The purpose of HIV/AIDS advocacy
Advocacy is a process of communication which is different from the mere dissemination of information and education (IEC). Advocacy goes beyond this and first seeks support, commitment and recognition from policy and decision-makers and the general public about the problem. Advocacy provides solutions and support in tackling issues. This Guide will not attempt to describe in detail how to organise advocacy campaigns, since these subjects are covered in greater detail in the IPPF Advocacy Guide, but will focus on the application of advocacy to HIV/AIDS prevention. The first requirement is solid factual information. Information from country situation analyses and baseline studies needs to be collected to understand risky practices and behaviours. Based on this information, advocacy work should include creating awareness of the magnitude and seriousness of the problem, diminishing discriminatory practices and removing policy and other barriers to prevention and care activities, and campaigning for effective and sustainable action. It should aim to influence the highest authorities in the country to provide leadership, political support and commitment. In detail, each individual advocacy plan should comprise the following elements:
• Identify the advocacy issue
• Identify the target audience: e.g. government officials,
policy makers, religious leaders, employers, health
professionals, communities, media etc.
• Expected results: e.g. clear government policies on HIV/AIDS, government commitment to information and
services, review of laws and practices, clear HIV/AIDS policies and practices at work places, etc.
• Suggested activities: e.g. gather information, develop fact sheets, join other activist organisations, conduct
sensitisation meetings with media, lawmakers, religious and community leaders. Advocacy is important in HIV prevention because it can enable things to be done which a single organisation could not do on its own; partnerships are key and create support for an HIV/AIDS prevention programme in a number of ways:
• By raising awareness, knowledge, and understanding among the general population about HIV/AIDS and
• By encouraging the mobilization of resources and commitment for the implementation of the STI/HIV
• By initiating and supporting campaigns for making anti-retroviral drugs widely and cheaply available
• By promoting good policies and practices
• By promoting knowledge about HIV and how it is spread
• By reducing the stigmatisation of HIV/AIDS-affected people
• By upholding the rights of HIV-positive people
• By strengthening solidarity between NGOs and people living with HIV/AIDS
• By involving people living with HIV/AIDS in education and prevention, where they have a key role to play.
Messages must be clear and have a credible source, such as IPPF’s International Medical Advisory Panel (IMAP) Statements or UNAIDS documents.
HIV and human rights
The protection of human rights is essential to safeguardhuman dignity in the context of HIV/AIDS and to ensure an effective, rights-based response to HIV/AIDS. An effective response requires the implementation of all human rights, civil and political, economic, social and cultural. Public health interests do not conflict with human rights. On the contrary, it has been recognized that when human rights are protected, fewer people become infected and those living with HIV/AIDS and their families can better cope with HIV/AIDS. When HIV first strikes, countries often go through a phase of denial and do not accept that the HIV/AIDS problem warrants serious attention. During this time the citizens are denied their rights to information and services and find themselves becoming the victims of a disease that their own governments have not recognized as a national disaster. The IPPF Charter on Sexual and Reproductive Rights identifies a number of basic human rights, which may be used for advocacy in the area of HIV/AIDS. HIV and gender It is important for organisations always to bear in mind the way in which gender roles have a part to play in the AIDS crisis: the sexual subordination of women makes it much more difficult for them to avoid infection. Biologically young women are more prone to infection, and their low social status and cultural expectations of sexuality further compound their vulnerability. Men are part of the solution to the HIV pandemic, and men need to understand how their actions contribute to the spread of HIV/AIDS. Men need to play an active role in promoting their own health as well as protecting their partners from the HIV infection, and advocacy can reinforce this process. Advocac initiatives that target young boys are increasingly being seen as valuable i promoting more gender-equitable relationships between men and women. Another important dimension of gender and HIV/AIDS is that of gender-based violence and discrimination against women and girls. This makes them vulnerable and unable to negotiate safer sex. Sexual violence and coercive sex, (which often carries a high risk of infection) must also be addressed. Studies confirm that women who disclose their HIV positive status often face further violence and discrimination. Advocacy initiatives should focus on eliminating all forms of violence against women and on campaigning to change laws where appropriate. Advocacy for gender-sensitive programming will hel identify the differential needs of men and women, boys and girls. Advocacy aimed at empowering women and giving them more negotiating skills is an important tool for combating HIV/AIDS as well as for the promotion of women’s rights. More specifically, advocacy aimed at improving women’s access to education and to economic resources, such as training, legal reform and credit schemes, can contribute to women’s overall decision-making power within households and in sexual relationships. Involving people with HIV/AIDS Involving people with HIV/AIDS in policy design, planning and the implementation of AIDS-related work is itself an important aspect of advocacy. Doing so will increase the relevance of such work; reduce discrimination; help the needs of people with HIV or AIDS to be recognized; assist in the process of destigmatising HIV/AIDS; enable a greater understanding of the impact of HIV/AIDS; and present a human face to AIDS. People living with HIV or AIDS also have a key role to play in education and prevention. Discrimination against such people is widespread, and involving them is a vital element in changing attitudes. HIV testing Organisations should advocate for good-quality, voluntary and confidential HIV testing and counselling to be made available and accessible, and discourage mandatory testing. Microbicides and vaccines The eradication of HIV/AIDS is likely to be hastened by the development of effective vaccines against HIV and efficient microbicides able to better protect against STIs and HIV transmission. NGOs should advocate for their governments to support the necessary research and development. Parent-to-child transmission of HIV Parent-to-child transmission of HIV is the most significant source of HIV infection in children below the age of 10 years.
