans.

Multisectoral ASRH/STI/HIV/AIDS Program (Geração Biz) Geração Biz is a national, multi-sectoral adolescent program, including the Ministries of Health, Youth and Sports, and Education and local NGOs, that integrates behavior change communication and youth-friendly services to improve ASRH, increase gender awareness, reduce unwanted pregnancies, and decrease vulnerability to STIs, HIV/AIDS, and unsafe abortion. Activities are well underway in the provinces of Gaza, Tete, Maputo City, Maputo Province, Zambezia, and Cabo Delgado, and at the central level with the Ministry of Youth and Sports and the Ministry of Education. The project reaches 36 districts in 6 of 11 Mozambican provinces, and involves 24 institutions in program implementation. Geração Biz has a cadre of 3,000 trained peer educators and has established 27 youth corners in schools and 14 youth corners in communities, reaching over 300,000 young people with information and life skills in 2003. The project offers youth-friendly services through 32 facilities and provided over 50,000 client visits and distributed over 230,000 condoms in 2003.

Geração Biz was selected as a “best practice” under the World Bank Initiative on Education and HIV/AIDS: A Sourcebook of HIV/ AIDS Prevention Programs. Most recently, the project developed two educational videos for youth that address issues of sexual and reproductive health, gender, and HIV/AIDS. Entitled Risco Zero and Trabalho para Casa, Nosso Trabalho Sobre o SIDA, the videos are being disseminated in Mozambique and internationally. Increasing Access to Youth-Friendly Care and Treatment in Mozambique Pathfinder recently received an award from the World Bank’s Treatment Acceleration Program (TAP) to expand youth-friendly HIV/AIDS care and treatment services through selected Geração Biz clinics in Maputo City and Maputo and Gaza Province. Over the three-year life of the project, Pathfinder will work in partnership with the Ministries of Health, Education, and Youth and Sports to improve the capacity of existing youth-friendly clinics to provide voluntary counseling and testing (VCT) services to young people, expand access to youth-friendly STI/HIV/AIDS clinical care and treatment services, including treatment of opportunistic infections and administration of ART, and improve the quality of life for youth living with HIV/AIDS by establishing and strengthening community home-based care (CHBC) programs and training Youth CHBC Activists in the community. R esearch with Inter-Agency Gender Working Group (IGWG) Pathfinder receives funding from USAID’s Inter-Agency Gender Working Group for activities that center on improving female recruitment, retention, and participation in adolescent peer education programs through operations research that tests specialized protocols for female peer educators in Gaza and Maputo. Results of qualitative and quantitative research led to the revision of certain approaches to recruitment, training, supervision, and follow-up of peer educators in the Geração Biz program. The new systematized protocol intends to demonstrate, in a user-friendly manner, the process of recruiting, training, and monitoring peer educators’ work to ensure quality peer educator activities and sustainability. Kulhuvuka Project with The Foundation for Community Development (FDC) Pathfinder, in partnership with Johns Hopkins University Center for Communications Program, was awarded a grant by the FDC to provide youth with information, life skills, and access to services in Inhambane Province. The beginning stages of the project concentrated on the development of a structured school-based program, which trained peer educators and established youth centers to reach students, teachers, and parents. The project expanded to reach out-of-school youth through partnerships with local youth associations. Pathfinder provides its expertise in ASRH, including development of training curricula, behavior change communication materials, and monitoring systems. The project trained 1,000 peer educators, established 14 youth corners in schools, built the capacity of three community youth associations, and developed a peer educator strategy to include HIV-positive youth. Global Fund to Fight AIDS, Tuberculosis and Malaria As a partner in the Mozambican Country Coordinating Mechanism, funded by the Global Fund to Fight AIDS, Tuberculosis, and Malaria, Pathfinder works to meet the requirements for grant agreement and disbursement. As a member of the core technical group of the Country Coordination Mechanism, Pathfinder collaborates with the National AIDS Council to accelerate Mozambique’s preparedness for contract signing. Pathfinder’s technical assistance focuses on the Ministries of Education, Health, and Youth and Sports to expand access to information, life skills, and services for youth in Nampula, Niassa, Manica, and Sofala provinces.

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Dr. Julio Pacca, Country Representative ♦ Pathfinder International/Mozambique Av. do Zimbabwe 830 ♦ Maputo, Mozambique ♦ Tel/Fax: +258 (1) 313-547 ♦ Email: [email protected] Tayla Colton ♦ HIV/AIDS Technical Services Associate ♦ Pathfinder International ♦ Email: [email protected]

USAID. 2001. Leading the way: USAID responds to HIV/AIDS. www.usaid.gov UNAIDS. 2004. Mozambique: Epidemiological Fact Sheets on HIV/AIDS and STIs. www.unaids.org

NIGERIA B ACKGROUND

HIV/AIDS Indicators at a Glance Nigeria has one of the fastest growing rates of new HIV/ Total Population (2003) 133.9 mil AIDS cases in West Africa and an enormous population. Findings from the Ministry of Health’s 2003 HIV seroAdult HIV Prevalence (2004) 5.4% prevalence survey revealed a national HIV prevalence rate of Estimated number of adults and 5%, similar to the recent UNAIDS estimate of 5.4%.1 Five children living with HIV/AIDS (2004) 3.6 mil states noted an increase in prevalence rates from 2001: Yobe, Estimated number of children orphaned Jigawa, Abia, Sokoto, and Cross River. The HIV/AIDS by HIV/AIDS 1.8 mil epidemic in Nigeria is fueled by the low status of women, low literacy levels, high rates of sexually transmitted infections Source: PRB World Population Data Sheet, UNAIDS, USAID, U.S. Census Bureau (STIs) in vulnerable groups, and a general lack of perceived risk. The design of effective national HIV/AIDS programs is a challenge due to the country’s diverse ethnic groups, languages, and religions.


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Over nearly four decades, Pathfinder has contributed to the progress and sustainability of reproductive health programs in Nigeria by supporting public, private, and non-governmental institutions and empowering communities to demand quality health services. Pathfinder assists local organizations to design health interventions and promote long-term, multi-sectoral collaboration.

The Nigeria AIDS Response Fund (NARF) In 2003, The Canadian International Development Agency (CIDA), in consultation with the National Action Committee on AIDS, launched the Nigerian HIV/AIDS Response Fund. Pathfinder serves as the local executing agency responsible for the administration of the Fund. The NARF is the first such initiative for CIDA’s Nigerian program and is expected to reduce vulnerability to HIV/AIDS and promote gender equality and respect for human rights. The five-year Fund will provide opportunities for a multi-sectoral approach to tackle HIV/AIDS prevention, care, and support, with specific attention on integrating gender and human rights into the HIV/AIDS response and building the capacity of civil society groups. Private Sector Family Planning Service Delivery Project This Packard Foundation-supported project is an innovative initiative designed to increase the availability of family planning and reproductive health (FP/RH) services in Northern Nigeria through a network of private sector service providers. Primary project components include: (1) advocacy to educate community and traditional leaders about FP/RH services through study tours, mentoring, exchange visits, sensitization seminars, and training; (2) sub-awards, to provide direct support for improved practices and facility upgrades; and (3) technical assistance to build the capacity of local NGOs to develop management systems. All Pathfinder-supported partners provide HIV/AIDS prevention information and counseling as part of their service package. Pathfinder is also working with geographically isolated groups to ensure access to HIV/AIDS education. Phase I of the project has been completed and a follow–on grant was awarded to continue and expand the project to include the Federal Capital Territory over the next three years.

