|African Women and AIDS: Scope, Impact and Response (UNESCO, 1999, 59 p.)|
By Karim Seek
(Public Health Medical Doctor, Deputy Co-ordinator of the National HIV/AIDS Programme in Senegal)
As the HIV/AIDS epidemic evolves in the world, the protection of women is increasingly becoming a major concern. Indeed, from a men-women ratio of 7/1 in 1990, the rate of infection has inverted to 1.5/1 in certain countries. Four out of six new cases of infections occur among women aged between 16 and 24 years.
The vulnerability of women to HIV has been widely documented. The gravity has been more widespread in sub-Saharan Africa. The low level of literacy among the majority of women constitutes a major obstacle to efforts to educate them on the mode of transmission of the disease. The peculiar nature of AIDS, a deadly disease associated with sexual behaviour, imposes specific educational strategies which make it possible not only to create awareness on the risk but also to bring about a change in behaviour with the aim of protecting women through better control of their sex lives.
The HIV/AIDS prevention education is the responsibility of the national AIDS programmes. They are assisted in this task by associations and Non-Governmental Organisations that most often constitute the operational link in direct contact with the "beneficiaries". Their educational role and assistance often go beyond the domain of the HIV/AIDS, to include health care, and other sectors of development.
This paper is a summary of experiences on HIV/AIDS prevention education of the organisations invited to this workshop. It provides a basis for discussion on a variety of strategies that have been used so far to tackle the various aspects of women's vulnerability to HIV/AIDS, strategies which seek to integrate the social and cultural realities of the target group in question.
Areas of Intervention
Two main groups of organisations are directly concerned: those whose activities are exclusively concerned with HIV/AIDS and those whose field of intervention is wider. The main activities of the first group of organisations centre around sensitisation, training, back-up support for AIDS patients or those affected and advocacy.
The second group of the organisations invests in other health care programmes (family planning, reproductive health, maternal or child health), as well as in such other sectors as the environment, economy, the spiritual and more generally, in the promotion of the women's status. The field of interventions can be summarised as follows:
· Education on STD/AIDS prevention
· Provision of medical and psycho-social care
· Reproductive Health IEC HIV/AIDS
· Family Health, Family Planning
· Maternal and Child Health
· Education on the environment
· Literacy, health, economy
· Rehabilitation of slums, Reforestation
· Water resources
Rights, Citizenship and Advocacy
· Promotion of rights
· Education For Citizenship
· Program against violence on women
· IEC On the right of women
· Civic Rights and Responsibility
· Training and education for development
· Training in Savings and credit management
· Handicraft, agriculture, cattle fattening
· Fight against poverty
· Facilitation and support for women in their religious and social endeavours.
Women, girls, the youth, whether in school or out-of school, constitute a common target of the two types of organisations. Organisations exclusively involved in HIV/AIDS have proposed a greater variety of targets based on their support activities for people living with HIV, as well as in the mobilisation of community leaders and other people in some social and professional categories.
With regard to illiterate and neo-literate women, the quasi-totality of the organisations already include them among their targets, in which they represent a proportion varying between 50% to 90%. The age brackets are very wide, most often ranging between the age of 15 and 70 years. However, particular attention is devoted to young people aged 15 to 25 years.
Target Groups of Specific Organisations:
· Women and girls in pen-urban and rural areas, either within organised groups or in high risk situations;
· Pupils and female Students;
· Young adolescent girls.
· Persons living with HIV/AIDS
· Prostitutes and their clients;
· Leaders and Policy makers;
· Men and women of the community;
· Organisations and individuals involved in projects;
· Police, social and judicial workers, traditional and political authorities.
· Socio-professional female Groups (seamstresses, dyers), women's associations, village women organisations;
· Young female students, girls;
· Some men;
Internal Structure (Organigramme)
It is generally composed of three to four levels: level of orientation/decision, level of execution and operational level.
For about 45% of the organisations, the level of orientation/decision is handled by a deliberating assembly (general assembly, Synod, Convention...) with decentralised membership based on areas of intervention (regional or provincial commissions). In the other organisations, the orientation/decision post is occupied by a chairwoman or a female co-ordinator.
The level of execution generally involves several units of intervention, led by the chief of programs. The number of units as well as their tasks vary according to the domains of intervention.