Since 1998, UNAIDS has recommended that pregnan women who are HIV-positive should be offered a short antiretroviral course which has been shown to reduce transmission by at least 50 per cent when used properly NGOs should advocate for their government to integrate such prevention interventions into existing reproductive health services. Other points to bear in mind:
• You are dealing with a controversial subject. Welcome this and try to turn it to your own advantage.
• Avoid any illegal or unethical activities.
• Hold policy-makers accountable for commitments.
• Keep a record of successes and failures.
• Monitor public opinion and publicise positive changes.
The promotion of the male and female condom for dual protection against STIs/HIV/AIDS and unwanted pregnancy is the common link between the traditional work of FPAs and HIV/AIDS prevention. The condom is quite simply the best means, and presently the only, there is to prevent the spread of the disease. Promoting the male condom The male condom is the best means of preventing the transmission of HIV and other STIs. Limits to the wider use of the condom include:
• Cost and availability
• Belief that it should only be used to prevent pregnancy
• Failure by service providers to promote the condom as an effective method of contraception
• Reliance on non-barrier methods of contraception
• Condom use by married partners is often not socially acceptable
• Religious opposition to its use – generally, or among the unmarried. Condom campaigns can have spectacular results. Thailand’s 100% condom campaign has averted 2 million infections, saving some $US 6 billion.
Promoting the female condom
The female condom is the first contraceptive barrier controlled by women that also protects against STIs, including HIV. It therefore expands the choices that both men and women have to protect themselves from HIV infection. The female condom is particularly important to women whose partners refuse to use the male condom. The female condom may initially meet opposition from both users (because it is unfamiliar) and providers (because it costs more than the male condom). Advocacy can play an important role in both making the female condom more widely available (through convincing providers that it is cost-effective), and in increasing its acceptability. Important points to stress include:
• In acceptance studies, 50 to 70 per cent of the women and men surveyed rated the female condom as acceptable. • Users should know that the female condom is made of polyurethane, which is a soft, thin plastic stronger than latex.
• The female condom can be inserted up to eight hours in advance of sexual intercourse, and therefore does not interrupt spontaneity, and it does not need to be removed immediately after ejaculation
• Because it has a higher unit cost, the female condom should be targeted at populations that already have ready access to the male condom or are not able to use the male condom consistently. By focusing on these groups, female condom use increases the number of protected sexual acts without necessarily decreasing male condom use.
• Recent research indicates that the female condom may not only be cost-effective but may even save costs, particularly when specifically targeted to groups that practise high-risk behaviours. Advocacy through the media (newspapers, magazines, radio, the Internet) can be used as an addition to information and education campaigns to inform the general public about the benefits of the female condom. Children and young people In developing countries, up to 60 per cent of new HIV infections are among 15 to 24-year-olds. Because of biological and social factors, young girls are especially vulnerable. In some places, among 15 to 19-year-olds, two girls are infected for every boy. Advocacy can contribute to reduce vulnerability faced by girls and in bringing about social change - for example, by correcting popular myths such as the idea that having sex with a virgin will cure a man of AIDS. Furthermore, the drastic increase in the rate of infection among women means a corresponding increase in HIV-infected babies born to them. In 2000, there were 1.4 million children under 15 living with HIV – though some of these will have been infected by sexual activity rather than by their mothers. Many young people are put at risk of HIV because they are denied access to HIV education, information, health care and means of prevention - access which adults usually have. This is a violation of the rights of children and adolescents to nondiscriminatory education and health,as well as a violation of their right to express their own views and to seek, receive and impart information and ideas of all kinds. FPAs and other SRH NGOs have a particularly important role to play here. Advocacy can play a key role in ensuring that education on sexual and reproductive health issues, including HIV/AIDS, is provided in schools and in settings where out-of-school youth meet. Such information needs to be supported with appropriate and accessible sexual and reproductive health services for adolescents. Studies have shown that sex education and HIV education do not encourage sexual activity. In fact, evidence shows that when young people are given complete information on sexuality it can help them to feel comfortable about themselves and in control of the decisions they make. Where sexuality education is comprehensive more young people practise safer sex or choose to postpone sex. Special efforts should be made to provide this education to children who are hard to reach, such as children of minorities, indigenous peoples and street children. Young people often face special difficulties of access t services. Inconvenient hours, legal hurdles, inaccessibility and high costs are among the factors that can severely curtail young people’s ability to use the services. Advocacy can be a useful tool to effect changes to break down barriers young people face when accessing services. All sexual exploitation and abuse, including that involved in the sale of children, child prostitution and early marriages, increase the risk of STI/HIV infection. Efforts made to stop these practices should integrate HIV concerns. Public information campaigns against child abuse and sexual exploitation, as well as education campaigns aimed at families, children and adolescents, should explain the risks of infection, means of protection and services available, if infection does occur. HIV/AIDS advocacy campaigns aimed at young people can benefit from young people’s participation in the design, implementation and evaluation. Successful strategies include peer education. Every effort should be made to involve young people.