Increasing Access to Reproductive Health Services The goals of this USAID-funded project are to increase access, improve quality, and enhance institutional sustainability of FP/RH services. The program serves the general population, as well as highly vulnerable groups, such as adolescents, the Police and Armed Forces, sex workers, and geographically isolated populations. In over 70% of the project sites, Pathfinder facilitates the implementation of integrated FP/RH and STI/HIV/AIDS services, including community mobilization and outreach, promotion of condoms and dual method use, management of STIs, counseling and referrals for HIV/AIDS, and behavior change communication (BCC) efforts. Recently, the project added a prevention of mother-to-child transmission (PMTCT) component with funding from the President’s Emergency Fund for AIDS Relief to encourage pregnant women and mothers-to-be to utilize voluntary counseling and testing (VCT) and PMTCT services. The project also works in Aba to provide STI/HIV/AIDS services and outreach to sex workers in 25 brothels, in collaboration with the Saint Anthony Hospital. Strengthening the National Assembly’s Response to Nigeria’s HIV/AIDS Public Health Emergency: The HIV/AIDS Democratization Project The National Democratic Institute (NDI) granted Pathfinder a follow-on agreement to expand upon accomplishments under its previous award, which linked democratization and governance activities with HIV/AIDS prevention. The objectives of the project are to increase awareness about HIV/AIDS among lawmakers, civil society, and constituents at the grassroots level, as well as to encourage creation of policies to fight HIV and improve care for people living with HIV/ AIDS. The project empowers community residents to advocate for realistic, locally appropriate solutions and encourages citizen participation in strategy and policy formation. Pathfinder/Nigeria will also conduct an assessment of current HIV/ AIDS policies in Nigeria and identify needs and priorities for further policy development. Support for Orphans and Vulnerable Children (OVC) Pathfinder completed a study of orphans in Sagamu, with a specific focus on orphans living with HIV/AIDS. The purpose of the JICA-funded study was to identify and assess the needs of HIV/AIDS and other orphans, and vulnerable children in Sagamu Town, an area with high HIV/AIDS prevalence. The study provided baseline information and appropriate strategies for meeting the needs of these OVC. Following this initial effort, Pathfinder, in collaboration with other development partners and the Federal Ministry of Women Affairs and Youth Development, planned and successfully executed a National Conference on OVC in February 2003. During this conference many strategic issues were raised that will pave the way for a national OVC program in Nigeria. STD/HIV Management Project This DfID-funded project addressed STI prevention, treatment, and RH complications to reduce high rates of STIs, including HIV. The project was conducted in Sagumu and Otukpo States. Pathfinder created a supportive environment for program activities by organizing advocacy meetings with community leaders as well as improving awareness of STIs and HIV/AIDS, prevention measures, and support for PLWHA. Working with local stakeholders (such as sex workers, truck drivers, and adolescents), Pathfinder implemented activities to increase knowledge and reduce STI/HIV transmission.

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Mike Egboh ♦ Country Representative ♦ Pathfinder International/Nigeria Plot 1456 Justice George Sowemimo Street ♦ Abuja, Nigeria Phone/Fax: +234-9 314-7374 ♦ Email: [email protected]

Tayla Colton ♦ HIV/AIDS Technical Services Associate ♦ Pathfinder International ♦ Email: [email protected] 1

UNAIDS. 2004. Nigeria: Epidemiological fact sheets on HIV/AIDS and STIs. www.unaids.org

TANZANIA

B ACKGROUND

The United Republic of Tanzania is comprised of Tanzania and the island of Zanzibar. In 2003, the Ministry of Health estimated the national HIV prevalence rate at 12%,1 with significant regional variation (as high as 15-20% in Kagera, Iringa and Mbeya), while recent UNAIDS data estimates the national prevalence rate at 8.8%.2 In Zanzibar, rates are lower than those in mainland Tanzania, but are steadily increasing. Youth, ages 15-24, comprise 20% of the population, but account for 60% of new HIV infections, disproportionately affecting young women.3 While knowledge of HIV prevention is high, this has translated to little in the way of behavior change and increased condom use. HIV/ AIDS has left nearly one million children orphaned.


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1.6 mil

Estimated number of children orphaned by HIV/AIDS

980,000

Source: PRB World Population Data Sheet, MOH, USAID, UNAIDS

T ANZANIA

Pathfinder began working in Tanzania in 1984 and has since developed a solid experience base with policy makers, service providers, labor organizations, and women’s and youth groups. Pathfinder pioneered community-based distribution, established a youth center program, supported an adolescent fertility survey and education project for young mothers, and strengthened the institutional capacity of a number of local partners in Tanzania. Its programs in Tanzania foster partnerships with public, private, and non-governmental organizations to decrease the spread of HIV/AIDS, provide care and support to people living with HIV/AIDS and their families, and deliver quality reproductive health services.

African Youth Alliance (AYA)/Tanzania Pathfinder works in partnership with PATH and UNFPA to form the African Youth Alliance (AYA). AYA is a five-year initiative funded by the Bill and Melinda Gates Foundation to improve adolescent sexual and reproductive health (ASRH) and reduce the spread of HIV in Botswana, Ghana, Tanzania, and Uganda. Through AYA, young people are educated about HIV prevention and provided with necessary information, skills, services, and support to protect their health. Pathfinder is specifically responsible for improving access to Youth Friendly Services (YFS) and Institutional Capacity Building (ICB) of implementing organizations. AYA operates in 10 districts of mainland Tanzania and Zanzibar through 14 implementing partner organziations. Partners include the Ministries of Health (Mainland and Zanzibar), City Council, three Municipal Councils in Dar es Salaam, Arusha Municipal Council, University of Dar es Salaam, the Family Planning Association of Tanzania (UMATI), Marie Stopes/ Tanzania, and a number of District Councils. Activities to date include pre-testing Pathfinder’s ASRH training curriculum, conducting institutional capacity assessments and action planning with selected partners, training on financial management, and monitoring and evaluation. Pathfinder also conducted YFS facility needs assessments, followed by joint action planning, clinic upgrades, ASRH training, and technical assistance with implementing partners.

