Tackling HIV-Related Stigma and Discrimination in South Asia
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DIRECTIONS IN DEVELOPMENT Human Development Tackling HIV-Related Stigma and Discrimination in South Asia Tackling HIV-Related Stigma and Discrimination in South Asia Tackling HIV-Related Stigma and Discrimination in South Asia Anne Stangl, Dara Carr, Laura Brady, Traci Eckhaus, Mariam Claeson, and Laura Nyblade © 2010 The International Bank for Reconstruction and Development / The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org E-mail: [email protected] All rights reserved 1 2 3 4 13 12 11 10 This volume is a product of the staff of the International Bank for Reconstruction and Development / The World Bank. The findings, interpretations, and conclusions expressed in this volume do not necessar- ily reflect the views of the Executive Directors of The World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. 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All other queries on rights and licenses, including subsidiary rights, should be addressed to the Office of the Publisher, The World Bank, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2422; e- mail: [email protected] ISBN: 978-0-8213-8449-7 eISBN: 978-0-8213-8451-0 DOI: 10.1596/978-0-8213-8449-7 Library of Congress Cataloging-in-Publication Data Tackling HIV-related stigma and discrimination in South Asia / Anne Stangl ... [et al.]. p. ; cm. Includes bibliographical references and index. ISBN 978-0-8213-8449-7 — ISBN 978-0-8213-8451-0 (electronic) 1. AIDS (Disease)—South Asia. 2. Stigma (Social psychology)—South Asia. I. Stang, Anne. II. World Bank. [DNLM: 1. HIV Infections—psychology—Afghanistan. 2. HIV Infections—psychology—Asia, Western. 3. Health Education—standards—Afghanistan. 4. Health Education—standards—Asia, Western. 5. Health Knowledge, Attitudes, Practice—Afghanistan. 6. Health Knowledge, Attitudes, Practice—Asia, Western. 7. Health Promotion—standards—Afghanistan. 8. Health Promotion— standards—Asia, Western. 9. International Cooperation—Afghanistan. 10. International Cooperation— Asia, Western. 11. Prejudice—Afghanistan. 12. Prejudice—Asia, Western. WC 503.7 T118 2010] RA643.86.S67T33 2010 362.196'979200954—dc22 2010022090 Cover photo: Shehab Uddin/Drik/Majority World The cover photo shows Rupali and Mithu, who work as community health workers for the Society for Positive Atmosphere and Related Support to HIV/AIDS (SPARSHA) to reduce HIV-related stigma in the villages of West Bengal. They live openly with HIV. Cover design: Naylor Design, Washington, DC Contents Preface xi Acknowledgments xvii Contributors xix Abbreviations xxi Chapter 1 Introduction and Background 1 Note 3 Reference 4 PART I Key Findings and Lessons Learned from 26 Stigma Reduction Innovations in South Asia 5 Chapter 2 Methods 7 Program Data 7 Case Study Methodology 8 Chapter 3 Program Findings 9 Findings across Programs 9 Lessons from Specific Program Approaches 11 Note 29 v vi Contents Chapter 4 Capacity-Strengthening Efforts and Lessons Learned 31 Types of Capacity-Strengthening Support and Technical Assistance Provided to Implementers 31 Recommendations for Strengthening Programmatic and M&E Capacity 34 References 35 Chapter 5 Recommendations for Action 37 Promote Intensified Government Support for a Scaled-Up Response to Stigma and Discrimination 37 Promote Government Adoption of Stigma Reduction Efforts in Health Care 38 Encourage Replication of Promising Approaches through Organization-to-Organization Knowledge Transfer 38 Promote Use of Multipronged Programming Strategies for Increased Effectiveness 39 Leverage Cultural and Media Efforts of SARDM Implementers to Maximize Reach and Results 39 Further Sharpen and Refine Tools for Religious Leaders 40 Foster Stronger Private Sector Engagement for Greater Economic Opportunity 41 Ensure That an Expanded Response to Stigma and Discrimination Provides Economic Opportunities for Marginalized Populations 41 Support Implementers in Strengthening Their Capacity to Expand 42 PART II Six Case Studies Highlighting Best Practices for Reducing Stigma and Discrimination 43 Chapter 6 Using Theater to Reduce Stigma and Discrimination against Men Who Have Sex with Men in Rural South India 45 Implementation 46 Results 47 Lessons Learned 51 Contents vii Chapter 7 Fighting Internalized Stigma