Advocacy for different groups of people at higher risk
FPAs have a mandate to work with and promote the interests of vulnerable groups in society. Those groups are likely to be at particularly high risk of being affected by HIV/AIDS. In some cases, advocacy can enable FPAs to persuade other organisations to provide services at no cost to the FPA; in other cases other NGOs or government agencies can share the cost load. Sex workers Sex workers, including indirect sex workers such as ‘beer girls’ in Cambodia, are particularly vulnerable to STIs/HIV and represent the most significant core group for transmission to the rest of the population through their clients.
The main factors influencing the spread of HIV include the number of clients a day and the proportion of men who visit sex workers regularly. The absence of condom use increases transmission even more. Sex work continues to be illegal in many countries so prevention remains difficult. Organisations should advocate for recognition of the problem and the protection of sex workers and their clients through 100 per cent use of condoms. Organisations can also recruit peer counsellors and condom distributors, as the Indonesian Planned Parenthood Association has done with transvestite sex workers in Jogjakarta (Lentera project). Clients of sex workers Advocacy can help to protect particular groups of clients of sex workers, such as truckers, labourers and fishermen.
FPAs in Thailand and India have shown how advocacy work with restaurant owners and brothel keepers on highways and at fishing ports can result in their co-operation in encouraging higher condom use. Injecting drug users In many parts of the world, injecting drug use is the major mode of HIV transmission. This is the case in a number of Asian countries, parts of eastern Europe and several of the Newly Independent States; a number of Latin American countries; and some western European countries such as Spain and Italy. In the Russian Federation, more than half of all reported HIV cases to date have been in injecting drug users. Drug use has an intimate connection with HIV. The connection occurs when drugs are injected using contaminated injecting equipment.
Furthermore, some drug use can lead to risky sexual behaviour, which can also result in HIV transmission. Of all the different ways that the virus can be passed on, directly injecting a substance contaminated with HIV into the blood-stream is by far the most likely to result in infection - much more so, in fact, than through sexual intercourse. What is needed is a comprehensive package of measures to prevent HIV spread among injectors – and grassroots NGOs can play an important role in advocating for its provision.
Such measures include providing sterile injecting equipment; raising awareness among and educating injectors and their sexual partners about HIV risks and safe practices; making available drug treatment programmes; providing access to counselling, to care and support for HIV-infected injectors, and to STI and other healthcare services; and providing condoms.Men who have sex with men Sex between men exists in most societies. It frequently involves anal sex. Unprotected penetrative anal sex carries ahigh risk of HIV transmission, especially for the receptive partner. HIV prevention programmes for men who have sex with men (MSM) are hindered by the following
• denial that sexual behaviour between men takes place
• stigmatisation, discrimination or criminalisation of men who engage in sex with other men
• inadequate or unreliable epidemiological information on HIV transmission through male-to-male sex
• the difficulty of reaching many of the MSM
• disregarding or ignoring safer sex practices
• inadequate or inappropriate health facilities, including STI clinics, and lack of awareness or sensitivity among clinic staff about the existence of anal, rectal and oral STIs
• lack of interest among donor agencies in supporting and sustaining prevention programmes among men who engage in same-sex behaviour, and a lack of programmes addressing male sex workers in particular
• lack of attention in national AIDS programmes to the issue of MSM. Effective advocacy can address many of these problems. For instance, through:
• peer education among MSM
• the promotion of high-quality condoms and water based lubricants, and ensuring their continuing availability
• safer sex campaigns and skills training, including the use of condoms and the promotion of lower-risk sexual practices as alternatives to penetrative sex
• strengthening organisations of self-identified gay men,enabling them to promote HIV prevention and care programmes
• promoting culturally appropriate mass medi campaigns
• education among health and clinic staff to overcome ignorance and prejudices about MSM.