Community Home-Based Care (CHBC) Project An anonymous donor supports Pathfinder’s three-year CHBC project in Tanzania. The project began in January 2002, and is based on the successful COPHIA model developed by Pathfinder/Kenya. Community health workers provide CHBC services in Dar es Salaam and Arusha. Following completion of a baseline needs assessment in project areas, the first round of community health workers were trained to provide physical and emotional support to people living with HIV/AIDS (PLWHA) and their caretakers. These health workers now train caregivers and provide referrals to medical facilities, support groups, and other social services as part of a continuum of HIV/AIDS prevention, care, and support. The CHBC program contributes to prevention by clarifying myths about HIV/AIDS, reducing stigma, and encouraging testing. Strong linkages to health facilities, support networks, and income-generating activities are maintained and 14 stakeholders, including the Ministry of Health, community- and faith-based organizations, NGOs, and PLWHA participate in the design and implementation of the program. A total of 193 community health workers and over 5,000 caregivers have already been trained by the project, which serves over 1,200 PLWHA. Promoting HIV/AIDS Prevention and Health-Seeking Behavior This one-year, Pfizer Foundation-funded HIV/AIDS prevention program was implemented in CHBC project areas in Dar es Salaam and Arusha. Pathfinder developed innovative communications materials and tools that continue to raise awareness about HIV/AIDS, train clients how to “live positively” with HIV/AIDS, encourage prevention and health-seeking behaviors (in particular voluntary counseling and testing and condom use), and increase the use of existing services by those infected and affected by HIV/AIDS. A training module on behavior change communication (BCC) was developed and incorporated into CHBC training for community health workers. In addition, a home-based care and support logo called TUTUNZANE (“Lets take care of each other”) was incorporated into two brochures on opportunistic infections and on CHBC, along with a fact sheet on HIV/AIDS and reprinting of a nutrition booklet for PLWHA. All of the TUTUNZANE materials were produced in Kiswahili, the national language of Tanzania. National Institute of Mental Health Tanzanian Project Pathfinder/Tanzania is a partner in the five-year National Institute of Mental Health (NIMH) Tanzanian Project, led by the Harvard Medical School (HMS), and funded by NIMH. The project involves two cross-sectional surveys, conducted by the National Bureau of Statistics (NBS) in Tanzania, an intervention consisting of home-visiting and community-based health promotion, and three child and parent mental health assessments during the intervention phase. In addition to NBS, Kiliminjaro Christian Medical Center (KCMC) is the main local partner, along with community-based organizations with years of HIV/ AIDS and youth experience. The surveys and interventions are conducted in 15 wards of Moshi, a district in Northern Tanzania. Pathfinder is responsible for pre-award capacity assessments of partners, building institutional capacity of partners, and providing technical assistance to the NBS in management information systems (MIS). Pathfinder organizes study tours for KCMC researchers to visit successful orphan and vulnerable children (OVC) programs in Tanzania and in neighboring countries. Pathfinder’s future plans including working with KIWAKKUKI and Youth Alive, community-based organizations, to design and implement community interventions, including CHBC, to improve child mental health and reduce vulnerability to HIV/AIDS.

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Nelson Keyonzo, Country Representative ♦ Pathfinder International/Tanzania United Nations Road, Plot 356, Upanga, PO Box 77991 ♦ Dar es Salaam, Tanzania Tel: +255 (22) 211-8284 ♦ Fax: +255 (22) 211-8283 ♦ Email: [email protected]


National Multi-Sectoral Strategic Framework On HIV/AIDS (2003-2007), Prime Minister’s Office, The United Republic Of Tanzania, February 2003. UNAIDS. 2004. Tanzania: Epidemiological fact sheets on HIV/AIDS and STIs. www.unaids.org UNAIDS. 2002. Tanzania: Epidemiological fact sheets on HIV/AIDS and STIs. www.unaids.org

UGANDA

B ACKGROUND

Uganda is often cited as the HIV/AIDS success story of Africa HIV/AIDS Indicators at a Glance because of the country’s strong political will, leadership, and Total population (2003) 25.3 mil commitment to HIV/AIDS prevention and care. According to Adult HIV prevalence rate (2003) 4.1% UNAIDS, HIV prevalence rates in Uganda decreased by 50% 1 between 1992 and 1999, with the current prevalence at 4.1%. Estimated number of adults and The Ministry of Health of Uganda estimates prevalence rates at children living with HIV/AIDS (2003) 530,000 between 6-8%. This decline occurred among urban and rural Estimated number of children orphaned populations as well as among women.2 Surveys suggest that by HIV/AIDS (2003) 940,000 major behavior changes have taken place, including increased Source: PRB World Population Data Sheet, UNAIDS, USAID, U.S. Census Bureau mean age at sexual debut among women (from 15.9 years in 1989 to 16.7 years in 2000) and increased condom use, especially in non-regular sexual relationships (33% used a condom with their last non-regular partner in 1995, compared to 51% in 1998).3 Despite these successes, HIV/AIDS continues to impact many Ugandans and has resulted in major decreases in life expectancy and increases in the crude death rate and child mortality. An estimated 530,000 people are currently living with HIV/AIDS in Uganda and there are nearly one million children who have been orphaned due to AIDS.4


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Pathfinder began working in Uganda in 1957, when it helped found the Family Planning Association of Uganda. Pathfinder pioneered community-based distribution of family planning through non-medical personnel in the 1980s. More recently, Pathfinder has been successful integrating HIV/AIDS efforts into existing reproductive, maternal, and child health programs. Pathfinder/Uganda also pioneered community home-based care approaches for people living with HIV/AIDS and developed training materials that are now used in a number of Pathfinder countries and by other organizations.

African Youth Alliance (AYA)/Uganda Pathfinder works in partnership with PATH and UNFPA to form the African Youth Alliance (AYA). AYA is a five-year initiative funded by the Bill and Melinda Gates Foundation to improve adolescent sexual and reproductive health (ASRH) and reduce the spread of HIV/AIDS in Botswana, Ghana, Tanzania, and Uganda. Through the Alliance, young people are educated about HIV/AIDS prevention and provided with necessary information, skills, services, and support to protect their health. Pathfinder is specifically responsible for increasing accessibility to Youth Friendly Services (YFS) and Institutional Capacity Building (ICB) of implementing organizations. AYA/Uganda collaborates with the Ministries of Health, Education, Finance, Planning, and Economic Development and Gender, Labour, and Social Development to improve ASRH in 13 of Uganda’s 56 districts. Pathfinder provides substantial support to the public sector, specifically the District Directorates of Health Services (DDHS), to integrate YFS into existing district health service delivery systems.

Pathfinder also works with the following AYA implementing partners to expand YFS and/or to build institutional capacity to plan and implement ASRH programs: Anglican Church of Uganda: Pathfinder works with the Busoga Diocese of the Anglican Church of Uganda to integrate YFS into the Diocese’s existing RH services. The Busoga Diocese provides health services at 40 rural clinics and, under AYA, will expand service delivery points to include 80 outreach sites and 220 social marketing outlets. The South Rwenzori Diocese of the Anglican Church provides over 40% of all health care and is scaling up to serve at least 35% of the 200,000 youth in Kasese District. Pathfinder provides training in order to integrate YFS into existing reproductive health and youth development services. Kampala City Council (KCC): Pathfinder assists the KCC to provide YFS and build institutional capacity. The City Council provides services to about 460,000 in- and out-of-school youth living in Kampala’s five municipal health units. YFS training is being conducted with peer providers and clinicians from KCC facilities and school clinics, and 25 youth outreach sites are being established in Kampala. MULAGO: Pathfinder provides technical assistance to the Makerere University Medical School, Department of Obstetrics and Gynecology (MULAGO), for the “Increasing Training Capacity for Adolescent Sexual Reproductive Health Service Provision” project. This project integrates ASRH curricula into pre-service training programs for health care workers in six Ugandan teaching hospitals. Uganda Youth Development Link (UYDEL): The “Health Matters for Disadvantaged Adolescents” project serves over 225,000 vulnerable youth, street children, and adolescent sex workers. Pathfinder provides technical assistance to increase access to reproductive health services, VCT, STI diagnosis and treatment, and other ASRH counseling and services. Community Home-Based Care (CHBC) Project Pathfinder/Uganda’s successful CHBC programs served as a model for the development of the COPHIA project in Kenya and subsequent CHBC projects in other Pathfinder countries. The Pathfinder country office in Uganda developed a CHBC training curriculum, a handbook for primary caregivers, and a flip chart for community health workers. Currently, Pathfinder is receiving funding from the IZUMI Foundation to implement CHBC training and activities in Mayuge and Iganga Districts. The project began in June 2003 and has provided training to 42 community health workers, who serve 450 households caring for people living with HIV/AIDS (PLWHA), and train over 900 people in care and support at the household level. Pathfinder also facilitates community mobilization activities through local partners. Community HIV/AIDS Initiative Pathfinder receives suport from the Elton John AIDS Foundation to support primary school education, vocational skills training, and income-generating activities for orphans, vulnerable children, and their guardians affected by HIV/AIDS in Mukon District. In its first year, the Mpoma Community Initiative enrolled 210 children in the school, directly assisted 91 orphans and 72 widows and guardians, and conducted community sensitization seminars.

