HIV/AIDS Prevention Guidance for Reproductive Health Professionals In

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HIV/HIV/AIDS Prevention Guidance for Reproductive Health Professionals in Developing-Country Settings AIDS HIV/AIDS Prevention Guidance for Reproductive Health Professionals in Developing-Country Settings One Dag Hammarskjold Plaza 220 East 42nd Street New York, New York 10017 New York, New York 10017 212-339-0500 212-297-5273 fax: 212-755-6052 fax: 212-297-4915 e-mail: [email protected] e-mail: [email protected] www.popcouncil.org www.unfpa.org

The Population Council is an international, nonprofit, nongovernmental organization that seeks to improve the well-being and reproductive health of current and future generations around the world and to help achieve a humane, equitable, and sustainable balance between people and resources. The Council conducts biomedical, social science, and public health research and helps build research capacities in developing countries. Established in 1952, the Council is governed by an international board of trustees. Its New York headquarters supports a global network of regional and country offices.

The United Nations Population Fund (UNFPA) supports developing countries, at their request, to improve access to and the quality of reproductive health care, particularly family planning, safe motherhood, and prevention of sexually transmitted infections (STIs) including HIV/AIDS. Priorities include protecting young people, responding to emergencies, and ensuring an adequate supply of condoms and other essentials. The Fund also promotes women’s rights, and supports data collection and analysis to help countries achieve sustainable development. About a quarter of all population assistance from donor nations to developing countries is channelled through UNFPA, which works with many government, NGO, and UN partners.

Population Council Library Cataloging-in-Publication Data

HIV/AIDS prevention guidance for reproductive health professionals in developing-country settings / Helen Epstein et al.—New York : The Population Council and UNFPA, 2002. 64 p. ISBN 0-87834-110-2 1. AIDS (disease)—Developing countries—Prevention. 2. HIV infections—Developing countries—Prevention. 3. Reproductive health—Developing countries. I. Population Council. II. United Nations Population Fund. III. Epstein, Helen.

RA 644 .A25 H3485 2002

This document was written by Helen Epstein, Daniel Whelan, Janneke van de Wijgert, Purnima Mane, and Suman Mehta. Helen Epstein and Daniel Whelan are consultants to the Population Council. Janneke van de Wijgert is program associate, and Purnima Mane is vice president and director, International Programs Division, Population Council. Suman Mehta is senior technical officer, Technical and Policy Division, UNFPA.

Any part of this publication may be photocopied without permission from the authors or publisher, provided that publication credit is given and that copies are distributed free. Any commercial reproduction requires prior written permission from the Population Council.

Funding for this document was provided by UNFPA (United Nations Population Fund). Contents

Acknowledgments iv

Introduction 1

Chapter 1 Contextual Factors Related to Reproductive Health and HIV/AIDS 3

Chapter 2 HIV Prevention Interventions in Family Planning Settings 9

Chapter 3 HIV Prevention Programs for Young People 25

Chapter 4 HIV Prevention Among Pregnant Women and Newborns 38

Chapter 5 HIV Prevention Through Management of Reproductive Tract Infections 49

Chapter 6 HIV Prevention Among Refugees and Other Displaced Persons 57 Acknowledgments

The authors are grateful to the many Gupatha, Vaishali Sharma Mahendra, reproductive health professionals who agreed Anurag Mishra, Anjali Nayyar, Saroj to be interviewed about the HIV prevention Pachauri, Anil Paul, G. Rangaiyan, K.G. programs they have implemented, including Santhya, Avantika Singh, Farah Usmani, Susan Allen (University of Alabama, Shalina Verma, and Anjali Widge. The United States), Mary Bassett (Rockefeller authors would like to thank them for their Foundation, Zimbabwe), Wafutseyoh valuable advice. El-Wambi (Friends of Street Children We are also grateful to the following Project, Uganda), Ron Gray (Johns Hopkins experts for their careful review of sections of University, United States), Louise Kuhn this publication: Martha Brady, Judith Diers, (Columbia University, United States), Fariyal Fikree, Andrew Fisher, Naomi Caroline Maposhere (Voices and Choices Rutenberg, and Johannes van Dam of the Project, Zimbabwe), Sostain Moyo Population Council; Ellen Weiss of the (Zimbabwe AIDS Prevention Project, International Center for Research on Zimbabwe), Geeta Oodit (International Women/Horizons program; Maria Jose Planned Parenthood Federation, United Alcala, Elizabeth Benomar, Sylvie Cohen, Kingdom), Mark Stirling (UNICEF, France Donnay, Lindsay Edouard, Francesca United States), and Johannes van Dam Moneti, Julitta Onabanjo, and Akiko Takai (Population Council, Horizons program, of UNFPA; Annette van der Laan of United States). UNESCO, Zimbabwe; and Charles In August 2001 an early draft of this Morrison of Family Health International. publication was reviewed at a meeting at the Finally, we extend a special thanks to Population Council’s office in New Delhi, Rose Maruru (Population Council), who India. Meeting participants included repro- provided invaluable logistical support ductive health professionals from the South throughout this project. We also thank and East Asia office of the Population Mar Aguilar, Monica Bhalla, Netania Council and the UNFPA Technical Advisory Budofsky, Barbara Friedland, and Anil Paul Programs in Nepal and Thailand (as well as at the Population Council for excellent Helen Epstein and Suman Mehta): Dinesh administrative assistance. Finally, we thank Agarwal, Monica Bhalla, Celine Costello Jared Stamm at the Population Council for Daly, Batya Elul, Heiner Grosskurth, M.P. editing and production.

iv Introduction

After more than two decades of sustained um from prevention of new infections to and expanding HIV/AIDS interventions, it providing treatment, care, and support for is clear that effective HIV services, programs, those infected, to mitigating the economic, and policies for prevention, care, support, social, and political impact of those affected treatment, and impact alleviation require by HIV/AIDS. The way in which any partic- multi-sectoral responses from governments, ular international agency responds is largely international agencies, and international and determined by its mandate and area of national nongovernmental organizations expertise. The Joint United Nations (NGOs). However, organizations and insti- Programme on HIV/AIDS (UNAIDS) is tutions that provide reproductive health serv- supported by eight UN co-sponsoring organ- ices—be they family planning services, ante- izations and a Secretariat.1 As a UNAIDS natal/postpartum clinics, maternal/child co-sponsoring agency, UNFPA plays a cen- health services, clinics for the treatment of tral role in spearheading HIV/AIDS inter- sexually transmitted infections (STIs), or any ventions as part of its overall stated goal of number of integrated service delivery ensuring universal access to high-quality sex- points—stand at the center of HIV/AIDS ual and reproductive health services to cou- interventions. While these programs and ples and individuals by the year 2015. More services are usually geared toward their own specifically, UNFPA’s recently published particular goals—providing information Strategic Guidance on HIV Prevention has about family planning options and technolo- emphasized three core areas: preventing HIV gies to meet the needs of individuals and infection in young people, strengthening couples, providing information about and male and female condom programs, and pre- appropriate treatment for STIs, providing venting HIV infection in pregnant women.2 information and care for pregnant and post- UNFPA has further stated its commitment partum women, and providing services that to promoting programming and policy activ- meet the special needs of youth—it is appro- ities within an overarching commitment to priate and indeed imperative that they be the goals outlined in the International aware of how their particular area of work Conference on Population and Development intersects with the demands of effectively (ICPD) Programme of Action, as further confronting HIV/AIDS at a national level. elaborated at ICPD+5 (United Nations It is now widely recognized and 1999, 1994). acknowledged that effective responses to While the integration of information, HIV/AIDS must intervene along a continu- technologies, and services to respond to

1 These are the World Health Organization (WHO), the United Nations Population Fund (UNFPA), the United Nations Children’s Fund (UNICEF), the United Nations Development Programme (UNDP), the United Nations Drug Control Program (UNDCP), the United Nations Educational, Scientific and Cultural Organization (UNESCO), the International Labour Organization (ILO), and the World Bank. 2 The UNFPA Strategic Guidance can be accessed at www.unfpa.org/aids/strategic/index.htm. 1 HIV/AIDS may seem closely related, there HIV/AIDS interventions into existing repro- are a variety of issues that continue to create ductive and sexual health programs and serv- obstacles to integration. Among these are the ices, and to provide some practical examples particularly stigmatizing nature of HIV of interventions that have been successful. infection and AIDS and discrimination faced However, providing comprehensive program- by those who are infected or perceived to be matic or training-related guidelines is beyond infected; sexual practices and identities that its scope. Whenever possible, references are remain socially unacceptable; gender roles provided to additional sources of information and relations that make it difficult for for service providers and program designers. women and men to access information, services, and technologies on HIV prevention; References reluctance to recognize the special needs and United Nations. 1994. Report of the vulnerabilities of young people; and the sig- International Conference on Population and Development, Cairo, 5–13, nificant barriers to service delivery created by September 1994, document broader economic, social, cultural, and polit- E.95.XIII.18. New York: United ical factors. Of perhaps greatest concern to Nations. reproductive health service providers are the ———. 1999. “Key actions for the further burdens associated with providing additional implementation of the Programme of services and resources needed for facilities, Action of the International Conference technologies, treatment options, and com- on Population and Development,” report of the Ad-Hoc Committee of the prehensive training. Whole of the Twenty-First Special This document is designed to provide an Session of the General Assembly (adden- overview of the issues, challenges, and oppor- dum), document A/S-21/5/Add. 1. New tunities around integrating a broad range of York: United Nations.

2 Chapter 1 Contextual Factors Related to Reproductive Health and HIV/AIDS

As the HIV/AIDS pandemic enters its third demic, yet only one-third of that commit- decade, the comparatively hopeful predic- ment has been met so far (Piot 2002). tions made in the early 1990s that the worst Understanding the enormity of the epidemics had reached their plateau have global pandemic of HIV/AIDS is only a first since yielded to the sobering reality that, step in mounting an effective set of respon- indeed, the pandemic continues apace—in ses. In reality, the “pandemic” actually com- some cases at alarming rates. Not only is this prises a variety of concurrent yet highly var- true in the case of relatively new epicenters ied regional epidemics, each with its own such as Eastern Europe and Russia, but it is qualities and characteristics. Although more also true in Africa—a continent that than 70 percent of all infections worldwide undoubtedly has borne the heaviest burdens occur as a result of heterosexual contact, a of HIV/AIDS since the disease was first variety of other economic, social, and politi- identified in the early 1980s. An estimated 5 cal realities in different parts of the globe million people throughout the world became determine the extent and severity of regional infected in 2001—800,000 of them children epidemics. These include demographic fac- (UNAIDS 2002). In the words of Peter Piot, tors (such as the age of a population), eco- the executive director of UNAIDS, nomic pressures associated with “globaliza- HIV/AIDS is simply “the worst epidemic in tion,” migration patterns, patterns of sexual human history.” While UNAIDS estimates behavior and drug use, and gender roles and that 40 million people currently live with relations. The depth and severity of regional HIV/AIDS, the number of deaths by the epidemics are also associated with poverty, year 2010 is likely to surpass 65 million lack of resources, intractable conflicts, and (UNAIDS 2002). As has been the case since human rights violations. the beginning of the pandemic, the resources needed to successfully meet the challenges of Sociocultural Norms About Gender Roles slowing the spread of new infections and and Vulnerability to HIV/AIDS effectively treating and caring for those As Rao Gupta (2000) points out, “gender” is infected or affected by HIV/AIDS far out- not synonymous with “sex.” It refers to the strip the resources that governments and widely shared expectations and norms within donors have made available. The Declaration a society about appropriate male and female of Commitment on HIV/AIDS agreed upon behaviors, characteristics, and roles. Gender by the United Nations General Assembly norms are widely reproduced in social insti- Special Session on AIDS in 2001 called for tutions, such as schools, workplaces, families, $10 billion annually to respond to the pan- and health systems (Population Council