The operational level has to do with field operators. It is made up of either grassroot community groups (village groups, associations) or community relay teams, peer educators, or even active members of organisations (voluntary women, project assistants, field teams). Whatever the composition, this operational level has, in all organisations, benefited from basic training related to field activities. This training has more often been organised in batches (training of trainers, field training) generally by IEC experts of the National AIDS campaign Programs, as well as by those from some national or international NGOs (INTRAH, AMPPF, AIDSCAP).
In the field, 60% of the work of the supervisor in most cases consists of co-ordinating activities and implementing programs according to the established plan. In some cases, however, they directly play the roles of animators and facilitators on the occasion of awareness-raising meetings.
ACTIVITIES ON EDUCATION FOR HIV/AIDS PREVENTION
Areas of Activities
The activities of the HIV/AIDS prevention education are made up of training, sensitisation, support and care, advocacy and various other types of activities associated with the development of aids, research and networking.
· Training of members;
· Training educational peers;
· Training in counselling, communication skills and self-assertion;
· Training of trainers (capacity building);
· Vocational training and post vocational support;
· Training of traditional birth attendants.
· Educational discussion, conferences, round table meetings;
· Marketing of subsidised condoms;
· Advocacy and awareness campaigns on HIV/AIDS.
Support and Care
· Taking charge of infected people;
· Advocacy for infected women and the affected;
· Home care during terminal phase
· Assistance to people living with HIV through micro-projects;
· Income generating activities.
Advocacy for the protection of the rights of women
· Advocacy for women empowerment;
· Centre for women in distress;
· Legal support;
· Promotion of women.
· Designing materials/aids;
· Collection and dissemination of information;
· Catering for STD patients;
· SR for teenagers;
· Networking and partnership.
Teaching/learning support and channels of communication
Major types of support materials
The most commonly support materials used are the graphic ones (folders, picture books, and posters) and audiovisual materials (video films). The demonstration on the utilisation of the condom with the help of model penis seems very common. On the other hand, fewer space is devoted to the theatre and plays. Most of these aids are either produced by the organisations themselves or by the national partners (Ministry of Health, national HIV/AIDS Programs) with the financial support from international partners.
Traditional support systems
The quasi-totality of organisations think that some of the messages designed for HIV/AIDS prevention can be transmitted through objects in use in daily life (cloth/pottery, etc.) and by so doing induce discussion, ease taboos and help as constant reminder. Several suggestions have been made to this effect:
· Weaving of loincloth with drawings showing the modes of transmission or signifying death and captions in the national language;
· Illustration of an AIDS patient by using an art object (clay),
· Tee shirt, loincloth, caps, gadgets but also songs, sketches and theatre;
· Training in tie-dying, batik and sengraphy using educational images on AIDS;
· Pottery, arts, plates, hand bags and market bags
Channels of communication
In close to two-thirds of the cases, research has been conducted to identify the most appropriate channels of information for the various target groups. The main methods used were:
· The organisation of proximity awareness meetings, talks (focus group) with the various men and women age groups in the villages,
· Baseline surveys and evaluation of target groups' needs;
· Personal contacts, family visits,
· Seminars and group discussions,
· Peer education.
Peer education is often highlighted as one of the best channels of communication (women-to-women, youth-to-youth, men-to-men) Further-more, dramatic activities seem to be more appropriate for illiterate people, out-of-school young people and those in rural areas, while video and play activities are appreciated by young people in school. The media as well as the traditional communicators (griots) are sometimes cited.
Designing and developing programmes
Close to 90% of the organisations have carried out preliminary studies before the preparation of the educational programmes. The methods often used are:
· The MARP (Participative Rapid Appraisal);
· Baseline surveys of KAP in associations, in urban and rural schools;
· Hospital statistics;
· EDS research reports;
Those who did not first carry out an initial assessment, prepared their program based on a community initiative which spontaneously highlighted the needs. Some organisations, however, conducted initial studies but in domains other than HIV/AIDS.
On the other hand, only 35% of the organisations conducted final or midterm assessment of their programs. In most cases, it was participatory self-assessment with leaders of focus groups to assess the impact of the messages. Some external evaluations were, however, undertaken by the research institutes, international NGOs and universities, the UNAIDS and co-operation agencies.