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Tom Fenn, Country Representative ♦ Pathfinder International/Uganda Plot 2 Kafu Road, Nakasero ♦ PO Box 29611 ♦ Kampala, Uganda Tel: +256 (41) 255-939 ♦ Fax: +256 (41) 255-942 ♦ Email: [email protected]


UNAIDS. 2004. Uganda: Epidemiological Fact Sheet on HIV/AIDS and STIs. www.unaids.org USAID. 2002. HIV/AIDS in Uganda: A USAID Brief. www.usaid.gov UNAIDS. 2002. Uganda: Epidemiological Fact Sheet on HIV/AIDS and STIs. www.unaids.org UNAIDS. 2004. Uganda: Epidemiological Fact Sheet on HIV/AIDS and STIs. www.unaids.org

VIET NAM

B ACKGROUND

HIV/AIDS is emerging as a major public health issue in HIV/AIDS Indicators at a Glance Southeast Asia. In the Mekong sub-region, comprising Total population (2003) 80.8 mil Cambodia, Laos, and Viet Nam, the overall HIV/AIDS Adult HIV prevalence rate (2003) 0.4% disease burden is expected to triple in the next 20 years unless successful HIV prevention measures are implemented. The first Estimated number of adults and HIV case was identified in Viet Nam in 1990, and it is currently children living with HIV/AIDS (2003) 220,000 estimated that over 220,000 adults and children in the country are living with HIV/AIDS.1 The spread of HIV in Viet Nam is Sources: PRB World Population Data Sheet, WHO, UNAIDS Millennium Development Report 2003 linked to population mobility, increasing rates of injecting drug use, a significant commercial sex industry, and the marginalization and stigmatization of such vulnerable groups. Behavioral surveys indicate that 28% of injecting drug users in Viet Nam share equipment, with HIV prevalence rates in this group ranging from 22% in Hanoi to 70% in Hai Phong City.2 HIV prevalence rates among commercial sex workers in Viet Nam vary, from almost zero percent in Da Nang, to 11% in Hanoi, and 21% in Ho Chi Minh City.3 HIV infection in young people is also a growing concern, representing 10% of total HIV cases in 1999.4


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Pathfinder was among the first international reproductive health organizations to work in Viet Nam. Since 1994, Pathfinder has worked with the Ministry of Health and eight provincial government partners to improve the quality and range of reproductive health (RH) services available through the public sector. Efforts have included extensive clinical and management training, facility upgrades, and advocacy. Pathfinder is one of the few organizations in Viet Nam that has worked with the private sector. Pathfinder recognizes the burgeoning HIV crisis in Viet Nam, and is using its existing platform to fight the virus among vulnerable groups and in the general population.

Integration of HIV/AIDS Support into Existing Reproductive Health Programs (RHPs) Since 2002, together with its partners in the Reproductive Health Projects (EngenderHealth and Ipas), Pathfinder/Viet Nam has made a strategic effort to integrate HIV/AIDS prevention into its existing programs. For example, training in universal precautions and stigma reduction was provided to a network of provincial government trainers, and the RHP partners are working to broaden their RH counseling approach to include sexual health issues and HIV risk assessment. In addition to efforts to integrate HIV/AIDS into current in-service program strategies and activities, Pathfinder is also supporting innovative work to adapt and expand the current medical education curriculum to include more of an emphasis on reproductive health, including HIV/ AIDS. Through the development of a more comprehensive RH curriculum for medical students in Viet Nam, topics such as HIV/AIDS among pregnant woman have been added, as well as cross-cutting themes highlighting the importance of non-judgmental and supportive attitudes in the care and treatment of people living with HIV/AIDS.

Improving STI/HIV/AIDS Services in Viet Nam: A Model Program of Public-Private Sector Collaboration Building on Pathfinder’s success in enhancing the institutional capacity of public sector health institutions in eight provinces in Viet Nam, Pathfinder recently initiated an innovative project with Pfizer Foundation support, linking the public and private sectors for more effective HIV/AIDS prevention and support at the provincial level. Pathfinder’s current effort aims to increase the capacity of a public sector referral center to offer high quality, model services in STI prevention and case management, HIV prevention counseling and referral, standard precautions, and stigma reduction. The improved services will be promoted within the public sector network as well as to private providers, including private hospitals, private clinics, and pharmacists. At the same time, the project reaches out to the private sector by offering training in related topics to private sector providers. Developing the capacity of the public sector to play a role in the provision of training and ongoing support, mentoring, and supervision to the private sector provides the basis for a continuum of STI/HIV/AIDS prevention and care services that links the public and private sectors.

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Laura Wedeen, Country Representative ♦ Pathfinder International/Viet Nam B4b Giang Vo Building ♦ 269 Kim Ma – Ba Dinh ♦ Ha Noi, Viet Nam Tel: +84(4) 846 0807 ♦ Fax: +84(4) 846 0806 ♦ Email: [email protected]


UNAIDS. 2004. Viet Nam: Epidemiological fact sheets on HIV/AIDS and STIs. www.unaids.org Ibid. 2004. Ibid. 2004. UNAIDS UN Viet Nam country team Millennium Development Report 2003

O VERVIEW

COMMUNITY HOME-BASED CARE

Over 95% of people living with HIV/AIDS (PLWHA) live in lower-income or developing countries and nearly two-thirds of PLWHA globally live in sub-Saharan Africa.1 As the number of PLWHA increases, the gap continues to widen between the demand for, and availability of, health care services. Relying on the strengths of family and community networks, community home-based care (CHBC) has emerged as an effective method of providing cost-effective, compassionate care to those infected and affected by HIV/AIDS. CHBC is not a replacement for hospital care, but instead is part of a comprehensive continuum of prevention, care, treatment, and support services that include the family, the community, and various levels of health care providers. In addition to providing support to families coping with HIV/AIDS, CHBC also contributes to prevention efforts. By involving community members in prevention, care, and support efforts, CHBC brings issues surrounding HIV/AIDS into the open, creating opportunities to clarify myths, reduce stigma, empower those infected and affected by HIV/ AIDS, and influence peoples’ willingness to know their HIV status or change risky behaviors. Pathfinder’s CHBC efforts provide PLWHA and their family members with practical nursing skills and emotional support. For PLWHA, CHBC programs offer palliative care, treatment of opportunistic infections, counseling and emotional support, contraceptives, and referrals to available health services. Pathfinder’s CHBC programs rely on volunteer community health workers, who regularly visit homes and teach family members how to provide emotional support and physical care to relatives and loved ones living with HIV/AIDS. The CHBC programs create strong two-way referral systems between the community and medical facilities. This allows community workers to refer clients to local clinics or hospitals and allows hospital staff to link discharged patients back to community health workers. Pathfinder believes that successful CHBC programs contain the following elements: Prevention efforts, including behavior change communication (BCC), contraceptive services and supplies, including condoms for dual protection; linkages to voluntary counseling and testing (VCT), and referrals for prevention of mother-to-child transmission (PMTCT) services Training in basic nursing care for loved ones and caregivers - such as skin care, mouth and nail care, changing soiled bedding, preparing nutritious food, and treating AIDS-related conditions Two-way referral linkages among CHBC providers, health facilities, other health providers, and VCT centers Community stakeholder participation in design, implementation, and monitoring of programs to increase impact and sustainability - this includes the involvement of PLWHA, health providers, local leaders, and faith-based groups Community mobilization and advocacy efforts to organize resources for prevention, care, and support activities - such as orphan care, food support, and emergency transportation Field-based training, monitoring, and continuing education to develop skills of community health workers to implement CHBC and the use of a “cascade” approach to training Strong linkages to emotional, social, spiritual, and economic support services - such as food banks, support groups, legal aid, micro-credit and income generating activities, child support services, and faith-based groups Support for orphans and vulnerable children, including linkages to nutrition support and health services, provision of school fees and uniforms and access to income generating activities and vocational training.