3 2001; Wingood and DiClemente 2000). By young men—at risk of infection because defining the societal ideals of feminine and such norms prevent them from seeking masculine behavior and sexuality, gender information or admitting their lack of norms greatly affect women’s and men’s knowledge about sex or protection. Many access to information and services and how men, as a result, have erroneous information they cope with illness. Gender roles reflect about sexual and reproductive health cultural prescriptions for masculinity (and (UNAIDS 1999; Barker and Lowenstein male sexuality) and femininity (and female 1997). sexuality). Gender influences what women Fidelity and multiple partnerships and men know and how they learn it, their Most societies view women’s sexual behaviors level of communication about sex and linked to reproduction as moral and those behavior within relationships, and their abili- linked to pleasure as immoral (Rao Gupta ty to access reproductive health resources, and Weiss 1993). In sharp contrast, in many technologies, and services. It is important to societies it is believed that men’s nature dic- remember, however, that in every society tates that they have variety in sexual partners there are many forms of masculinity and and that men will inevitably—and should— femininity that vary by social class, ethnicity, seek multiple partners for sexual release (Rao sexuality, and age. It is also now recognized Gupta 2000; Weiss et al. 1996; Mane et al. that the multiple forms of masculinity and 1994). Results from sexual behavior studies femininity are dynamic, subject to change, from around the world indicate that married and constructed through social interaction and single heterosexual men, as well as (Rivers and Aggleton 2001; Gutmann homosexual and bisexual men, have higher 1996). reported rates of partner change than women Content and levels of knowledge about (Orubuloye et al. 1993; Rao Gupta and sexual risk for HIV Weiss 1993; Sittitrai et al. 1991). This sexual A recent analysis of knowledge about “double standard” compromises the effective- HIV/AIDS prevention in 23 developing ness of HIV and STI prevention efforts that countries found that levels of knowledge are assume men will be faithful and reduce the almost always higher among men than number of sexual partners they have (Rao among women, with 75 percent of men, on Gupta 2000). Moreover, men’s failure to meet average, possessing accurate information certain masculine expectations—for example, about HIV/AIDS transmission and preven- providing for the family—can lead them to tion as compared to roughly 65 percent of reclaim self-esteem by complying with other women (Gwatkin and Deveshwar-Bahl masculine norms, such as engaging in sex 2001). Where women are better informed with multiple partners (Silberschmidt 2001). and have accurate information about sexual risk for HIV, the societal expectation that a Access to services woman (especially a young woman) should Sociocultural norms that define male and be naïve makes it difficult for her to demon- female roles and responsibilities also affect strate her knowledge by being proactive in women’s and men’s access to and use of negotiating safer sex. Simultaneously, prevail- health services, including reproductive health ing norms of masculinity presume men to be and HIV/AIDS services. In countries where more knowledgeable and experienced about “son preference” is the norm, in times of sex. This assumption puts men—particularly scarcity families allocate resources to men

4 and boys first and women and girls later or men’s ability to protect themselves from not at all. For example, in Pakistan, lower- infection and cope with the epidemic. income households seek health care more often for boys than girls and are more likely Economic Factors That Influence Men’s to use higher-quality providers for boys and Women’s Reproductive Health (Alderman and Gertler 1997). Women Over the past several decades, global eco- themselves perpetuate this pattern because nomic growth has noticeably decreased the they are socialized to sacrifice their own numbers of individuals living in absolute interests. They often put the health of their poverty worldwide. Women’s economic sta- children and families first and do not seek tus has also shown significant improvement medical attention until they are seriously ill over the last decade. The gender gap in edu- (Buvini´c and Yudelman 1989). cation is significantly lower than in the past, Women are further constrained from and there are more women earning an using services where gender norms limit their income today than ever before. Despite these mobility. Practices such as purdah, common general trends, however, there is substantial in Hindu and Islamic societies, confine evidence to suggest a number of gender- women to their homes and prevent them related factors have resulted in uneven gains from traveling to use services unless they are for women as opposed to men. Furthermore, accompanied by an adult male family mem- macro-economic policies that are meant to ber. Such practices also demand that health facilitate the entry of countries into global care services employ women caregivers and markets (one aspect of “globalization”) have provide the privacy, modesty, and seclusion led to gender-determined consequences—the necessary for women to feel comfortable “feminization” of poverty for example—that using the service (Mehra et al. 1992). have a differential impact on women’s and Female service providers may be scarce in men’s reproductive health. In terms of HIV such settings, further limiting women’s prevention, these economic factors foster access to them. vulnerability to HIV differently for women The barriers that men face in using serv- and men—realities that should inform the ices are often related to sociocultural norms design and delivery of reproductive health that ascribe reproductive responsibilities services, including those for HIV/AIDS. entirely to women and shut men out of par- The commodification of sex and the lack of enting or nurturing roles. For example, fami- women’s economic leverage in the household ly planning, antenatal, and child health clin- Studies from across the developing world ics are typically not designed to reach men or indicate that poverty is overwhelmingly the encourage their participation in the care of root cause of women’s bartering sex for eco- their partners (see Chapter 2). Because nomic gain or survival (UNAIDS 1999). HIV/AIDS information and services are pro- When sex “buys” food, shelter, or safety, it is vided primarily in these settings, men are very difficult to follow prevention messages therefore less likely to benefit from them and that call for a reduction in the number of therefore less likely to be fully informed sexual partners. There are a number of about HIV/AIDS prevention, care and sup- “transactional” sexual partnerships that port, and treatment options (Mane and women use as a rational means to make ends Aggleton 2001; UNAIDS 2001). This phe- meet besides “traditional” commercial sex nomenon has significant implications for work. For example, in Haiti, single mothers

5 faced with trying to balance the multiple and providing water and firewood; 80 per- demands of family and economic survival cent of food storage and transport; and 60 often enter into a series of sexual relation- percent of harvesting and marketing (World ships, called plasaj, in order to obtain food Bank 1989). Taking time to use services is and housing for themselves and their chil- particularly difficult for rural women because dren. Alarmingly, research has shown that they also have to take time to travel to urban women in this setting who have entered a areas or village centers where services are sexual relationship out of economic necessity located. have increased odds of acquiring syphilis and Women’s economic needs and responsi- HIV infection (Fitzgerald et al. 2000). bilities further constrain their use of time. Women who are economically vulnera- Many women work in insecure jobs with ble are less able to negotiate the use of a con- long hours, poor pay, and few or no bene- dom or fidelity with a nonmonogamous fits (United Nations 2000). In such jobs male partner and less likely to leave relation- women have little control over the hours or ships that they perceive to be risky because conditions of work, making it difficult for they lack bargaining power and fear aban- them to take time off. The long hours are donment and destitution. Data also show added to women’s already large burden of that a number of women in high-risk rela- domestic work, leaving less time in the day tionships perceive the short-term costs of for them to make use of health services. leaving a relationship as much greater than Further, poor pay makes the cost of services the long-term potential health costs (Weiss more prohibitive for women; and the possi- and Rao Gupta 1998; Heise and Elias 1995; bility of losing their insecure and small Mane et al. 1994). income, which in many instances is never- Economic factors related to access to and use of theless critical to a family’s survival, makes health services the opportunity cost of missing work larger Economic factors also affect women’s access for women. Even in families in which to and use of services. Economic con- income and resources are pooled from mul- straints—such as lack of money to pay for tiple individuals, women are still at a disad- services or transportation or high opportuni- vantage in accessing funds for health servic- ty costs of lost time—create significant barri- es because families typically allocate ers to women’s use of health services (Moses resources to men and boys first (Buvini´c et al. 1992; Leslie and Rao Gupta 1989). and Yudelman 1989; International Center The workloads of women who live in pover- for Research on Women 1989). ty or in low-income settings make it more In summary, sociocultural gender difficult for them to take the time to access norms reflect how society constructs male services. Worldwide, women spend between and female sexual roles and behaviors that 10 and 16 hours a day doing housework, influence their risk for and vulnerability to collecting water and firewood, caring for poor reproductive health generally and HIV children, and producing their family’s infection in particular. These same norms food—a daily burden of work that is signifi- increase women’s economic vulnerability cantly larger than men’s (Buvini´c and and dependence, which in turn increase Yudelman 1989). For example, African their vulnerability to being infected, restrict women perform about 90 percent of the their access to much-needed information work of hoeing, weeding, processing food, and services, and expose them to severe con-

6 sequences when infected or affected by countries,” Social Science and Medicine HIV/AIDS. For men, gender-related norms 40(7): 933–943. and economic need force them to migrate International Center for Research on Women. 1989. Strengthening Women: without their families in search of work, cre- Health Research Priorities for Women in ating situations that foster multiple sexual Developing Countries. Washington, DC: relationships that may lead to HIV infec- ICRW. tion. Overall, poverty greatly exacerbates Leslie, J. and G. Rao Gupta. 1989. both women’s and men’s vulnerability by Utilization of Formal Services for restricting access to information and services Maternal Nutrition and Health Care in the Third World. Washington, DC: and making it more difficult to cope with ICRW. the impact of the epidemic. Mane, Purnima and Peter Aggleton 2001. “Gender and HIV/AIDS: What do men References have to do with it?” Current Sociology Alderman, H. and P. Gertler. 1997. “Family 49(6): 23–37. resources and gender differences in Mane, Purnima et al. 1994. “Effective com- human capital investments: The demand munication between partners: AIDS and for children’s medical care in Pakistan,” risk reduction for women.” AIDS in L. Haddad, J. Hoddinott, and H. 8(suppl 1): S325–S331. Alderman (eds.), Intrahousehold Resource Mehra, Rekha et al. 1992. Engendering Allocation: Methods, Application, and Development in Asia and the Near East: A Policy. Baltimore, MD: Johns Hopkins Sourcebook. Washington, DC: ICRW. University Press, pp. 231–248. Moses, S. et al. 1992. “Impact of user fees Barker, G. and I. Lowenstein. 1997. “Where on attendance at a referral centre for sex- the boys are: Attitudes related to mas- ually transmitted diseases,” Lancet culinity, fatherhood, and violence 340(8817): 463–466. toward women among low-income ado- Orubuloye, I.O., J.C. Caldwell, and P. lescent and young adult males in Rio de Caldwell. 1993. “African women’s control Janeiro, Brazil,” Youth and Society 29(2): over their sexuality in an era of AIDS: A 166–196. study of the Yoruba of Nigeria,” Social Buvini´c, Mayra and Sally Yudelman. 1989. Science and Medicine 37: 859–872. Women, Poverty and Progress in the Third Piot, Peter. 2002. “Keeping the promise,” World. New York: Foreign Policy opening speech, XIV International Association. AIDS Conference, Barcelona, Spain. Fitzgerald, D.W. et al. 2000. “Economic 7–12 July. hardship and sexually transmitted dis- Population Council. 2001. Power in Sexual eases in Haiti’s rural Artibonite Valley,” Relationships: An Opening Dialogue American Journal of Tropical Medicine Among Reproductive Health Professionals. and Hygiene 62(4): 496–501. New York: Population Council. Gutmann, Matthew C. 1996. The Meanings Rao Gupta, Geeta. 2000. “Gender, sexuality, of Macho: Being a Man in Mexico City. and HIV/AIDS: The what, the why, and Berkeley: University of California Press. the how,” plenary address, XIII Gwatkin, D.R. and G. Deveshwar-Bahl. International AIDS Conference, 2001. Inequalities in Knowledge of Durban, South Africa, 9–14 July. HIV/AIDS Prevention: An Overview of Rao Gupta, Geeta and Ellen Weiss. 1993. Socio-Economic and Gender Differentials in Women and AIDS: Developing a New Developing Countries, unpublished draft. Health Strategy. Washington, DC: ICRW. Heise, Lori and Christopher Elias. 1995. Rivers, K. and P. Aggleton. 2001. Men and “Transforming AIDS prevention to meet the HIV Epidemic. New York: United women’s needs: A focus on developing Nations Development Programme.