Migrants and refugees Migrants and mobile people may be highly marginalized and have little or no access to HIV information, health services and means of AIDS prevention. The most vulnerable are refugees, those without legal status, and women and girls. Refugees often lack the security offered by their families and communities. Lack of educational facilities and jobs in campsettings can lead to boredom, substance abuse and risky sexual behaviour. Advocacy can forcefully present the case against discrimination and in favour of the provision of services for these people. Efforts must be made to build partnerships and develop multisectoral (health-education and community services) prevention and care services.
Armed forces Military personnel are a population group at special risk of exposure to STIs, including HIV. In peace time, STI rates among armed forces are generally two to five times higher than in civilian populations; in times of conflict the difference can be 50 times higher or more. Probably the single most important factor leading to high rates of HIV in the military is the practice of posting personnel far from their accustomed communities and families for varying periods of time. As well as freeing them from traditional social controls, it removes them from contact with spouses or regular sexual partners and thereby encourages the growth of sex industries in the areas where they are posted.
Paradoxically - and fortunately - strong traditions of organisation and discipline give the military significant advantages if they move decisively against HIV/AIDS. A real impact can be made by reaching senior military and defence ministry personnel through advocacy, as is shown by the work done by the Planned Parenthood Association of Thailand (PPAT) with the Royal Thai Air Force. With a minimal budget, PPAT worked through the military structures to achieve remarkable results. (See page 22). Prisoners Male prisons have been shown to make a significant contribution to some countries’ HIV epidemics, both through male-to-male sex and injecting drug use. Several factors contribute to risks of onward transmission of HIV infection within prison environments.
Overcrowding is one such factor. In 1995, the prison population of the United States was 1.6 million, a doubling over 10 years. In a major Eastern European prison, individual cells hold up to 35 prisoners each. Violence, often a feature of prison life, produces tensions, recriminations and an atmosphere of fear. Many of those in prison are there because of drug use or trafficking, and they often find ways to continue drug use inside. Drug injecting with shared, nonsterile equipment is the factor probably accounting for the greatest number of new HIV cases in prisons worldwide.
Unprotected anal sex and male rape are also important factors for HIV transmission in prisons. Here, an FPA or NGO can make an important impact by training peer educators (including ex-prisoners and exinjectors) who can provide education on using clean injecting equipment, as well as help in drug cessation programmes. Through advocacy, they can reach senior officials and persuade them to provide free clean syringes and sterilising bleach for drug users, and general access to lubricated condoms.
HIV/AIDS has direct economic costs on businesses both large and small, and the business community is therefore highly motivated to work on preventive measures for economic reasons and for the welfare of their employees. Many large businesses also respond out of philanthropic concerns. Many businesses will be open to approaches to help them with talks, training of trainers and the production of posters, leaflets and videos, because they are dealing with an unfamiliar and delicate area. Good examples are the work of the FPA of Mauritius with young unmarried workers in the Export Processing Zone (EPZ) factories and workshops, and the services provided by the FPA of Kenya workplace motivators.
Larger businesses could be asked to consider paying fees or making a donation in exchange for FPA professional help. The Thai Business Coalition has had great success in persuading businesses that HIV awareness and prevention is in their interest. Simple, non-threatening messages, coupled with offers of co-operation, are often effective in persuading senior managers. Businessmen are as open to peer pressures as anyone else. Word of mouth through chambers of commerce and business clubs, and the example of big businesses, can quickly persuade companies that they need a policy on HIV/AIDS.
The example of Jardine Matheson in Bangkok, which has introduced AIDS awareness for all 3,500 new employees every year at their starter session, is a powerful one for local businesses. Examples can help show why there is a need for a firm policy on AIDS. In Beijing it was suspected an Italian chef at a fivestar hotel had AIDS. His co-workers clubbed together to buy him a ticket back to Rome. Unfortunately, through ignorance about the disease, when he had gone they tore down the wallpaper in his room, ripped up the carpet, and burned it at the back of the hotel. Soon afterwards, the hotel introduced an HIV awareness and prevention policy. Effective HIV programmes will be integrated into organisational structures, and minimise work disruption and financial burden to the company and employees.
| Copyright 2004