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P ATHFINDER ’ S C OMMUNITY H OME -B ASED C ARE P ROJECTS

Community-Based HIV/AIDS Care, Support, and Prevention (COPHIA) Program: Kenya COPHIA improves the ability of local communities to manage and implement HIV/AIDS prevention, care, and support activities for PLWHA, their families, and orphans and vulnerable children. The COPHIA program was initially a three-year, USAID-funded initiative, but program successes have resulted in a three-year extension and commitment of additional funds, including funding from the President’s Emergency Plan for AIDS Relief (PEPFAR) to expand orphan and vulnerable children work within the community home-based care context. COPHIA provides community home-based care and support for PLWHA, orphans, and their families in nine districts: Nairobi, Mombasa, Malindi, Thika, Busia, Siaya, Butere-Mumias, Bungoma, and Kakamega, with a total catchment area of over 10 million people. COPHIA mobilizes local communities to identify their needs and develop and carry out prevention, care, and support activities. The program also builds the capacity of communities, local implementing partners, volunteers, PLWHA, and members of vulnerable households to develop appropriate coping strategies. To date, COPHIA has trained over 36,000 family members to provide CHBC. The COPHIA program serves as a model for other home-based care programs in Kenya, as well as in other Pathfinder countries. Community Home-Based Care Project: Uganda Pathfinder/Uganda’s successful CHBC programs served as a model for the development of the COPHIA project in Kenya and subsequent CHBC projects in other Pathfinder countries. The Pathfinder country office in Uganda developed a CHBC training curriculum, a handbook for primary caregivers, and a flip chart for community health workers. Currently, Pathfinder is receiving funding from the IZUMI Foundation to implement CHBC training and activities in Mayuge and Iganga Districts. The project began in June 2003 and has provided training to 42 community health workers, who serve 450 households caring for PLWHA, and train over 900 people in care and support at the household level. Pathfinder also facilitates community mobilization activities through local partners. Community Home-Based Care Project: Tanzania An anonymous donor supports Pathfinder’s three-year CHBC project in Tanzania. The project initiated activities in January 2002, and is based on the successful COPHIA model developed by Pathfinder/Kenya. Community health workers provide CHBC services in Dar es Salaam and Arusha. Following completion of a baseline needs assessment in project areas, the first round of community health workers were trained to provide physical and emotional support to PLWHA and their caretakers. These health workers now train caregivers and provide referrals to medical facilities, support groups, and other social services as part of a continuum of HIV/AIDS prevention, care, and support. The CHBC program contributes to prevention by clarifying myths about HIV/AIDS, reducing stigma, and encouraging testing. Strong linkages to health facilities, support networks, and income-generating activities are maintained and 14 stakeholders, including the Ministry of Health, community- and faith-based organizations, NGOs, and PLWHA participate in the design and implementation of the program. A total of 193 community health workers and over 5,000 caregivers have already been trained by the project, which serves over 1,200 PLWHA. Integrated Environmental and Reproductive Health Program: South Africa This community-based program was initiated in 1998 through a partnership of the National Population Unit, UNFPA, Planned Parenthood Association of South Africa (PPASA), and the Working for Water Program. With funding from the Compton and Summit Foundations, Pathfinder provided PPASA with technical support to implement the community-based reproductive health components of the program. Pathfinder developed a CHBC module within the training curriculum for community health workers in the Western and Eastern Cape.

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Tayla Colton ♦ HIV/AIDS Technical Services Associate ♦ Pathfinder International ♦ Email: [email protected]

UNAIDS/WHO. 2004. Report on the global AIDS epidemic. www.unaids.org

PREVENTING MOTHER-TO-CHILD TRANSMISSION

OVERVIEW

OF

HIV

UNAIDS estimates between 600,000 and 700,000 infants become HIV-infected through mother-to-child transmission (MTCT) each year, and in 2003 alone, nearly 500,000 children died of AIDS-related causes.1 The overwhelming majority of these children are born in the developing world, primarily in sub-Saharan Africa. Without interervention, 25 to 30% of pregnant mothers living with HIV/AIDS will transmit the disease to their children during pregnancy, labor and delivery, or through breastfeeding. In higher income countries, the rate of MTCT has decreased to less than 3% because of access to antiretroviral therapy (ART), preventative delivery techniques, and access to safer infant feeding methods. However, in many developing countries these services are often not available or accessible and MTCT continues unabated. The limited, primarily facility-based prevention of mother-to-child transmission (PMTCT) programs that do exist in developing countries have done little to reduce transmission. The numbers of mothers that can be supported appropriately with formula and all its requirements are few, many women do not seek services for fear of stigma, discrimination, or violence, and ART is not accessible for most women. Despite this, there are missed opportunities to prevent MTCT through other community- and facility-based strategies. While preventing HIV infection among women and men of reproductive age is the most effective PMTCT strategy, it is also crucial to assist women living with HIV/AIDS to avoid unwanted pregnancies and to reduce the risk of perinatal infection for pregnant women living with HIV/AIDS. Pathfinder believes that effective PMTCT programs: Minimize the risk of HIV transmission at each stage of the maternity cycle Strengthen and add to existing maternal and child health (MCH) services Provide ongoing support, including antiretroviral treatment, to the mother Integrate facility and community-based services for maximum impact on MTCT, the health of the mother, and community mobilization.2 PMTCT programs should be integrated into existing reproductive health (RH) and MCH programs for a number of reasons. A majority of women and children already utilize these existing services and integration is efficient when exsiting personnel and facilities are used. Pathfinder’s integrated PMTCT model contains many elements of a Safe Motherhood program. The ultimate goal is to successfully integrate these strategies so PMTCT programs will benefit all mothers and babies, regardless of their HIV status, which is often unknown. Pathfinder’s approach to PMTCT includes interventions throughout the maternity cycle and in both the facility and in the community. Pre-pregnancy interventions: community and individual awareness and mobilization on safer sex and HIV/AIDS; access to family planning and prevention of unwanted pregnancy; access to voluntary counseling and testing (VCT); and access to training, education, and poverty reduction programs Antenatal interventions: essential antenatal care package for all women that integrates PMTCT - including screening for STIs, TB, and other opportunistic infections; tetanus toxoid vaccinations; malaria prophylaxis; nutrition counseling and support; safer sex and contraceptive counseling; access to VCT; ARV therapy, if available; birth planning and counseling on infant feeding options; and encouraging support of partner, family, and the community

Labor and delivery interventions: normal labor and continuous labor support; infection prevention techniques; avoid artificial rupture of bag of waters; minimize episiotomy and lacerations; avoid use of forceps or vacuum extraction; identify and train home birth attendants on safe motherhood, including PMTCT; ARVs (Nevirapine) if available; caesarian section if facilities are available; early initiation of exclusive breastfeeding if that is the feeding choice; and immediate newborn care following Baby Friendly Hospital Initiative principles Postpartum interventions: access to emergency care; follow-up monitoring visits; contraceptive planning, which includes counseling on dual protection; access and linkages to food support and other community resources, such as homebased care; monitoring of HIV status; and treatment of opportunistic infections Infant feeding: if HIV status is unknown, encourage exclusive breastfeeding for at least six months; if HIV-positive status is known, provide counseling on infant feeding and PMTCT in order to balance risks and individualize a plan (consider cost of replacement feeding, availability of safe water, fuel, and time related to the use of formula); consider stigma and return to fertility associated with not breastfeeding; counsel on safe use of replacement feeding if that is the choice; encourage exclusive breastfeeding with as little mixed feeding as possible for at least six months if the woman chooses to breastfeed; provide linkages to community resources; and provide home-based breastfeeding support, treatment of breast infections, and treatment of oral thrush in the baby.