7 Silberschmidt, Margarethe. 2001. “Dis- Weiss, Ellen and Geeta Rao Gupta. 1998. empowerment of men in rural and Bridging the Gap: Addressing Gender and urban East Africa: Implications for male Sexuality in HIV Prevention. Washington, identity and sexual behavior,” World DC: ICRW. Development 29(4): 657–671. Weiss, Ellen, Daniel Whelan, and Geeta Rao Sittitrai, Werasit et al. 1991. “The survey of Gupta. 1996. Vulnerability and partner relations and risk of HIV infec- Opportunity: Adolescents and HIV/AIDS tion in Thailand,” Abstract MD4113. in the Developing World. Washington, VII International AIDS Conference, DC: ICRW. Florence, Italy, 16–21 June. Wingood, Gina M. and Ralph J. UNAIDS. 1999. Gender and HIV/AIDS: DiClemente. 2000. “Application of the Taking Stock of Research and Programmes. theory of gender and power to examine Geneva: UNAIDS. HIV-related exposures, risk factors, and ———. 2001. Working with Men for HIV effective interventions for women,” Prevention and Care. Geneva: UNAIDS. Health Education and Behavior 27(5): ———. 2002. Report on the Global HIV/AIDS 539–565. Epidemic 2002. Geneva: UNAIDS. World Bank. 1989. Women in Development: United Nations. 2000. The World’s Women Issues for Economic and Sector Analysis, 2000: Trends and Statistics. New York: Policy, Planning, and Research. United Nations. Washington, DC: World Bank.

8 Chapter 2 HIV Prevention Interventions in Family Planning Settings

Health providers who work in family plan- the frequency of sex with infected partners. ning settings are in a unique position to offer Both sets of risks are greater for women than HIV prevention services. Their clients are for men. Men are not at risk of unintended sexually active people who acknowledge pregnancy in the same way as women, being at risk for unintended pregnancy— because men do not get pregnant. Sexual therefore they may also be at risk for transmission of HIV and several other STIs HIV/STIs. There is a natural affinity appears to be more efficient from men to between the goals of family planning and women than vice versa, partly because semen disease prevention. Both are included in the remains in the vagina for some time after basic human right to the highest attainable sex. Furthermore, gender dynamics and standard of mental and physical health— socioeconomic circumstances often make it embodied in a variety of human rights docu- more difficult for women than men to modi- ments, reiterated in the Programmes of fy their risk behaviors. The majority of the Action of ICPD, Beijing, and their respective world’s women want children; they cannot follow-on implementation processes, and use condoms while trying to conceive. In fully endorsed by WHO, the Secretariat of many cultures, being a mother is considered UNAIDS, UNFPA and a number of other to be a feminine ideal. In addition, children UN specialized agencies, and the governing often provide a social identity for women bodies of these organizations. However, there and status in kinship groups, and they some- are also a number of differences, which may times guarantee economic support from the at times be incompatible between the goals father (UNAIDS 1999; LeFranc et al. 1996). and approaches of family planning and dis- Reducing the number of sexual partners may ease prevention programs. not be feasible for those women who, Although results of the same human because of limited educational and employ- behavior, pregnancy and HIV/STIs have ment opportunities, are financially depend- fundamentally different risk profiles (Cates ent on their male partners. Moreover, a sig- and Steiner 2002). Risk for pregnancy is nificant proportion of monogamous women determined by when in the cycle and how have male partners who are not monoga- often sex with any partner occurs—assuming mous, and these women have little control that both the woman and her partner(s) are over their partners’ behavior. fertile. Risk for HIV/STIs, on the other Most HIV infections in sub-Saharan hand, is determined primarily by the part- Africa occur during heterosexual intercourse ners with whom intercourse occurs, the like- between couples (Painter 2001). Even in lihood that these partners are infected, and countries where the prevalence of HIV

9 remains relatively low, STIs and other repro- may mean that the funds needed to train ductive tract infections (RTIs) often are health workers and counselors, procure con- common (see Chapter 5). In these contexts, doms, and produce information, education, many family planning clients may be in need and communication materials are not avail- of early detection and treatment of RTIs that able. Despite these objections to integration, can, if untreated, greatly facilitate the trans- however, it has become increasingly clear mission of HIV between individuals. that program success in one area usually Many attempts have been made to inte- translates into better reproductive and sexual grate HIV prevention services into family health and more effective family planning planning settings, which might include pro- outcomes overall (WHO 1999a). For exam- viding information about HIV/STIs, incor- ple, in many areas family planning programs porating risk assessment for both unintended have been expanding in creative ways to pregnancy and HIV/STIs into counseling reach members of the community not typi- sessions, promoting condoms, and referring cally served by these programs, including clients to other HIV/STI services as needed. older men, single adolescents, and young Reproductive and sexual health services adults of both sexes. These expanded services could also be fully integrated, providing fam- may improve use of contraception in general, ily planning, STI/RTI diagnosis and treat- with the result that the number of unwanted ment, voluntary counseling and testing for pregnancies among young, unmarried people HIV, antiretroviral therapies for the preven- may be reduced. tion of mother-to-child transmission of HIV, Contraceptives are often grouped into and antenatal and postpartum services. three categories based on their perfect-use Services that are fully integrated face a differ- and typical-use effectiveness in preventing ent set of issues than those that provide only pregnancy (Cates and Steiner 2002). The family planning and basic HIV prevention. first category includes methods that are high- This chapter addresses the full range of ly effective and do not depend on user issues, however, in order to promote effective adherence. This category includes steriliza- integration of services, to provide a blueprint tion, hormonal implants and injectables, and for those services that are considering inte- intrauterine devices. The second category gration, and to raise the general level of contains only the oral contraceptive pill. All awareness of service providers who may be in pills are highly effective if used correctly and a position of having to refer clients to alter- consistently, and most pills are relatively for- native service delivery points outside the giving of imperfect use. The third category scope of their clinic. includes all barrier methods, which are less Some have raised concerns that incorpo- effective than the methods included in the rating HIV prevention into family planning first two categories, primarily because they settings will stigmatize family planning pro- require correct and consistent use during grams, leading to a reduction in the number every act of intercourse. The third catego- of family planning clients. So far, however, ry—as with traditional strategies of pregnan- this has not been observed with any integrat- cy prevention such as withdrawal and peri- ed services (WHO 1999a). Of greater con- odic abstinence—is quite unforgiving of cern, perhaps, is that expansion of family imperfect use. Some methods allow couples planning services inevitably increases staff to prevent pregnancy and HIV infection workload. In addition, resource constraints simultaneously, while others do not. Other

10 methods may actually increase a woman’s susceptibility to HIV infection under certain RECOMMENDED HIV/STI/RTI SERVICES FOR FIRST-TIME CLIENTS AT FAMILY PLANNING circumstances. The following discussion CLINICS should enable service providers with the appropriate information to provide clients HIV/STI prevention with the most reliable information available. • Information, education, and communication about the risks of HIV infection and infection with other STIs; Methods for Family Planning and Their • Counseling about dual protection against pregnancy and HIV/STIs; Relationship to HIV Prevention • Demonstration and provision of male and/or female condoms; • Encouragement of communication about sex between partners; Male condoms •Partner notification where appropriate and if consent is obtained (in In 2001 the U.S. National Institute of the absence of mandatory partner notification laws); and Allergy and Infectious Diseases, the U.S. • Screening for STIs/RTIs. Centers for Disease Control and Prevention, HIV prevention specifically and the World Health Organization pub- • Onsite voluntary counseling and testing for HIV for those who request lished an extensive review of the literature on it; and the effectiveness of male latex condoms in • Referral to appropriate services. preventing STIs (U.S. National Institute of Allergy and Infectious Diseases 2001). The review concluded that there is strong evi- (Sittitrai 2001). Some of these declines have dence that correct and consistent use of male been dramatic, as in the case of Thailand, latex condoms prevents HIV infection in where an official policy of 100 percent con- men and women and gonorrhea in men; and dom use in brothel-based commercial sex that there is some evidence that it may pre- settings has yielded impressive results vent gonorrhea in women and chlamydia (Sittitrai 2001). In general, over the past 15 and trichomoniasis in men and women. The years, “condom literacy” among men and data were considered incomplete for genital women has risen dramatically, and condoms ulcer diseases (genital herpes, syphilis, and are now more widely available than ever chancroid) and diseases caused by human before. However, structured observations in papillomaviruses (genital warts and cervical family planning services in many sub- dysplasia or neoplasia) because the pathogens Saharan African countries have shown that as associated with these diseases can infect a few as one-quarter of family planning clients wide area of the genitalia that is exposed receive information on prevention of even when a male condom is used. HIV/STIs (Miller et al. 1998). Furthermore, Since the earliest days of the HIV pan- despite increased availability in most regions demic, the use of male condoms has been of the world, recent analysis of the need for the staple of HIV prevention efforts. When and availability of condoms in sub-Saharan incorporated into a comprehensive set of Africa describes a “condom gap”—the differ- prevention messages—including reducing ence between the number of condoms need- the number of sexual partners, practicing ed to provide protection for sexually active mutual monogamy, delaying onset and couples and the actual number of condoms reducing frequency of penetrative sex, and provided by donor agencies, national govern- getting treatment for STIs—male condom ments, and commercial distribution points. use has clearly resulted in decreases in the The estimated condom gap ranges from incidence of HIV infection in some settings 1.9 to 13 billion condoms per year for