These assessments resulted in the adaptation of strategies and orientations, messages or the educational materials. The results of the surveys have also been used for the:
· rectification of sketches, based on the suggestions of resource persons in theatre and the target group.
· inclusion of women teachers in target groups of the project destined only for mothers and their girls.
· production of materials in vernacular language with reinforced graphics
· modification of the time chosen for intervention as well as the subjects discussed at meetings.
· developing more specific themes such as negotiations on the use of the condom, relationship between STD/HIV.
There is a large predominance of the tripod of "abstinence - fidelity -condoms". These topics are however, arranged according to targets. Abstinence and fidelity are especially destined for young school children, with an orientation toward condom use for non-school going youths. Fidelity and use of male and female condoms are advocated for couples. For young girls, emphasis is placed on protective behaviour vis-a-vis premature sexuality. The wider pubic is especially provided with information of a general nature on AIDS, the modes of prevention, risky behaviour, family and sexual health and promotion of AIDS tests.
· Abstinence and fidelity for teenagers and young persons especially in school environments;
· Condoms for out-of-school youth;
· Stopping sexual exploitation of children.
· Reciprocal fidelity;
· Use of male and female condoms for married couples.
· Choice of a faithful partner;
· "I love my body";
· "Young girls you have the right to say no"
Persons Living with HIV
· Solidarity with persons suffering from HIV/AIDS;
· Adopting the right attitude towards infected people.
The Wider Public
· Adoption of risk-free attitude to sex;
· Definition of AIDS and modes of prevention,
· Family and sexual health;
· Sexually Transmitted Diseases;
· Promotion of AIDS testing and diagnosis.
More Specific Features
The gender approach
Close to the two-thirds of the organisations assert that they take Gender into account in the preparation and dissemination of educational messages. The biological and socio-economic vulnerability of women in addition to the fact that sexual intercourse is forced on women often justify this approach. But concern on the need to raise the level of risk awareness should also be taken into account so as to encourage men to show greater respect and protection toward women.
The approach goes beyond mere dissemination of the message. Some organisations are involved in overall promotion of women in order to achieve greater balance of power between men and women. Concretely, it can boil down to efficient management of homes by both men and women such that each and everyone has the opportunity to attain their full social, moral and economic potential. The most relevant strategy to achieve this objective consists in organising awareness workshops on Gender, to encourage women and men to first think separately then to discuss together.
The gender approach is not, however, universally applied. Some organisations believe that only women should be involved considering the fact that they are composed of women specifically. For others, men and women run the same risk of contamination. Promotion of methods of prevention familiar to women such as the use of female condoms is another reason adduced to reduce the emphasis placed on male condoms for too long.
The majority of organisations encourage couples, parents and/or children to discuss these issues related to sexual health. Two types of methods are used:
· peer education that encourages dialogue within the same age-group (IEC program "children-to-children" in schools, sensitisation "Parents-to-parents");
· the introduction of programs based on communication workshops which encourage dialogue between various age-groups (mother-to-daughter, parents-to-children).
Promotion of risk-free sex
Sexuality among the youth is a subject which has been widely integrated by the organisations. Starting from the notion that the youth are sexually active but immature, they have some specific needs in terms of prevention. The role of elders as models of good behaviour is also recommended. Some indications testify to this preoccupation, for example, the presence of young animators in the organisations, and the holding of public meetings without distinction of sex among youth organisations.
Issues associated with casual sexual relations outside marriage are also incorporated by organisations. Several types of strategies have been put in place, among others:
· Emphasis on spiritual precepts: "God and the Church condemn sexual relations before marriage known as fornication while the extra-marital sex is termed adultery";
· Sensitisation on the risk of social stigmatisation faced by women, a risk that does not weigh as much on men.
80% of the organisations hold the view that their program strengthens the capacity of women and men to negotiate in risk-free sexual relations. This opinion is based on the specific experiences of training in sexual relations negotiations especially with prostitutes. Furthermore, among couples, women are encouraged to discuss and use contraceptives. In a similar vein, women gain more confidence through specific training programs on self-affirmation and the capacity to communicate, and by strengthening their economic independence. Besides, some indicators give an idea on this change through the ability to convince husbands to use the condom, confidence and freedom to speak in public on these issues.