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P ATHFINDER ’ S PMTCT P ROJECTS

Prevention of Mother-to-Child Transmission of HIV/AIDS Program: Kenya In April 2002, Pathfinder began a three-year CDC and President’s Emergency Fund for AIDS Relief (PEPFAR)-funded project to expand PMTCT activities in Kenya. The program extends PMTCT services to eight districts in Kenya: Trans Nzoia and Nandi, Nairobi, Uasin Gishu, Meru North, Meru South, Meru Central, and Tharaka. In order to increase knowledge of HIV/ AIDS among the general public and decrease stigma and discrimination, Pathfinder facilitates the implementation of integrated and comprehensive PMTCT services on two levels: In health care facilities: including optimal antenatal care, voluntary counseling and testing, optimal obstetric care, the use of anti-retroviral drugs and appropriate infant feeding recommendations In the community: where Pathfinder organizes, trains, and supports community-based organizations and health workers to identify and provide support to women who need PMTCT services during pregnancy, labor and delivery, and the postnatal period, including support for optimal infant feeding practices Increasing Access to Reproductive Health Services: Nigeria The goals of this USAID-funded project are to increase access, improve quality, and enhance institutional sustainability of FP/ RH services. Pathfinder gears activities towards underserved populations, including the Nigerian Police and Armed Forces and their families. The program also serves the general population as well as highly vulnerable groups, such as adolescents and geographically isolated populations. In over 70% of the project sites, Pathfinder facilitates the implementation of integrated FP/ RH and STI/HIV/AIDS services, including community mobilization and outreach, promotion of condoms and dual method use, management of STIs, counseling and referrals for HIV/AIDS, and behavior change communication (BCC) efforts. Recently, the project added a PMTCT component, with PEPFAR funding, to mobilize pregnant women to utilize VCT and PMTCT services. Pathfinder is responsible for community-focused activities in Edo State and the Federal Capital Territory.

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Ellen Israel ♦ Senior Reproductive Health Associate ♦ Pathfinder International ♦ [email protected]

UNAIDS. 2004. Report on the Global AIDS Epidemic. www.unaids.org Israel, E. and Kroeger, M. 2002. Integrating prevention of mother-to-child HIV transmission into existing maternal, child, and reproductive health programs. Pathfinder International Technical Guidance Series, No. 3. Watertown, MA: Pathfinder International. www.pathfind.org 1 2

STI/HIV/AIDS PROGRAMS

WITH

O VERVIEW

VULNERABLE GROUPS

Commercial sex workers (CSWs), injecting drug users (IDUs), men who have sex with men (MSM), truckers, and migrant workers have long been blamed for bridging HIV into the general population and targeted for interventions as “high-risk” groups. While many programs provide information and condoms, and in some cases harm reduction services, few employ participatory approaches, address public policies and social factors fueling the epidemic, and build capacity of associations of vulnerable groups. High rates of STIs among many of these groups, overwhelming stigma that discourages health-seeking behavior, and deeply entrenched social inequalities increase their vulnerability to contracting and spreading HIV. STI/HIV/AIDS programs with vulnerable groups must recognize the totality of individuals and not just their sexual or drug use behavior, moving beyond condom social marketing to include advocacy, harm reduction, capacity building, community development and sensitization, and nurturing of enabling environmental factors. Pathfinder believes programs with vulnerable groups should: Enhance the active participation of members of vulnerable groups in the planning, implementation, and evaluation of interventions, thereby promoting group empowerment and project ownership. Sensitize healthcare providers, the police, and the society at large to begin to de-stigmatize sex work and other controversial behaviors, such as drug use. Conduct advocacy and policy activities to enlist the support of governments, policy makers, brothel owners, and community organizations. Build the capacity of vulnerable groups and associations in social mobilization, project management, and advocacy as a way to diversify funding sources and ensure the sustainability of interventions. Address underlying conditions that make people vulnerable to HIV/AIDS, such as poverty, limited literacy, gender inequality, sexual exploitation, and harmful traditional beliefs and practices. Conduct behavior change communication activities that address both social and individual changes. Offer holistic services, such as childcare, income generation and linkages to micro-credit, support groups, and legal assistance, and not just services that focus on a person’s risky behaviors. Include outreach services, such as peer education, satellite or outpost clinics, and drop-in centers. Form support groups for people living with HIV/AIDS (PLWHA) and provide training in home-based care.

H IGHLIGHTS

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P ATHFINDER ’ S STI/HIV/AIDS P ROJECTS

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V ULNERABLE G ROUPS

Targeted Interventions for Groups at Risk (TIGRIS): India Pathfinder, through the Avahan Initiative, is implementing the TIGRIS Project in Pune metropolitan area and 10 other districts of Maharashtra. TIGRIS aims to decrease STI prevalence rates, increase HIV/AIDS awareness and treatment seeking behavior, and increase consistent condom use among brothel and non-brothel based sex workers and their partners through a combination of clinic and community-based STI diagnosis and treatment, HIV education and prevention, and behavior change programs. A network of clinics will be established in brothel and non-brothel areas in Pune and the project will train, supervise, and support facility upgrades for existing preferred providers working with vulnerable groups in 10 districts. Clinic-based activities will be complemented by community-based outreach activities with sex workers, clients of sex workers, madams, and brothel owners implemented by NGOs and sex worker associations. The project also seeks to create enabling environments within which behavior change can occur and build the capacity of sex workers’ associations.