11 sub-Saharan Africa (Myer et al. 2001; within commercial or casual relationships in Shelton and Johnston 2001). some settings (e.g., in Thailand), their intro- Male condoms can be used for vaginal, duction into stable or married relationships oral, and anal sex (although condoms has proven to be more problematic for a vari- impregnated with a spermicide are not ety of reasons. A commonly cited objection intended for oral or anal use). In the past to condom use by both women and men is few years research and development and bet- that condoms interfere with sexual pleas- ter quality control by the condom manufac- ure—and male erection—and create a signif- turing industry have resulted in a male latex icant barrier to intimacy between partners condom that is more reliable and safer than (Little et al. 2002; Rhodes and Cusick 2002). ever before (Gilmore 1998). Extra-strong Many women and men find discussion of male condoms, intended for use during anal sexual risk and condom use embarrassing, sex, have been available for quite some time. and raising these subjects within a relation- Looking beyond latex, studies are underway ship may introduce an element of distrust to evaluate the effectiveness and acceptability into that relationship. This is due in part to of male condoms with a looser fit made of the association of condoms with casual and materials such as polyurethane and styrene commercial sex. Women are often limited in ethylene butylene styrene (Finger 2001). their ability to get their male partners to use Efforts are also underway to design and pro- a condom because of social, cultural, and mote condoms with special designs that may economic gender inequalities (see Chapter enhance sexual pleasure. It is not yet clear to 1). Some women may even face significant what degree these kinds of alternative con- risks, such as violence or abandonment, doms will actually affect consistency of con- when they make an attempt to negotiate dom use if and when they are available. condom use, or they may be accused of Despite the by-now-well-known effec- being “loose” or promiscuous. Finally, given tiveness of male latex condoms in prevention a general lack of knowledge about their own of HIV transmission and their increased sexual and reproductive anatomy, some availability, there are numerous drawbacks women have reported being afraid to use associated with relying solely on male con- condoms, for fear that the condom might doms within HIV prevention programs. become dislodged or stuck in the body There is evidence to suggest that overall use (Little et al. 2002; Rhodes and Cusick 2002). of male condoms within any given popula- Female condoms tion reaches a certain “plateau.” A recent In order to offer women a barrier method study carried out among adult urban popula- over which they have more control, and in tions in Benin, Cameroon, Kenya, and response to other concerns about male con- Zimbabwe found that condom use with non- doms, the female condom was developed, spousal partners was generally low (21–25 approved by the U.S. Food and Drug percent for men and 11–24 percent for Administration (FDA), and introduced in women). Furthermore, aggregate levels of 1993. In December 2001, the United States condom use by city could not be used to dis- Agency for International Development criminate between cities with high and low (USAID) sponsored a technical update on HIV prevalence (Lagarde et al. 2001). While the female condom (USAID 2001). Meeting substantial headway has been made in participants concluded that if the female improving the consistent use of condoms condom is used correctly and consistently, it 12 is as effective as the male condom in prevent- used without the cooperation of the male ing HIV/STIs and unwanted pregnancy, but partner. that more research is needed to confirm the Despite these problems, acceptability method’s effectiveness in general popula- studies in sub-Saharan Africa, Asia, Latin tions. In addition, because the outer ring of America, and the United States have shown the female condom partially covers the exter- that subsets of women in each setting like nal genitalia, the female condom may pro- the female condom and succeed in sustain- vide greater protection against genital ulcer ing its use (Hatzell and Feldblum 2001). diseases and human papillomavirus than the Results from a study in Zambia suggested male condom. that female condoms might be more accept- The female condom has been approved able among married couples than male con- for one-time use only, but in several develop- doms (Musaba et al. 1998). Results from ing-country settings re-use as a way to reduce Zimbabwe indicated that sex workers who cost has been reported. Preliminary data on often experience male condom breakage or the safety of re-use indicate that the majority have sex with drunk clients preferred female of female condoms still meet quality assur- to male condoms (Ray et al. 2001). Several ance requirements after repeat use, disinfec- studies have shown that use of the female tion, washing, drying, and re-lubrication condom can encourage use of male condoms (Farley et al. 2002). However, excessive or as well, because it facilitates discussions rough handling of female condoms could about safer sex. When faced with the damage them. prospect of using a female condom because a Female condoms were introduced into female partner insists on it, some men opt to over 70 countries between 1997 and 2001 use male condoms instead (Feldblum et al. (Hatzell and Feldblum 2001). Many of these 2001; Musaba et al. 1998). In any case, the introduction programs were small pilot activ- number of protected sexual acts increases ities, but more recently there have been sev- when such options are available. eral large-scale efforts. Although use rates of Cervical barriers, spermicides, and microbicides female condoms were relatively high soon Although female condoms are an important after introduction, interest in and consisten- HIV prevention method, they cannot be cy of use has tended to drop off over time, used without male partner cooperation. Two probably because the novelty has worn off categories of contraceptive methods that do (Hatzell and Feldblum 2001; Kerrigan et al. not necessarily require male partner coopera- 2000; WHO 2000a). Problems with long- tion, and have been around for decades, are term acceptability have also been reported. currently being evaluated for their HIV/STI Research indicates that a significant number prevention effectiveness: cervical barriers and of women and men have some difficulty spermicides. with female condom use, including problems The best-known cervical barrier is the with insertion, discomfort during sex, and traditional diaphragm, but several new cervi- excess lubrication (Kerrigan et al. 2000). cal devices have recently been approved by Furthermore, while the woman usually the FDA or are currently under development inserts the female condom, and women have (Moench et al. 2001). These include the more control over the use of a female as Leah’s shield (a loose-fitting rubber cervical opposed to a male condom, the female con- cap with a loop for easy removal), the dom is visible after insertion and cannot be FemCap (similar to the cervical cap but with 13 a brim designed to fit into the vaginal for- formulations, including gels, creams, suppos- nices), the SILCS diaphragm (a new one- itories, films, and sponges. Laboratory size-only device expected to be easier to research conducted in the 1970s and 1980s insert and remove), and disposable showed that N-9 could inactivate pathogens diaphragms (some of which may come with such as chlamydia and gonorrhea, and even pre-applied microbicide). Because these HIV (WHO 2002). However, recent ran- devices are worn inside the vagina, they are domized controlled clinical trials point to a less obtrusive and less subject to imperfect lack of protection against STIs and HIV use than are male and female condoms. They infection in women using N-9 products cover the cervix and are therefore likely to without a cervical barrier, and a potential protect the cervix from infection by STIs increase in risk for HIV with frequent and and HIV, but they do not cover the vaginal multiple daily use (Wilkinson et al. 2002). walls. However, research has shown that the WHO therefore currently advises not using cervix is probably more susceptible to infec- N-9 for HIV prevention (especially not dur- tion with HIV and other STI pathogens ing anal sex) and contraception if one is at than the vagina (Moench et al. 2001). high risk for HIV infection (WHO 2002). Furthermore, cervical barriers could be used Detergents (including N-9) disrupt cell in combination with microbicides that cover membranes of pathogens and sperm, but also parts of the vaginal wall. The combined use of healthy vaginal epithelial cells, and of a cervical barrier and a microbicide may researchers believe that disruption of the lat- provide much better protection than the use ter may facilitate the transmission of of a cervical barrier or microbicide alone. pathogens, including HIV. The failure of N- Studies are currently underway to evaluate 9 to protect women from HIV and other the effectiveness against HIV and other STIs STIs makes the development of non-deter- of cervical barriers alone, or in combination gent microbicides that much more urgent. with a microbicide. Hormonal contraceptives Some perceive diaphragms and cervical The next category of family planning meth- caps as having low acceptability because only ods includes oral contraceptives, injectables, a very small proportion of contracepting and hormonal implants. Obviously these are women use them. Furthermore, diaphragms not barrier methods, as they do not physical- have been associated with vaginal anaerobic ly impede the union of sperm and ovum. overgrowth and bladder infections (Cates and They tend to be more effective than barrier Steiner 2002). However, recent studies suggest methods for pregnancy prevention (in partic- that acceptability may be much higher if these ular injectables and hormonal implants that methods are perceived to provide protection require less in the way of consistent use on from disease as well as pregnancy, particularly the part of the user). However, they do not in countries hardest hit by the AIDS epidemic prevent direct contact of a woman’s epithelial (Bukusi et al. 2002; Padian et al. 2002). tissues with a man’s fluids (e.g., semen) or Spermicides have also been available for tissues, and therefore cannot prevent the decades. Almost all currently available sper- transmission of HIV and other STIs. micides are bio-detergents, and by far the There has been some concern that hor- most popular ingredient is nonoxynol-9 (N- monal methods that contain progestins— 9). N-9–containing products are available including combined oral contraceptive pills, worldwide over the counter in a variety of DMPA and NetEn injectables, and 14 Norplant®—could facilitate HIV transmission. This concern arose as the result of a A NEW HOPE: MICROBICIDE DEVELOPMENT study that found that monkeys given the hor- ome promising vaginal microbicides, as well as diaphragms and cer- mone progesterone were more likely to S vical caps, are now being evaluated for HIV prevention, and it is become infected after vaginal exposure to hoped that new methods will become available in the next five to ten simian immunodeficiency virus (SIV), a virus years. Microbicides are chemical or biologic substances capable of closely related to HIV (Smith et al. 2001). blocking infection when used during vaginal (and potentially anal) inter- The progesterone seemed to make the vaginal course. They could come in a gel, cream, suppository, film, or sponge lining thinner, thus facilitating transmission form and would provide women with a method of protection they could of the virus. As for the effects in humans of initiate themselves. The first microbicide compound studied was nonoxynol-9, which was already available as a spermicide in various for- contraceptives containing progestin, however, mulations for many years. N-9 is a detergent that disrupts the outer more research is needed to examine the rela- membrane of pathogens like HIV, but also that of normal cells. It can tionship between these methods and HIV therefore cause significant irritation when used frequently. After exten- transmission. The published epidemiological sive research by UNAIDS and others, WHO recommends that N-9 no data on the association between combined longer be recommended for HIV prevention. However, many other prom- oral contraceptive pills and DMPA injectables ising products that do not act as detergents but have different mecha- and HIV transmission are inconclusive (Wang nisms of action are being developed and evaluated. et al. 1999; Martin et al. 1998; Mati et al. Products such as the carrageenan-based Carraguard™ (developed by the 1995), while scarce data exist on the relation- Population Council), Dextrin-2-sulphate, and PRO2000 block attachment of ship between other hormonal methods and pathogens to the mucosal surface of target cells, thus inhibiting entry of HIV transmission. Currently, a large prospec- infectious pathogens. Still others, such as PMPA gel, have antiretroviral tive study being conducted in Thailand, activity, preventing a virus from entering cells or from replicating once it Uganda, and Zimbabwe is following 6,200 has entered cells. A microbicide might also maintain high acidity levels in low-risk, HIV-negative women for up to 24 the vagina during intercourse. Examples include Acidform and BufferGel, months to provide data on this critical issue.3 which enhance the natural defense mechanisms of the vagina against pathogens. Many safety and acceptability studies of these different types Intrauterine devices of vaginal microbicides have been successfully conducted, and two Phase It has long been known that intrauterine 3 effectiveness trials are underway, including the Population Council’s devices (IUDs) can facilitate the migration of trial of Carraguard in Botswana and South Africa and the HIV Prevention RTIs from the lower to the upper reproduc- Trials Network trial (HPTN 035) of BufferGel and PRO2000/5 gel in India, tive tract around the time of insertion (Cates Malawi, South Africa, Tanzania, the United States, Zambia, and Zimbabwe. and Steiner 2002). Some have raised con- For more comprehensive information on current developments concern- cerns that IUDs might increase the risk of ing microbicides, see van de Wijgert and Coggins 2002, Population female-to-male transmission of HIV, as well Council 2001, and the Web site of the Alliance for Microbicide as cause dangerous complications in HIV- Development at www.microbicide.org. positive women. However, recent studies suggest that IUDs do not increase cervical shed- ding of HIV or pose greater risks to HIV- mission. In fact, vulnerability to HIV and positive women (Richardson et al. 1999). STIs may increase, as sterilization obviates Sterilization the need to visit a family planning clinic or Sterilization—including vasectomy—does center on a regular basis. Thus, the opportu- not provide protection against HIV trans- nity to reach clients with information and

3 Family Health International is conducting these studies with support from the U.S. National Institute of Child Health and Human Development. For more information, see Family Health International 2001.