among Injecting Drug Users in Bangladesh: A Combination Program to Support Economic and Social Reintegration 53 Implementation 54 Results 56 Lessons Learned 57 Chapter 8 The Gateway to Public Opinion: Harnessing Local Journalists to Fight Stigma and Discrimination in Bangladesh 61 Implementation 62 Results 63 Lessons Learned 64 Notes 66 Chapter 9 Taking It to the Village: Reducing Stigma through Traditional Street Theater in Tamil Nadu 67 Implementation 68 Results 70 Lessons Learned 73 Chapter 10 Celebrating Those Who Care: A Radio Program by HIV-Positive Journalists in Maharashtra 77 Implementation 79 Results 80 Lessons Learned 81 Recommendations 83 Chapter 11 Ensuring Dignity and Rights among Female Sex Workers in Bangalore: A Community-Led Advocacy Campaign to Reduce Stigma and Discrimination 85 Implementation 86 Results 87 Lessons Learned 89 PART III Project Summaries of the 26 Stigma Reduction Projects 91 Chapter 12 Afghanistan 93 Afghan Family Guidance Association 93 viii Contents Afghan Help and Training Program 97 Concern Worldwide 101 Chapter 13 Bangladesh 105 Drik Picture Library 105 Job Opportunity and Business Support–Bangladesh 108 Nari Unnayan Shakti 112 Chapter 14 India 117 Ashodaya Samithi 117 Development Initiative 120 ISTV Network 123 Lotus Integrated AIDS Awareness Sangam 126 Nalandaway Foundation 129 Sai Paranjpye Films 131 Saral 134 Society for Positive Atmosphere and Related Support to HIV/AIDS 137 Swathi Mahila Sangha 141 The Communication Hub 144 Voluntary Health Association of Tripura 148 We Care Social Service Society 151 Chapter 15 Nepal 155 Federation of Sexual and Gender Minorities Nepal 155 Himalayan Association against STI-AIDS 159 National NGOs Network Group against AIDS–Nepal 163 Chapter 16 Pakistan 167 Integrated Health Services 167 New Light AIDS Control Society 170 Pakistan Press Foundation 174 Chapter 17 Sri Lanka 179 Alliance Lanka 179 Lanka+ 182 Contents ix South Asia Region Development Marketplace Summary Table 184 Index 201 Boxes 3.1 Beauty and Brains 15 3.2 Using Theater to Teach Tolerance 22 4.1 Indicators That Can Be Used to Assess Stigma at the Community Level 32 10.1 Radio Episode Highlighting the Importance of Networks of People Living with HIV 78 Figure 12.1 Pre- and Postcourse Assessment Results 103 Tables P.1 Highlights from Experiences of 26 SARDM Implementers xiv 12.1 Trainee Groups 102 Preface In its 2008 round, Tackling HIV and AIDS Stigma and Discrimination, the South Asia Region Development Marketplace1 (SARDM) supported 26 implementers from six countries to pilot innovative interventions over a 12- to 18-month period. Total grant support was US$1.04 million, with a maximum grant size of US$40,000. In making these grants, SARDM focused on field innovators. After consulting with stakeholders, including marginalized populations most affected by stigma, SARDM offered rela- tively small grant amounts to ensure that these groups and community organizations would be able to compete with larger groups. The response to the initial call for proposals was immense, with almost a thousand sub- missions from Afghanistan, Bangladesh, Bhutan, India, Nepal, Pakistan, and Sri Lanka. The findings in this report are based on project monitoring and evalu- ation data collected by SARDM implementers and six case studies con- ducted by the International Center for Research on Women (ICRW). No one formula can capture the diversity and ingenuity reflected in this body of work. However, the findings do suggest some broad crosscutting prin- ciples as well as programmatic lessons associated with specific approaches. xi xii Preface In terms of broad lessons and principles, the experiences of SARDM implementers suggest the following: • Community organizations can achieve a great deal for relatively little investment. The 26 SARDM implementers reached 96,264 people, trained 4,905 people, led to 504 news articles, and developed 426 products such as training curricula; information, education, and com- munication materials; documentaries; and plays. Overall, the results suggest a high return on investment. • Development Marketplace grants seeded considerable innovation. Project approaches reflected enormous creativity, ranging from beauty pag- eants to restaurants run by sex workers. The grants led to new alliances, such as those between panchayat (municipal government)