NGO Service Delivery Project (NSDP): Bangladesh NSDP NGOs throughout rural and urban Bangladesh provide diagnosis and treatment of STIs at static and satellite clinics. Selected NSDP NGOs provide STI services for vulnerable groups, such as truckers, rickshaw pullers, sex workers, and dock laborers in coordination with AIDS-prevention programs supported by USAID. Special satellite clinic sessions and community mobilization activities are held for vulnerable groups at truck and bus stands, halting points along the India-Bangladesh border, boat terminals, and in brothels. NSDP collaborates with CARE to conduct HIV/AIDS work and coordinates with other HIV/ AIDS efforts in Bangladesh. Interventions with Commercial Sex Workers: Brazil Pathfinder collaborates with the Brazilian Network of Commercial Sex Workers by supporting the publication of newsletters and booklets addressing issues related to sexual and human rights and HIV/AIDS prevention. In Bahia, Pathfinder aims to increase the capacity of APROSBA, an association of CSWs, to address the vulnerability of CSWs to HIV/AIDS. Activities include training CSWs as peer educators, developing HIV/AIDS educational materials prioritizing issues such as safe sex, negotiation skills, condom use, and sexual violence, and establishing referral networks with health, legal, and social systems. The program covers about 1,500 CSWs in eight areas of Bahia. Pathfinder more recently began another program for CSWs in the border towns of Foz do Iguaçú and Corumbá. Interventions with Drug Users: Brazil At the national level, Pathfinder is currently supporting the Brazilian Association of Harm Reduction Agents (ABORDA) and the National Association for Harm Reduction (REDUC) in the definition and implementation of their strategic plans. In Bahia, Pathfinder coordinates with a local NGO to improve STI/HIV prevention among drug users in Salvador City. Activities include the development of training and monitoring tools and educational materials, training community harm reduction agents in counseling, establishing a referral system for legal, social, and psychological services, and outreach activities that emphasize prevention and condom use. Interventions with Men Who Have Sex with Men: Brazil After assisting the National Association of Gays, Lesbians, and Transvestites (ABGLT) in the definition of its strategic plan, Pathfinder is now supporting the Association to implement its workplan, mainly focused on institutional communication and advocacy for human rights. ABGLT recently awarded Pathfinder a medal in recognition for its outstanding support of the gay movement in Brazil. At the local level, Pathfinder is continuing its successful partnership with the Gay Group of Bahia (GGB), focusing on implementation of community development activities with young gay men in poor communities of Salvador. African Youth Alliance: Uganda In Uganda, with funding through the African Youth Alliance (AYA), Pathfinder strengthens the Uganda Youth Development Link (UYDEL) to provide holistic services, including condoms, STI treatment, and vocational skills to young CSWs through static drop-in centers and by delivering ASRH services in mobile posts, such as in bars. Interventions with Commercial Sex Workers and their Clients: Nigeria The main purpose of the DFID-funded STD/HIV Management project was to reduce rates of STIs and HIV/AIDS in Sagumu and Otukpo. Pathfinder created a supportive environment for program activities by organizing advocacy meetings and improving awareness of STIs and HIV/AIDS, prevention measures, and support for PLWHA. Pathfinder and its partners worked with key stakeholders, including hotel owners, sex workers, and truck drivers, to reduce transmission among these vulnerable groups. Currently, Pathfinder also works in Aba to provide STI/HIV/AIDS services and outreach to sex workers in 25 brothels, in collaboration with the Saint Anthony Hospital.

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Tayla Colton ♦ HIV/AIDS Technical Services Associate ♦ Pathfinder International ♦ Email: [email protected]

O VERVIEW

HIV/AIDS PROGRAMS

IN THE

WORKPLACE

HIV/AIDS poses a serious threat to the workplace given that a productive and stable labor force is the key to profitable business and economic growth. Worker absenteeism due to illness, caring for relatives, or attending funerals has a serious impact on productivity levels. The financial impact of high employee turnover is exacerbated by elevated training costs from the loss of experienced professionals. Health care costs also rise as companies provide clinical services to a growing portion of their employees and are required to pay higher medical insurance and benefit costs.1

In many developing countries, a large proportion of men, and increasingly women, are employed in the armed or police forces. International and national uniformed services, including peacekeepers, national, and civil defense forces are among the groups most affected by STIs and HIV/AIDS.2 Over 22 million people serve in the armed forces worldwide and a majority are men between ages 20 and 30.3 In most countries, soldiers live in enclosed societies where masculinity and machoism prevail. Like migrant factory or mine workers, they spend long periods away from home and they may alleviate boredom or stress with heavy alcohol consumption and casual sex with multiple partners, making them vulnerable to sexually transmitted infections (STIs), including HIV/AIDS. The unique characteristics of workplaces and the armed forces make them ideal settings for influencing attitudes and sexual behaviors and providing health services to alleviate the impact of HIV/AIDS. These arenas offer structured environments for sharing information, reinforcing behavior change, and implementing interventions with a captive audience. Pathfinder is a partner member of the Global Business Coalition on HIV/AIDS and, through its experience, believes that essential elements of comprehensive workplace HIV/AIDS programs include: • Non-discriminatory policies: The establishment and implementation of a non-discriminatory policy is the cornerstone of an effective HIV/AIDS program in the workplace, underpinning campaigns to promote the use of voluntary counseling and testing (VCT), as well as treatment. These policies should be applied consistently to all involved personnel to avoid stigma or discrimination based on actual or perceived HIV status.4 • Leadership commitment and employee involvement: Company management and military leadership should provide adequate financial and logistical investment to ensure that programs run effectively and efficiently. Workers should be involved at all levels and in all aspects of designing and implementing structured responses to the epidemic, such as involvement in peer counseling and education. Active involvement of trade and employee unions should also be encouraged. • HIV/AIDS prevention, education, and care initiatives including:5 Provision of accurate and up-to-date information on HIV/AIDS and on personnel benefits Gender-specific approaches addressing the underlying forces that increase vulnerability to HIV/AIDS Attention to the special reproductive health (RH) needs and vulnerability of women VCT and STI diagnosis and treatment, with counseling on HIV prevention Wide condom distribution and training on how to use condoms and negotiate their use Care, support, and access to antiretroviral treatment for workers and their families Legal support Outreach into the surrounding community.

H IGHLIGHTS

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P ATHFINDER ’ S HIV/AIDS P ROJECTS

IN THE

W ORKPLACE

HIV/AIDS P REVENTION IN G ARMENT F ACTORIES: L ESOTHO Pathfinder conducted a needs assessment that informed an HIV/AIDS workplace policy and subsequent prevention and support program for China Garment Manufacturers (CGM) workers in Lesotho. The assessment and pilot program, funded by CGM, took place in a garment factory that employs over 7,000 workers, mainly young women. W ORKPLACE -B ASED HIV/AIDS S ERVICES : E THIOPIA Pathfinder works with its local implementing partner organizations to train workplace promoters, youth peer promoters, and health service providers as counselors and primary caretakers in the workplace. To date, 300 people have been trained and are now providing services in sugar, textile, cement and flour factories, and at agricultural centers. Activities include condom distribution, peer and community education, STI diagnosis and treatment, and VCT referral. Pathfinder also partners with the Addis Ababa Chamber of Commerce in the “Preventing HIV/AIDS is Protecting Business” Program to carry out advocacy and sensitization activities with national businesses. It also implements programs with middle- and long-distance bus and truck drivers and their assistants at major transport stops and halting points, such as along the Ethiopia-Djibouti highway. HIV/AIDS E DUCATION AND R EPRODUCTIVE H EALTH S ERVICES TO G ARMENT W ORKERS : B ANGLADESH Pathfinder currently works with local NGOs to provide factory-based health services to garment workers in Bangladesh, of whom an overwhelming majority are young, unmarried women. The workplace programs are part of a large national program to provide clinic- and community-based essential health services in partnership with 41 local and national NGOs. Pathfinder trains paramedics and clinic aides to provide family planning (FP) and RH education, counseling, services, and supplies in selected factories in an industrial area near Dhaka city.

I NTEGRATED R EPRODUCTIVE H EALTH P ROJECT FOR THE A RMED AND P OLICE F ORCES : N IGERIA The Nigerian Armed and Police Forces (Army, Navy, Air Force, and Police Force) represent a large segment of the population, with over 2.5 million uniformed personnel and their dependents. Members of the Forces and their families reside in barracks throughout Nigeria as well as in foreign countries, such as Rwanda, Liberia, Somalia, and Yugoslavia, where they are deployed for peacekeeping missions. Pathfinder, in collaboration with EngenderHealth, provides clinic- and community-based RH education and services in several Armed Forces medical facilities and Police hospitals and clinics. The project integrates STI/HIV prevention with other RH efforts in the barracks through male mobilizers. Pathfinder organizes advocacy meetings with Service Chiefs and sensitization seminars with local stakeholders, trains service providers, male motivators, and community outreach workers on FP/RH and HIV/AIDS, and promotes male involvement and responsibility through behavior change communication initiatives. Pathfinder supports family life education for adolescents enrolled in the Armed Forces secondary schools and advocates with high-ranking military officials to ensure widespread support for the project. Pathfinder currently supports or has previously supported other integrated workplace-based projects in Bolivia, Brazil, Mexico, and Swaziland.