15 screening services for STIs is diminished. cult for them to adopt a single method Service providers should counsel individuals (although condom use could be focused on and couples who choose sterilization to con- potentially infected partners). Second, the tinue to visit other sexual and reproductive adoption of a second method may interfere health services on a regular basis. with consistent use of the first. Third, promoting condoms primarily as a method for Issues Surrounding Dual Protection disease prevention may stigmatize them, and Dual protection is defined as protection this, in turn, could inhibit people at risk for against both STIs and unintended pregnancy. HIV/STIs from using condoms. Fourth, a Currently it is achieved by consistent use of major challenge for service providers is to condoms (male or female) alone or in combi- ensure that infrastructure for expanded serv- nation with a highly effective contraceptive ice provision is in place, and to change coun- and ideally should be backed up by emer- seling strategies to include dual-method use. gency contraception (the use of a high dose Finally, resource constraints—within the of contraceptive hormones within 72 hours family planning setting itself or at the level of unprotected intercourse to prevent preg- of the client—may prohibit the use of two nancy) and abortion in the case of method methods. Studies examining the success of failure (although no backup exists for viral the dual-method approach are limited and STIs). A less frequently mentioned dual pro- results are often contradictory. tection strategy is condom use in combina- In the absence of evidence-based recom- tion with a second barrier method. It is mendations, service providers should assist hoped that the number of available dual pro- each woman (or couple) in assessing her risk tection strategies will increase in the future, of infection and unintended pregnancy (Cates when microbicides and cervical barriers are and Steiner 2002). To achieve dual protection added to the dual protection method mix. under typical circumstances, tradeoffs must Unfortunately, as described above, cur- be made. A key factor is a person’s likelihood rently available methods with the greatest of exposure to infection, which may be success rate for preventing pregnancy under assessed either by the prevalence of STIs in typical use conditions (sterilization, hormon- the community or by the specific risk behav- al methods, and IUDs) provide little to no iors of the person. In settings where exposure protection against HIV/STIs. Alternatively, to HIV is likely, such as sub-Saharan Africa, condoms can reduce the risk of many STIs, condom promotion for prevention of both but are associated with relatively higher preg- pregnancy and infection should be empha- nancy rates than other contraceptives for sized. On the other hand, in settings where most users. This situation poses a dilemma unintended pregnancy is the greater concern for family planning providers and their and cost is less of an issue, such as in many clients: Is it better to use two methods, or to family planning clinics in Europe and the rely on condoms for prevention of STIs/HIV United States, emphasizing a dual-method and pregnancy? approach may be appropriate and feasible. Several arguments against promoting the The potential consequences of unintended use of two methods have been raised (Cates pregnancy and infection should always be and Steiner 2002). The first concerns the considered. An unintended pregnancy, for willingness of family planning clients to example, may be acceptable to women if they adopt two methods when in fact it is diffi- were using family planning to delay child-

16 bearing and an earlier-than-planned pregnan- ing vulnerability to HIV/AIDS and other cy is acceptable. The availability of backup STIs is not simply a matter of listing abstract services—including emergency contraception risks and behaviors; rather it is about helping and safe and affordable abortion—may clients find healthier, safer ways to live. increase the acceptability of barrier methods Effective counseling can help clients and cou- as family planning methods. Lastly, the ples to explore, express, understand, and potential consequences of switching meth- accept feelings and process information in ods—or introducing a new method—on the order to foster informed decisionmaking to relationship should be considered. A woman reduce risk of and vulnerability to STIs. To who is already using one method of contra- do this, service providers must go beyond ception that offers little or no protection mere risk prevention and may need to against infections may not be able to intro- address male and female sexuality and the duce or switch to condoms without arousing gender power relations that underscore sexual her male partner’s suspicions and fears as to behaviors that contribute to HIV risk and the woman’s motivations. Doing so may vulnerability. As one staff member in introduce mistrust into the relationship, and Honduras reported after the service she may lead to gender-related violence or other worked in was expanded to include HIV and negative consequences (see Chapter 1). RTI counseling: “Before, we used to talk These obstacles to enhancing dual-pro- about methods and we’d arrive at an agree- tection strategies for women and men point ment with a client about a method. But now to the need for family planning services to we go much deeper. We ask if she has an promote the involvement of men in the infection, we look for risk factors, we can talk design and delivery of these services. The about other things such as sexual relations, most important approaches should aim at about her sex life in general, about her part- improving men’s access to clinic-based serv- ners” (Becker and Leitman 1997). Such dis- ices in general. Promotion messages targeted cussions help improve the quality of both specifically at men might include campaigns family planning and HIV prevention services. that encourage men to use condoms consis- Resources and settings for tently whenever they engage in “outside” sex- family planning staff ual relationships. Interventions of this nature Acquiring the time, skills, and resources for should be incorporated within the wider pro- effective family planning counseling is always motion of male responsibility for the health a challenge. Integrating HIV prevention into of the wife/partner and children. family planning settings increases that challenge considerably. The Population Council Counseling for Family Planning studied four projects that combined family and HIV Prevention planning and HIV prevention in East Africa As mentioned earlier, family planning work- and found that counselors often failed to ask ers are sometimes the only people in a posi- clients important questions about risk behav- tion to provide reliable and accurate informa- ior and STI symptoms (Miller et al. 1998). tion and counseling to sexually active men Counselors expressed embarrassment about and women who need HIV prevention infor- raising such issues with clients, even though mation and technologies in addition to fami- the clients themselves rarely objected to talk- ly planning counseling and services. However, ing about them. In addition, the counselors as with family planning counseling, address- often assumed their family planning clients

17 of ethical issues surrounding the protection of PROMOTING FAMILY PLANNING AND HIV client confidentiality in all circumstances. PREVENTION IN ZAMBIA: THE ZAMBIA– Finally, counselor training must address UNIVERSITY OF ALABAMA AT BIRMINGHAM HIV RESEARCH PROJECT trainee concerns related to increased job demands that accompany the integration of n response to popular demand, an HIV prevention project in Zambia HIV prevention into family planning work. I recently expanded to offer family planning services. Project staff began by offering only condoms, but clients expressed a demand for Counseling couples other contraceptives too, because family planning services in Lusaka Research from around the world has shown were inadequate. Condom use among clients remained high even after that despite societal norms that encourage other contraceptives were offered. In fact, project staff found that users monogamy within marriage and stable, long- of other types of contraception were more likely to use condoms as well, term relationships, it is unwise to assume and that condom users were twice as likely to start using another form of mutual monogamy within all marriages or contraception as well when it was offered to them. “All we had to do to long-term relationships. While this is true of increase contraceptive use was to make it easy to get. That was the both men and women, research suggests that secret,” said the director of the project. men have higher rates of partner change than According to the director, advertising these new services was straightfor- women, and are more likely to have multiple ward. “First we had to educate the community, and we did that by recruit- partners even if they are married or in a long- ing the first couples who came to the center to be outreach workers. We term relationship (Jenkins et al. 1995; paid them to go to their friends and spread the word about what we were Orubuloye et al. 1993; Sittitrai et al. 1991). doing. We also distribute invitations to the center door to door, and about Even when a monogamous woman is aware one-third of the people who receive them come in.” that her male partner has outside relationships, she may have great difficulty raising were not at high risk of infection, which was concerns about it or negotiating condom use not necessarily the case. without creating conflict or arousing suspi- Counselor training should include cion about her own behavior. This is especial- efforts to help trainees overcome their own ly difficult when a woman who has been fears about HIV and prejudices about HIV- using another form of contraception for years positive people. Counselors should under- decides she wants to introduce condoms into stand HIV risk and dual protection strate- the relationship. One way to address this gies, as well as gender-related vulnerabilities problem is to encourage greater communica- that underlie risk and influence their clients’ tion between partners. Couples-counseling, ability to modify risk. Counselors should often used among high-prevalence popula- have access to specific guidelines and check- tions, has proven effective in reducing high- lists to guide their counseling sessions.4 risk behavior, particularly among HIV-discor- Ideally, these guidelines should take local cir- dant couples (Painter 2001). Studies also cumstances (HIV/STI prevalence, gender indicate that it is far easier to persuade men issues, and sexual risk patterns in the com- to use condoms when couples are counseled munity) into account. Counselors should together. As one counselor in East Africa told have privacy to counsel clients and adequate a focus group, “It is easier to counsel a single time to address both family planning and person, but it is more important to counsel a HIV prevention topics. They should be aware couple.” Although it is not always easy to