Rape and sexual harassment appear to get less attention from the organisations. Less than two-thirds of them tackle these problems, either by setting up specific programs (Program against violence on women, periodic seminars on the prevention of rape in homes and places of work), either through mobilisation and advocacy (support to young women victims of sexual harassment, wide-scale mobilisation against proven cases of rape and testimonies of victims). Sensitisation on the risks of AIDS associated with rape and on the rights of women, is among the applied strategies.
Accessibility to male condoms is encouraged by almost all the programs without distinction of sex. Distribution at the community level, free distribution especially among target groups (prostitutes, young people), or the orientation of people toward sales outlets or distribution points promote easy access. On the other hand, femidon remains an object of curiosity or for experimentation in many countries, whereas it is available at affordable prices in certain regions of the continent.
The majority of organisations (83%) feel they provide answers to the problems associated with the use of condoms by both men and women. There is a wide variation in the methods employed: campaign against false notions on the use of condoms, sustained promotion of the condom, group discussions and workshops as well as forums attended by the two sexes are among the advocated methods.
Training on the use of the condom almost always concerns men and women. The latter often play the role of contact-person within homes and in their community and most educational sessions end with a demonstration on how to use condoms. The use of drawings and posters seems to be a good way of conveying messages on this topic. Some organisations, however, have complained about the difficulties they encounter when meetings are organised simultaneously for the two sexes.
SUPPORT FOR PERSONS LIVING WITH HIV/AIDS
Organisations working exclusively on HIV/AIDS say they provide support for persons who are HIV positive so that they can live positively with HIV/AIDS. They achieve this mainly through sensitisation on the need for solidarity and non-rejection of sick persons as well as by undertaking some psycho-social work (listening to persons, support, food and medical support, income generating activities).
The few organisations of this type that do not initiate support activities have said that they require improved training to meet the needs and that they collaborate with those more experience in the meantime. The formulation of messages seems in most cases to take into account the needs of infected people. Avoiding such words as "victim", dissociating HIV/AIDS from the mode of living, sessions on the needs of infected persons are some of the ways of reducing discrimination and creating an environment of solidarity and compassion around such persons.
PROSPECTS AND EXPECTATIONS
The organisations have expressed their needs regarding the improvement of their programmes and as regards the workshop.
Immediate Requirements for Improving Prevention Education Programmes
These can be classified as follows:
· Need of adapted materials/aids which can be used easily by the illiterate women while conveying the appropriate messages;
· Needed expertise for more judicious evaluation of needs, more adequate planning, better approach to new techniques and to the concept of gender;
· Material needs: audiovisual, teaching aids, logistics;
· Financial Needs.
Strategic and operational requirements/or:
· strengthening of prevention education activities among female groups;
· change of behaviour particularly at grassroots level;
· identifying key issues to be considered mainly for the youth;
· efficient communication strategies for women and the young.
The need for research on:
· the role of culture/tradition on HIV/AIDS prevention education;
· influences of social norms and especially the gender imbalance on the implementation of prevention programs;
· effectiveness of peer education within the programs;
· role of community educators in the anti-HIV/AIDS campaign.
Strategic needs associated with the status of women in order to:
· reinforce the power of women and the youth;
· protect women against risky-behaviour (prostitution);
· reinforce the rights of women (access to resources and inheritance),
· understand the relations between tradition, status of women and HIV/AIDS prevention,
· ensure the sustainability of activities led by women,
· promote education to self-help,
· promote the use of female condoms
Support to infected persons
· Setting up of monitoring and counselling centres,
· More positive support for the sick by the society
Female vulnerability to HIV/AIDS is no longer in doubt According to WHO, it even seems as if female seropositivity is likely to become one of the major challenges of public health in the coming years Numerous activities have been initiated for the benefit of women, to protect them against infection sensitisation, training, skills acquisition or more globally, promotion of the status of women, are among the responses provided to various degrees by the women's grassroot organisations At this stage of the evolution of the epidemic and knowledge about it, the objective has, in fact, gone beyond the mere dissemination of information to create a real perception of risk likely to lead to the change of behaviour To this effect, the recommendations of the UNAIDS are, among others, to support the development of prevention programs that provide the messages and the appropriate skills as well as support services destined for both men and women including the marginalised or those who are difficult to reach These programmes should lay emphasis on the importance of condom use and on the mutual responsibility of men and women to adopt safe sex practices It has also been recommended that these programmes be integrated in other community development activities such as literacy and income-generating activities.