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Tayla Colton ♦ HIV/AIDS Technical Services Associate ♦Pathfinder International ♦[email protected]

Global Business Coalition on HIV/AIDS. Managing HIV in the Workplace. http://www.gbcaids.com/wpp_tool.asp UNAIDS. 2004. Report on the global HIV/AIDS epidemic. www.unaids.org Healthlink worldwide. 2002. Combat AIDS: HIV and the world’s armed forces. Ibid. Family Health International. 2002. “Workplace HIV/AIDS Programs: An Action Guide for Managers.”

OVERVIEW

HIV/AIDS PROGRAMS

WITH

YOUTH

An estimated 10 million people aged 15-24 are living with HIV/AIDS and half of all new infections (over 6,000 daily) occur among young people.1 Widespread HIV prevalence rates among the world’s youth can be attributed to their physical, social, psychological, and economic vulnerabilities. Often, they may not perceive themselves to be at risk or they do not have access to reproductive health information or services. Social norms, such as older men engaging in sex with younger girls, gender power imbalances, and the high incidence of coerced sex, increase young women’s vulnerability to HIV/AIDS. Two-thirds of all young people living with HIV/AIDS live in sub-Saharan Africa, and 75% of these are young women. Poverty and lack of education and employment opportunities can lead young people to engage in risky behaviors, such as exchanging sex for money or engaging in survival sex. While young people are extremely vulnerable to HIV, they are also making remarkable progress in changing behaviors to decrease their vulnerability and offer the greatest hope to change the course of the epidemic.2 Since the 1970s, Pathfinder has worked with young people in more than 30 countries. In addition to addressing STIs and HIV/ AIDS, Pathfinder’s integrated approach includes access to comprehensive adolescent sexual and reproductive health (ASRH) information, pregnancy prevention, and counseling on making and implementing decisions related to SRH. Pathfinder’s youth programs sometimes include job training and life skills education. Pathfinder involves young people in the design, implementation, and oversight of projects, which include efforts to: Reach youth with prevention and education activities before they become sexually active Provide youth-friendly services (YFS) Promptly detect and treat STIs and promote correct and consistent condom use Provide quality ASRH and HIV/AIDS education and counseling programs through peer education, outreach, and in schools Conduct innovative behavior change communications (BCC) activities designed by youth, with tailored messages depending on the age and gender of the audience Provide condom negotiation, assertiveness, and communication skills for young women Redefine masculinity with an emphasis on males as partners and male responsibility Improve parental communication and involvement Involve youth in community home-based care and support programs Strengthen policies and programs which reduce the vulnerability of young people Sensitize policy makers, parents, teachers, and health workers about the special needs of youth.

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Y OUTH

African Youth Alliance (AYA): Botswana, Ghana, Tanzania, and Uganda AYA is a collaborative, five-year project implemented by Pathfinder, UNFPA, and PATH. This Bill and Melinda Gates Foundation-funded project seeks to improve ASRH in Botswana, Ghana, Tanzania, and Uganda. AYA reaches young people between the ages of 10 and 24, with a particular emphasis on 10-19 year-olds. Program goals are to contribute to reduced rates of HIV/AIDS, STIs, and pregnancy among young people, promote delay of sexual debut, promote condom and other family planning use among youth that are already sexually active, and to eliminate harmful traditional practices and forced and coerced sex. Pathfinder is specifically responsible for YFS and institutional capacity building within AYA.

“Geração Biz” Project: Mozambique Geração Biz is a national, multi-sectoral program, including the Ministries of Health, Youth & Sports, and Education and local NGOs, that integrates BCC and youth-friendly services to improve ASRH, increase gender awareness, reduce unwanted pregnancies, and decrease vulnerability to STIs, HIV/AIDS, and unsafe abortion. Activities are well underway in Gaza, Tete, Maputo City, Maputo Province, Zambezia, and Cabo Delgado. The project reaches 36 districts in six provinces, and involves 24 institutions in program implementation. Geração Biz has a cadre of 3,000 trained peer educators and established 27 youth corners in schools and 14 youth corners in communities, reaching over 300,000 young people. In 2003, 32 YFS facilities received over 50,000 client visits and distributed over 230,000 condoms. Geração Biz was recently selected as a “best practice” project by the World Bank and with their funding, began to integrate HIV/AIDS care and treatment services, including voluntary counseling and testing (VCT), treatment of opportunistic infections, and antiretroviral therapy (ART), into selected youthfriendly clinics. University-Based Peer Education Adolescent Reproductive Health Project: Kenya This project is based at the Kenyatta University and Egerton University campuses, which serve more than 20,000 students and 4,000 staff. Youth-focused initiatives include peer counseling, family life education, human sexuality education, and the provision of integrated reproductive health services (including family planning, treatment of STIs, condom distribution, and emergency contraception). Through these initiatives, Pathfinder aims to improve youth access to services, reduce student pregnancy and the incidence of STIs and HIV/AIDS, and increase student knowledge about RH, and especially HIV/AIDS. Pathfinder involves youth at all levels of program design and implementation and equips students with basic computer and other skills necessary to compete in the job market. Adolescent Reproductive Health: India The primary objective of this seven-year project, funded by the Bill and Melinda Gates Foundation, is to improve RH among adolescents served by NGOs in India through school- and community-based interventions. Pathfinder increases awareness about RH services for adolescents and improves the capacity of NGOs to deliver such services. Implementing NGOs conduct activities in Delhi slum areas, Tamil Nadu, Rajasthan, and Madha Pradesh. Although the primary focus of the project is to delay first births and child spacing, STI and HIV/AIDS activities are integrated by training NGO staff in HIV/AIDS counseling, providing referrals for VCT and STI treatment, and through BCC. Youth-Friendly Services: Vietnam The Reproductive Health Projects (RHPs), a partnership between Pathfinder International, EngenderHealth, and Ipas, has worked in collaboration with the Ministry of Health since 1994 to improve and expand the quality and range of public-sector RH services. In 2003, YFS were introduced in three RHP provinces: Hanoi, Ho Chi Minh City, and An Giang with the intent of further expansion. Service providers have been trained in ASRH with a heavy emphasis on HIV prevention, including dual protection from STIs/HIV and unwanted pregnancy. Alternative channels, such as pharmacies and culture houses, are also being used to reach young people with HIV prevention messages and condoms.

“Yellow Card” Since 1998, Pathfinder has been working with Media for Development International to produce and promote Yellow Card, an African media project geared towards young African audiences. Yellow Card is a feature-length film that addresses themes of adolescent sexuality, including unintended pregnancy, STIs and HIV/AIDS, “baby dumping,” and male responsibility – all in an entertaining and engaging medium. Originally produced in English, the film has been dubbed into six languages. A series of supporting materials complement the movie and are used by teachers, youth leaders, and others to guide discussion about HIV/ AIDS and other issues brought forth in the film.

F OR M ORE I NFORMATION , C ONTACT :

Gwyn Hainsworth ♦ ASRH and Training Associate ♦ Pathfinder International ♦ Email: [email protected] 1 2

UNAIDS. 2004. Report on the global HIV/AIDS epidemic. www.unaids.org USAID. 2001. USAID programs: Youth and HIV/AIDS fact sheet. www.usaid.gov and UNAIDS. 2002. Report on the global HIV/AIDS epidemic. 2002. www.unaids.org