4 For information on counseling people who attend antenatal clinics, see WHO 2000b. For information regarding reporting and partner notification guidelines, see WHO 1999b. For a general overview of HIV counseling, see UNAIDS 2002. 18 persuade men to appear at counseling centers, community education campaigns to encour- TRAINING FAMILY PLANNING COUNSELORS IN HIV PREVENTION: EXAMPLES FROM LATIN age male participation may help. AMERICA AND THE CARIBBEAN It is important for family planning providers to be aware of the potential obsta- n order to talk to clients about their reproductive health, staff must cles to couples-counseling they may I become comfortable with the language of sexuality and learn to over- encounter. Women in difficult relationships come their own prejudices against people affected by HIV. In pilot proj- may seek counseling sessions without their ects in Brazil, Honduras, and Jamaica, training sessions helped staff husbands in order to have a safe place to dis- overcome embarrassment by conducting discussions about sexual acts using both formal language and local slang. Members of the staff were cuss intimate issues and personal challenges asked to submit anonymous questions about sex so that the group could in their lives. Family planning providers discuss them. The questions included such topics as masturbation, oral should be trained to recognize these poten- sex, and orgasm. In addition, the sessions involved role-playing, which tial problems and recommend individual allowed staff to practice counseling people about sexual abuse, extramar- counseling for women who may face risks or ital sex, and homosexuality. Staff were also shown how to use a penis difficulties as a result of being counseled model to demonstrate how to put on condoms, and to demonstrate, in along with their male partner or husband. eye-catching ways, the strength of condoms by filling them with water or by putting them on their feet like socks. Group counseling Group counseling sessions, such as those Source: Becker and Leitman 1997. carried out in International Planned Parenthood Federation (IPPF) clinics in rural Africa and Asia, can help people recog- Voluntary HIV Counseling and Testing nize their own problems and risks by listen- in Family Planning Settings ing to others talk about their experiences. Voluntary HIV counseling and testing pro- Geeta Oodit of IPPF (in a personal commu- grams have become a cornerstone of nication with Helen Epstein, August 2001) expanded responses to the HIV/AIDS pan- described these sessions as a way for both demic. Their importance is based on several individuals and communities to address factors. First, individuals have a right to issues that concern them: know their serostatus in order to protect We announce that there is going to be a themselves and others from infection. meeting about health in the communi- Second, voluntary counseling and testing ty. Men are also encouraged to attend. may help individuals and couples cope with You have to find out what people want the anxieties associated with the uncertainty to talk about. Often it’s family plan- of not knowing their serostatus. Third, early ning, and we gain their trust by talking detection of HIV infection allows people to about that, but this gives us an oppor- gain access to sources of support and a vari- tunity to talk about HIV and STIs as ety of treatments for HIV infection itself well. These group meetings help break and information on preventing mother-to- down barriers. Hearing other people child transmission and opportunistic infec- talk openly about their problems helps tions associated with HIV and AIDS. Given some women open up about their own. the increasing pressure from the internation- For example, some women have learned al community on developed-country govern- that their vaginal discharge is not nor- ments and pharmaceutical companies to mal, and learning this encourages them make antiretroviral drugs and other AIDS to seek help. medications more widely available in devel- 19 oping countries, service providers may have HIV TEST KITS more reason to encourage testing and clients he World Health Organization provides guidance on purchasing HIV more incentives to be tested as treatment T test kits that are more than 99 percent accurate. All HIV test kits from options improve. Finally, voluntary counsel- reputable companies are highly sensitive and specific. Until recently, the ing and testing has been shown to promote standard test kit used in developing countries was the enzyme immunoas- behavior change (de Zoysa et al. 1995). say (EIA), but now highly specific and sensitive rapid HIV tests have been Voluntary HIV counseling and testing is developed that can be performed in 30 minutes or less and allow clients to also part of a holistic approach to promoting see for themselves the results of the test immediately. This enables health sexual and reproductive health among indi- care providers to supply results to patients at the time of testing, potential- viduals and couples and within the commu- ly increasing the effectiveness of counseling and testing. These tests usual- nity at large. It makes sense, therefore, that ly employ viral antigens immobilized in a solid matrix, such as nylon or cel- such programs be integrated into family lulose membranes, latex, microparticles, or individually packed plastic planning settings, especially in high-preva- cards, allowing for individual testing of samples. With the visual develop- lence countries. ment system, rapid tests do not require laboratory equipment—a great In low-prevalence settings, however, advantage for regions where laboratory facilities are scarce. Moreover, resources may not be available for wide- with rapid tests a return visit to the clinic is not required. On the other spread HIV testing. Research in progress hand, rapid tests can be more expensive than EIAs. Laboratories must thus suggests that highly sensitive counseling can balance concerns about cost with concerns about ensuring that services be as effective as testing at encouraging rapidly reach the largest number of people. Since EIA tests are carried out behavior change (Johannes van Dam, per- on 50 or more samples at one time, laboratories often wait days or even sonal communication, August 2001). In weeks until they have accumulated enough samples. Studies have shown such instances, family planning services may that up to half of all women in developing countries may not return for their be more likely to continue to concentrate on EIA results, hence rapid tests may encourage more women to complete the contraceptive provision, while also making voluntary counseling and testing process and undertake vital prevention women and men more aware of HIV, STIs, activities that can help support and protect themselves and their families. and RTIs through counseling services. A negative rapid test does not require further testing. A reactive rapid test, Despite the widely acknowledged bene- on the other hand, must be confirmed by another test of a different type fits of voluntary counseling and testing pro- (most commonly an EIA or another rapid test), especially in populations grams, there are also negative implications where HIV prevalence is low. that family planning service providers should be aware of. Once their serostatus is known, Studies have also found that by far the most expensive component of vol- HIV-positive people may be subject to stig- untary counseling and testing services is counseling, not testing, even ma, discrimination, or violence when they when the more costly rapid tests are used. The estimated cost of ensuring disclose their status to others. An HIV-posi- that adequate numbers of well-trained counselors are available to all tive test result can also contribute to anxiety women who need them is many times more per client than the rapid test. and depression. Where health services are For these reasons, rapid tests are becoming the norm in many places. generally poor and few treatments are avail- Even so, in Lusaka, Zambia, for example, HIV testing services can handle able for HIV-positive people, people may only 50 clients a day, and demand for testing is far greater. feel the risks of knowing and disclosing their For more information about HIV/AIDS commodities see UNFPA 2002; serostatus far outweigh the benefits. WHO 2002; and www.who.int/bct/main_areas_of_work/BTS/hiv_ The Population Council’s Horizons pro- diagnostics/. gram evaluated the HIV counseling and testing program in Tanzania and found that men and women sought testing for different 20 reasons. Men usually said they were tested to reassure themselves or their partners that DOMESTIC VIOLENCE AS A RESULT OF HIV DIAGNOSIS they were uninfected, whereas women usually came only if they already suspected they hen women are tested for HIV, counselors must be alert to the might be HIV-positive because of their own W risks of abuse and violence if women disclose their status to their illness or that of a child or spouse. Unlike families. In addition to endangering the safety of women, coercive or vio- men, many women said they needed permis- lent behavior prevents negotiation of safer sex and clearly increases risk sion from male family members before they of infection because of possible damage to tissues. A study carried out by could seek testing. The implications of this the Population Council’s Horizons program in Tanzania found that among fact are that women may be expected to dis- women ages 18–29 years who came for voluntary counseling and testing, those who were HIV-positive were ten times more likely to have been close their status to family members or oth- physically abused by their partners in the past three months than women ers. For women, an HIV-positive result who were HIV-negative. Some women who then disclosed their HIV- might lead to violence, loss of social support, positive status found this triggered another episode of violence (Maman abandonment, or loss of their children et al. 2002). In other studies, between 30 and 80 percent of women who (Maman et al. 2001). discovered they were HIV-positive did not tell their partners. It is not Counseling HIV-positive women and men known whether women who know their status but do not tell their part- For many people, the prospect of disclosing a ners practice safer sex. Insisting on condom use might well arouse a positive test result to partners and/or family partner’s suspicions and create the very conflicts the woman sought to members is likely to generate feelings of avoid in the first place (see Chapter 1). shame and perhaps guilt. Counselors should HIV prevention counselors need to question clients who come for HIV help clients address their immediate concerns testing about violence in their lives and help them find safe ways to dis- and make decisions about disclosure and close their status to partners and family. In some situations it may be sources of support in their families and com- safest for women not to disclose their status until circumstances are munities. Referral to HIV support groups, more favorable. especially groups of people living with HIV/AIDS, is critical. Post-test counseling of HIV-positive people should include informa- While some HIV-positive women want tion about the stages of HIV infection and to prevent pregnancy to protect their own other infections and illnesses associated with health and avoid transmitting the virus to a AIDS in order to raise clients’ awareness of child, counselors are likely to encounter their options for treatment. The global HIV-positive people who, for a variety of movement to secure better and more com- reasons, want to have children. In many soci- prehensive access to antiretroviral therapies eties, having children is central to a woman’s means that service providers should be aware identity and status. Children also provide of those drugs and proper guidelines for hope and purpose in people’s lives. As one their administration and client adherence to HIV-positive woman in the United States available regimens.5 Counselors should also told a family planning provider, “If I have a assist clients in ensuring good nutrition and child, I will take care of my child and I will receiving prompt treatment for opportunistic be active. I can work because I know I have and other illnesses associated with AIDS, someone to take care of” (Chan 2001). especially tuberculosis. Some HIV-positive women may also wish to

5 Service providers should consult WHO/UNAIDS 1998.

21 become pregnant to replace a child lost to polyurethane female condom after multi- AIDS. For some women, becoming pregnant ple cycles of disinfection, washing, dry- may help them allay the suspicions of others ing, and re-lubrication,” Abstract TuOrD1233. XIV International AIDS that they are HIV-positive. All of these rea- Conference, Barcelona, Spain, 7–12 July. sons place a substantial burden on family Feldblum, P.J. et al. 2001. “Female condom planning counselors to continue to provide introduction and sexually transmitted clear, accurate information about HIV and infection prevalence: Results of a com- AIDS, in order to allow clients to make munity intervention trial in Kenya,” informed decisions about handling an HIV- AIDS 15: 1037–1044. positive diagnosis and subsequent family Finger, W. 2001. “Condom offers STI protection: Condom use should be encour- planning. Issues surrounding pregnancy and aged among people at risk of HIV and HIV-seropositivity will be discussed in other STIs,” Network 20(4): 22–25. greater detail in Chapter 4. Gilmore, C. 1998. “Recent advances in the research, development and manufacture References of latex rubber condoms,” in E. Becker, Julie and Elizabeth Leitman. 1997. McNeill, C. Gilmore, W. Finger et al. Introducing Sexuality Within Family (eds.), The Latex Condom: Recent Planning: Three Positive Experiences from Advances, Future Directions. Research Latin America and the Caribbean, Triangle Park, NC: Family Health Quality/Calidad/Qualité no. 8. New International, pp. 36–43. York: Population Council. Hatzell, T. and P.J. Feldblum. 2001. “The Bukusi, E.A. et al. 2002. “Acceptability of female condom: Beyond acceptability to the diaphragm among women at risk for public health impact,” Sexually sexually transmitted diseases in Nairobi, Transmitted Diseases 28(11): 655–657. Kenya,” Abstract MoPeD3658. XIV Jenkins, Carol et al. 1995. Women and the International AIDS Conference, Risk of AIDS: Study of Sexual and Barcelona, Spain, 7–12 July. Reproductive Knowledge and Behavior in Cates, Willard and Markus Steiner. 2002. Papua, New Guinea, Women and AIDS “Dual protection against unintended Research Program Research Report pregnancy and sexually transmitted Series no. 10. Washington DC: ICRW. infections: What is the best contracep- Kerrigan, D. et al. 2000. The Female Condom: tive approach?” Sexually Transmitted Dynamics of Use in Urban Zimbabwe. Diseases 29(3): 168–174. New York: Population Council. Chan, J. 2001. “Fertility desires and inten- Lagarde, E. et al. 2001. “Condom use and tions of HIV-positive men and women,” its association with HIV/sexually trans- Family Planning Perspectives 33(4): mitted diseases in four urban communi- 144–152. ties of sub-Saharan Africa,” AIDS de Zoysa, Isabel et al. 1995. “Role of HIV 15(suppl 4): S71–S78. counseling and testing in changing risk LeFranc, E. et al. 1996. “Working women’s behavior in developing countries,” AIDS sexual risk taking in Jamaica,” Social 9(suppl A): S95–S101. Science and Medicine 42(10): 1411–1417. Family Health International. 2001. “Several Little, F. et al. 2002. “Barriers to accessing counseling options are likely if further free condoms of public health facilities research suggests an increased STI risk across South Africa,” South African from hormonal methods,” Network Medical Journal 92(3): 218–220. 20(4), www.fhi.org/en/fp/fppubs/ net- Maman, Suzanne et al. 2001. HIV and work/v20-4/nt2047.html. Partner Violence: Implications for HIV Farley, T.M.M., W. Potter, J. Gerofi, and M. Voluntary Counseling and Testing Pope. 2002. “Structural integrity of the Programs in Dar es Salaam, Tanzania. 22 Washington, DC: Population Council, intervention for HIV/AIDS prevention Horizons. in sub-Saharan Africa,” Social Science ———. 2002. “HIV-positive women report and Medicine 53(11): 1397–1411. more lifetime partner violence: Findings Population Council. 2001. The Case for from a voluntary counseling and testing Microbicides: A Global Priority. New clinic in Dar es Salaam, Tanzania,” York: Population Council. American Journal of Public Health 92: Ray, S. et al. 2001. “Female-initiated meth- 1331–1337. ods of STI/HIV prevention: Constraints Martin, H. et al. 1998. “Hormonal contra- faced by sex workers in use of female ception, sexually transmitted diseases, and male condoms for safer sex in urban and risk of heterosexual transmission of Zimbabwe,” Journal of Urban Health human immunodeficiency virus type 1,” 78(4): 581–592. Journal of Infectious Diseases 178: Rhodes, T. and L. Cusick. 2002. 1053–1059. “Accounting for unprotected sex: Stories Mati, J.K.G. et al. 1995. “Contraceptive use of agency and acceptability,” Social and the risk of HIV infection in Science and Medicine 55: 155–159. Nairobi, Kenya,” International Journal of Richardson, B. et al. 1999. “Effect of Gynaecology and Obstetrics 48: 61–67. intrauterine device use on cervical shed- Miller, K., H. Jones, and M.C. Horn. 1998. ding of HIV-1 DNA,” AIDS 13(15): “Indicators of readiness and quality: Basic 2091–2097. findings,” K. Miller et al. (eds.), Clinic- Shelton, J. and B. Johnston. 2001. Based Family Planning and Reproductive “Condom gap in Africa: Evidence from Health Services in Africa: Findings from donor agencies and key informants,” Situation Analysis Studies. New York: British Medical Journal 323: 139. Population Council, pp. 29–85. Sittitrai, Werasit. 2001. HIV Prevention Moench, Thomas R., Tsungai Chipato, and Needs and Successes: A Tale of Three Nancy S. Padian. 2001. “Preventing dis- Countries—An Update on HIV ease by protecting the cervix: The unex- Prevention Success in Senegal, Thailand plored promise of internal vaginal barri- and Uganda. Geneva: UNAIDS. er devices,” AIDS 15: 1595–1602. Sittitrai, Werasit et al. 1991. “The survey Musaba, E. et al. 1998. “Long-term use of of partner relations and risk of the female condom among couples at HIV infection in Thailand,” high risk of human immunodeficiency Abstract MD4113. VII International virus infection in Zambia,” Sexually AIDS Conference, Florence, Italy, Transmitted Diseases 25: 260–264. 16–21 June. Myer, L., C. Mathews, and F. Little. 2001. Smith, S.M., G.B. Baskin, and P.A. Marx. “Condom gap in Africa is wider than 2001. “Estrogen protects against vaginal study suggests,” British Medical Journal transmission of simian immunodeficien- 323: 937. cy virus,” Journal of Infectious Diseases Orubuloye, I.O., J.C. Caldwell, and P. 182(3): 708–715. Caldwell. 1993. “African women’s con- UNAIDS. 1999. Gender and HIV/AIDS: trol over their sexuality in an era of Taking Stock of Research and Programmes. AIDS: A study of the Yoruba of Nigeria,” Geneva: UNAIDS. Social Science and Medicine 37: 859–872. ———. 2002. HIV Voluntary Counselling Padian, N. et al. 2002. “Diaphragms are well- and Testing: A Gateway to Prevention and accepted in sexually active Zimbabwean Care. Geneva: UNAIDS, www.unaids. women,” Abstract TuOrD1236. XIV org/publications/documents/health/ International AIDS Conference, counselling/JC729-VCT-Gateway-CS- Barcelona, Spain, 7–12 July. E.pdf. Painter, T.M. 2001. “Voluntary counseling UNFPA. 2002. “HIV prevention now: and testing for couples: A high leverage Voluntary counselling and testing 23 (VCT) for HIV prevention,” AIDS: Public Health and Human Programme Brief no. 5. Geneva: Rights Implications. Geneva: WHO, UNFPA, www.unfpa.org/aids/ www.who.int/HIV_AIDS/knowledge/ prevention/hivprev5a.htm. rptngdiscl.html. United States Agency for International ———. 2000a. The Female Condom: Development, Bureau for Africa/Office A Guide for Planning and Programming. of Sustainable Development (OSD). Geneva: WHO. 2001. Technical Update on the Female ———. 2000b. Voluntary Counseling and Condom. Washington, DC: USAID. Testing for HIV Infection in Antenatal U.S. National Institute of Allergy and Care: Practical Considerations for Infectious Diseases. 2001. Scientific Implementation. Geneva: WHO, Evidence on Condom Effectiveness for www.who.int/HIV_AIDS/ Sexually Transmitted Disease Prevention, knowledge/implvct3.html. summary report of a workshop held in ———. 2002. Sources and Prices of Herndon, VA, 12–13 June. Selected Drugs and Diagnostics for van de Wijgert, Janneke and Christiana People Living with HIV/AIDS. Coggins. 2002. “Microbicides to pre- Geneva: WHO, www.who.int/ vent heterosexual transmission of HIV: medicines/library/par/ Ten years down the road,” AIDScience hivrelateddocs/prices-eng.pdf. 2(1), www.aidscience.org/articles/ WHO/UNAIDS. 1998. Nine Guidance aidscience015.asp. Modules on Antiretroviral Treatments. Wang, C.C., J.K. Kreiss, and M. Reilly. Geneva: WHO, www.who.int/ 1999. “Risk of HIV infection in oral hiv_aids/antiretroviral_modules/ contraceptive pill users: A meta-analy- indexar.htm. sis,” Journal of Acquired Immune Wilkinson, D. et al. 2002. “Nonoxynol-9 Deficiency Syndromes 21: 51–58. spermicide for vaginally acquired HIV WHO. 1999a. Integrating STI Management and other sexually transmitted infec- into Family Planning Services: What Are tions: Systematic review and meta-analy- the Benefits? document WHO/RHR/ sis of randomized controlled trials 99.10. Geneva: WHO. including over 5,000 women,” plenary ———. 1999b. Questions and Answers on address at Microbicides 2002, Antwerp, Reporting, Partner Notification and Belgium, 12–15 May. Disclosure of HIV Serostatus and/or

24 Chapter 3 HIV Prevention Programs for Young People

UNAIDS estimates that every day around among young people, and therefore of their 6,000 people ages 15–24 years contract HIV, vulnerability to HIV/AIDS. Recent data and young people now account for nearly half show that more than 25 percent of boys ages of all new adult infections each year 15–19 in Brazil, Hungary, and Kenya report (UNAIDS 2002). In some countries the pro- having had sex before the age of 15 portion is even greater, exceeding 60 percent (UNICEF/UNAIDS/WHO 2002). In of new infections in sub-Saharan Africa and Bangladesh, 88 percent of unmarried boys many parts of Asia (UNAIDS 2002). The risk and 35 percent of unmarried girls living in of and vulnerability to HIV infection among urban areas have had sex before the age of 18 young women are particularly striking: Young (UNICEF/UNAIDS/WHO 2002). Males women now account for 62 percent of the and females under age 25 account for 11.8 million young people living with approximately one-third of the 333 million HIV/AIDS (UNICEF/UNAIDS/WHO new cases of curable STIs per year 2002). In Western Kenya, nearly one in four (UNICEF/UNAIDS/WHO 2002). Without girls 15–19 years old was infected with HIV appropriate treatment for STIs, their risk of by the mid-1990s, compared with one in 25 contracting HIV increases by as much as boys in the same age group (Glynn et al. three- to fivefold (Wasserheit 1992). 2001). In Zambia, 16 times as many girls as Economic, social, and political condi- boys were infected (Glynn et al. 2001). Most tions in many developing countries create important, perhaps, is the fact that only a circumstances that make young people par- very small fraction of young people who are ticularly vulnerable to HIV infection. Some infected are even aware of it (UNICEF/ children may be living on the fringes of soci- UNAIDS/WHO 2002). The epidemic ety, out of reach of formal school- and com- among young people—which has become far munity-based services. Street children may worse than anyone predicted ten years ago— be fugitives from violent homes, or orphaned represents one of the most severe challenges to as a result of losing one or both parents to the future health and development of many HIV/AIDS. They may be refugees or inter- countries around the world. It requires hard nally displaced, growing up in urban or peri- thinking and setting new priorities in HIV urban slums. They may be children who prevention and sexual and reproductive health must work, who are out of school, or who service delivery for the coming decades. are isolated by prejudice and discrimination Rates of pregnancy and STIs among because of alternative sexual orientations. adolescents ages 15–19 provide indications Economic circumstances may compel them of the extent of unprotected sexual activity to sell or barter sex for protection, a meal, or

25 A TEN-POINT STRATEGY FOR PREVENTING HIV INFECTION IN YOUNG PEOPLE

recent publication released by UNICEF, UNAIDS, and WHO ensuring that information is communicated in a manner rele- A advocates a ten-step strategy for reducing young people’s vant to young people’s lives. risk for and vulnerability to HIV/AIDS. The steps reinforce each 7. Engage young people who are living with HIV/AIDS. Young other and can be adopted by countries according to resource people living with HIV/AIDS are in a unique position to rein- availability and the particular epidemiological situation. force information about the need to adopt and maintain safe behaviors. They can also help reduce the stigma and discrimi- 1. End the silence, stigma, and shame. Stigma and discrimina- nation associated with HIV/AIDS, and assist in the develop- tion prevent young people from seeking out and adopting pre- ment of prevention and support programs for others infected ventive strategies such as voluntary counseling and testing or otherwise affected by HIV/AIDS. for HIV and STIs, using condoms, adhering to treatment, or disclosing their HIV status to their partners. National and 8. Create safe and supportive environments. Even well- community leaders must break the silence and challenge stig- designed interventions will meet with limited success if the ma and discrimination to create a suitable environment in intervention environment is hostile or unsupportive of youth. which prevention initiatives may succeed. Schools and communities must be unequivocal in condemning sexual coercion and violence, abuse, and exploitation of chil- 2. Provide young people with knowledge and information. dren and young people. Beyond this, schools and other com- Adolescents need to know the facts about HIV/AIDS before munity organizations can work toward supporting positive they become sexually active. A basic education of accurate norms to reduce the negative gender stereotypes that create and reliable information about sexuality and HIV—in schools, vulnerability to HIV among young girls and boys. communities, and via the media—is essential for all children. 9. Reach out to young people who are most at risk. Those 3. Equip young people with the skills to put knowledge into young people who are at especially high risk for contracting practice. Life skills—skills in negotiation, conflict resolution, HIV—males who have sex with males, children living on the critical thinking, decisionmaking, and communication—are street, child soldiers, young refugees and internally displaced vital for the success of young people’s ability to use the people, children orphaned by AIDS, young people who use knowledge about sexuality and HIV that they have obtained. drugs, and children who are sexually exploited—are often on 4. Provide youth-friendly health services. Services should pro- the periphery of society and face enormous challenges in vide a full range of information, technologies, and services to improving their circumstances. They need access to liveli- young people in a welcoming, confidential, conveniently locat- hoods training, education, and services to enable them to ed, and affordable setting. Youth-friendly services can be free- build a better future. standing or integrated into existing clinics or recreational 10. Strengthen partnerships and monitor progress. Meeting facilities. the prevention needs of young people requires the efforts of 5. Promote voluntary and confidential HIV counseling and all sectors of society, not just public health. Partnerships must testing. Studies have shown that young people have a keen also include governmental and nongovernmental organiza- interest in knowing their HIV status. Voluntary counseling and tions, the private sector, and civil society organizations such testing allows adolescents to evaluate their own behaviors as faith-based and community institutions. Reducing the risks and the consequences. It provides advice and skills for stay- and vulnerabilities of young people also requires active moni- ing HIV-negative, and offers a critically needed point of refer- toring and evaluation of new and existing prevention initia- ral to treatment and sources of support for those who are tives in order to establish what works and why, and requires HIV-positive. opportunities for new and innovative ways to reach young 6. Work with young people and promote their participation. people with what they need. Involving young people in prevention efforts educates them about HIV and gives them a sense of responsibility and pride. It also leads to more effective program design and outreach, Source: UNICEF/UNAIDS/WHO 2002.

26 a place to sleep. Sexual interaction may be exploring the complexities of integrating one of the few opportunities these young HIV prevention interventions within broad- people have to experience human warmth er reproductive health, family planning, and and intimacy. An estimated one million chil- maternal and child health services and set- dren each year are forced into the sex trade, tings, this chapter looks at opportunities to often by their families who are in search of reach young people in diverse settings, citing security in an age when globalization is dis- a wide range of approaches that have been rupting local economies and family struc- successful. tures. In many parts of the world, the age of marriage for girls is significantly lower than School-Based HIV Prevention that for men. In addition, husbands may Information, Education, and have multiple partners or high rates of part- Skills Development ner change, contributing further to young The relationship between education and risk women’s risk and vulnerability. Higher fre- of HIV infection is complex. In sub-Saharan quency of sex within marriage (often “on Africa, for example, more-developed coun- demand”) along with pressure to become tries and better-educated people tend to have pregnant results in women having little room higher rates of HIV infection. However, for adopting protective strategies. Drug use while better-educated populations seem to may also be part of the “culture” of at-risk have been more susceptible to HIV early in youth—a response to feelings of loneliness, the epidemic, they also appear to be changing boredom, and despair. their behaviors more rapidly. In the future, as The face of HIV/AIDS is thus becom- better-educated groups take steps to protect ing ever younger, not only in terms of the themselves, it is likely that those at highest numbers of people under the age of 25 who risk of acquiring HIV will be people with less are HIV-positive, but also in terms of bur- education. Therefore, increasing access to densome economic and social consequences education in general, and HIV-related educa- of the pandemic. Taking action to minimize tion in particular, should lead more people to the threat of HIV/AIDS to young people is change their behaviors to protect themselves both a matter of human rights and an from HIV (Hargreaves and Glynn 2002; absolute necessity for slowing the HIV pan- Gregson et al. 2001). HIV-related education demic. Experience to date shows that inter- can have an even greater effect on prevention ventions for, and in partnership with, young efforts if it is linked with other HIV preven- people are among the most effective. Such tion efforts in the community. Research has interventions derive their effectiveness from shown that education about sexual health the fact that young people are less resistant does not promote early sexual activity or to change than are adults and are generally promiscuity, as some critics contend, but more willing to examine the social norms rather delays the initiation of sex and encour- that contribute to their risk and vulnerabili- ages safer sexual behaviors. In 1997 a ty to HIV. UNAIDS review of 53 sexual health educa- A number of elements of an expanded tion programs found that about half had no response to HIV/AIDS are appropriate for effect on sexual behavior, while the remaining addressing the special needs and vulnerabili- half either delayed the onset of sexual activity ties of young people. While the focus of this or reduced the rates of unplanned pregnancy document up to this point has been on and STIs (UNAIDS 1997).

27 HIV prevention programs in schools Innovative Methods for School-Based have the potential to reach large numbers of Programs: Peer-Led Education, Theater, young people before they become sexually and Role-Plays active, as well as when they are struggling In addition to content, designers and imple- with their emerging sexual identities, feel- menters of programs for in-school youth ings, and relationships. For some young must consider a variety of methods besides people, school is the most important institu- formal, lecture-style delivery of information. tion in their experience, and school policies One method that has met with success in a and programs can help many adults as variety of situations and circumstances is well—including school personnel, parents, peer-led education. For example, Family and the wider community—cope with HIV. Planning Private Sector, an NGO in Kenya, For example, HIV prevention programs can initiated a peer-education project for sexual promote tolerance and respect for people and reproductive health in collaboration with infected with HIV/AIDS and can reduce staff and students in nine colleges. Student stigmatization of teachers and students representatives and deans from each college affected by the virus and offer them social were brought together to develop an outline support (WHO 1999). curriculum. Student leaders then established Ideally, school-based HIV prevention AIDS Awareness Clubs that became the main programs should begin early and be sus- coordinating bodies for activities. Peer educa- tained and phased in by age group, from tors organized a variety of activities, including early childhood through adolescence. This condom distribution and the publication of is particularly desirable in developing coun- newsletters. Qualitative evaluation revealed tries where primary school attendance rates that a number of students were reached may be relatively high but few students through the project, which also increased stu- reach secondary school. Content appropri- dents’ access to services and information. ate for children should be integrated into Among the most innovative aspects of the life-skills education programs at an early work was the way in which the project team age—before children become sexually secured the support of the colleges’ adminis- active. tration. In addition, success stemmed largely Teachers who are appropriately trained from the fact that young people themselves and respected by students should be were involved in all aspects of project design involved in HIV prevention education as and implementation. much as possible. However, program design- Another successful method is theater ers should be aware of the barriers to effec- and role-plays. In Vanuatu, for example, the tive teacher-led sexuality education. For Wan Smolbag Theatre developed a popular example, many teachers are embarrassed program for secondary school students that when talking about sex and feel they will dealt with family planning and infections. lose esteem in their students’ eyes if they do The theater group devised sketches showing so. Sometimes outside specialists can be how such infections as gonorrhea are trans- recruited for this work, but even then teach- mitted through sex. Models of a penis and ers should be trained how to identify issues vagina were put onstage, and actors played that merit discussion and how to provide the roles of an STI germ, a sperm, and the referral to further information and services liquid that carries sperm. The sketches lasted for students. about 30 seconds each, and afterward audi-

28 WHAT SHOULD CHILDREN OF DIFFERENT AGES KNOW ABOUT HIV AND OTHER SEXUALLY TRANSMITTED INFECTIONS?

he World Health Organization (WHO) and the United symptoms and consequences, and how to prevent con- T Nations Educational, Scientific and Cultural Organization tracting them; (UNESCO), in their jointly published School Health Education • be aware that they can take actions to avoid disease and to Prevent AIDS and Sexually Transmitted Diseases (1995), pregnancy; recommended that the content of school-based programs • recognize the social issues, including gender differences, should emphasize life skills and attitudes, as well as biologi- that put people at risk of contracting HIV or other STIs; in cal facts. HIV prevention education must be relevant to the addition, boys should understand that responsible sexual cultural context and should emphasize delaying sexual activi- behavior and respect for girls is a positive aspect of mas- ty, mutual monogamy, and, where appropriate, condom use. culinity; Staff should promote an atmosphere of tolerance toward oth- • show concern for people infected with HIV; ers, including people infected with HIV. In addition, stereo- • communicate messages about HIV prevention to their fam- types about people with HIV must be overcome. For example, ilies, peers, and others; they should also know where to an evaluation of an HIV prevention program sponsored by find information and services related to sexual health; and the Ministry of Health in Bogotá, Colombia found that despite • recognize the importance of resisting peer pressure and the project’s efforts, students still associated HIV/AIDS with acquire basic negotiation skills to help them do this. sinful behavior and assumed it only affected sex workers, transvestites, and drug users. Young children, preadoles- Information for adolescents should teach them to: cents, and adolescents have different information needs, as • recognize the behaviors that place people at risk of con- outlined below: tracting HIV or other STIs and how the risk of contracting

Information for young children should help them to: these infections can be lessened by delaying the initiation • know that HIV is a virus that causes a disease called of sexual activity and using condoms; AIDS; HIV cannot be transmitted by casual contact, such • know how to use a male and female condom, and where to as touching and hugging or sharing utensils; and people get them; can be HIV-positive and still look healthy, but when people • know where to go for HIV counseling and testing, if become sick there is as yet no cure for them; available; • accept and not fear people who are HIV-positive or have • understand that people do not always behave the way they AIDS; themselves believe they should; • understand the concept of socially defined gender roles and •have a positive attitude toward HIV prevention and be the need for males and females to respect one another; willing to encourage others to protect themselves; and • learn communication skills to resolve conflicts and make healthy decisions to deal with stress; and • be able to refuse to have sexual intercourse and to • be able to recognize inappropriate sexual advances by negotiate safer alternatives to intercourse. older children or adults and report them immediately to Curricula for HIV/STI prevention and other health issues can adults whom they trust. be obtained from governmental or nongovernmental agencies Information for preadolescents should teach them to: or from teachers’ unions. School Health Education to Prevent • understand the physical changes that take place during AIDS and Sexually Transmitted Diseases (WHO/UNESCO adolescence; know what a virus is and how viruses, includ- 1995) can be obtained through country UNAIDS officials or ing HIV, are transmitted; and know about other STIs, their WHO country and regional offices.

29 ence members were invited to explain what Africa, high rates of infection among teach- had just happened and to ask questions. ers and students have devastated many Members of the Wan Smolbag Theatre have schools (UNAIDS 2002). Furthermore, data documented improved rates of family plan- from studies on girls’ educational attainment ning use and greater understanding of HIV in agricultural communities indicate that and STIs among their audiences. often they are pulled out of school earlier than boys to fulfill household responsibili- Creating a Safe Environment for ties, as when adult household members Successful School-Based Interventions become ill or die as a result of HIV/AIDS Program designers should recognize that not (UNAIDS 2002; King and Hill 1993). In all schools are salutary places for young peo- addition, as household resources to hire agri- ple—especially young girls. In the regions of cultural laborers are depleted, girls are likely the world most seriously affected by to be pulled out of school to fill the gaps in HIV/AIDS, epidemiological data reveal that food production (Levine et al. 1996). young women are infected in school as a Creating a safe environment for young result of unsafe and sometimes coerced sex people includes providing them with accurate with classmates or teachers. In Mwanza, information that promotes frank, honest dis- Tanzania, for example, parents of children at cussion about risky sexual behavior. Programs one school complained that teachers were that endorse the importance of virginity for harassing girls sexually. The school appointed girls do not necessarily protect girls from several student guardians—female staff infection with HIV or STIs. Studies carried members to whom girls (and boys, if neces- out by the International Center for Research sary) could turn if they had questions about on Women found that girls may engage in sexual health or if they were being harassed other forms of risky behavior, such as anal by a teacher or classmate. The guardians sex, in order to remain, at least technically, reported allegations to the district authori- virgins. Promoting virginity may even increase ties, who in turn supported the guardians if girls’ risk because it will discourage them from they faced threats from men accused of asking for prevention information or gaining harassing students. Training the guardians to access to condoms. Programs that promote help the girls, moreover, helped the either postponement of sex or the practice of guardians deal with issues of sexual harass- protected sex seem to be more successful at ment in their own lives. The involvement of encouraging safer behavior than programs other institutions in addition to the schools that promote abstinence (Weiss et al. 1996). themselves, including district authorities and the courts, reinforces the importance of pre- Community Support for HIV/AIDS and vention for the entire community, and cre- Sexual Health Education ates the kind of collective will that seems to School-based HIV prevention programs are be required to slow the spread of the virus likely to fail if strong community support for (UNICEF/UNAIDS/WHO 2002). them is lacking. Many communities and Program designers and implementers governments resist school-based HIV preven- should also be aware of the consequences the tion programs, fearing that discussion of sex HIV/AIDS epidemic has had on the number will encourage immoral behavior. of available teachers and on young people’s Community members must therefore be ability to stay in school. In sub-Saharan involved in the earliest planning stages,

30 through community meetings, parent– Involving Parents, Teachers, and teacher associations, and religious centers. A Community Institutions school-based HIV-education program in While many young people report that they Masaka, Uganda failed because teachers did would prefer to have parents or other family not feel comfortable talking about sex and members be primary sources of information condoms in front of students, even though and advice about sexuality and sexual health, they had been trained to do so. The authors sometimes the home environment does not of the study speculate that community atti- support this type of parent–child communi- tudes toward the program remained nega- cation. In addition, adults in the household tive, so the program was implemented in a may not have accurate information about desultory, inconsistent way (Kinsman et al. sexual risk in order to properly advise their 2001). children. Some young people may find it Evidence-based programs—that is, pro- embarrassing or frightening to discuss inti- grams that are informed by surveys or opera- mate issues with their parents; conversely, tions research and situation analyses—often some parents may prefer to rely on schools help convince communities of the necessity to educate their children about matters they of HIV prevention in schools. Such evidence themselves find difficult or embarrassing to might provide information on HIV and STI discuss. Other trusted adults in the commu- prevalence among young people in the area, nity—such as teachers, health workers, and rates of unwanted pregnancy, and rape and counselors—can help fill the gap if they have sexual violence. a good relationship with the young people School health programs need leadership, around them. and the World Health Organization recommends the formation of school health Programs for Out-of-School teams—comprising students, teachers, par- Young People ents, and health workers—to coordinate and Worldwide, approximately 120 million pri- monitor all health-promotion activities, mary-school-age children are not in school— including HIV prevention (WHO 1999). with 40 million of them in sub-Saharan School health teams might be supported by Africa—despite the fact that most countries community advisory committees, consisting formally recognize children’s right to receive of HIV prevention counselors, community primary-level education free of charge members infected with HIV/AIDS, politi- (UNICEF/UNAIDS/WHO 2002).6 In cians, sports stars, and others who want to some cases, macroeconomic adjustment poli- build community support for HIV preven- cies have resulted in a lack of resources for tion and help obtain funding for programs. schooling in terms of facilities or the number Ideally, each level of community administra- of available teachers. These realities occasion- tion would at least be aware of, if not ally coincide with a trend in public school involved in, the planning of a school health financing whereby a greater share of the costs education program. of education has shifted to families in the

6 This right has been affirmed in Article 26 of the Universal Declaration of Human Rights; Article 13 of the International Covenant on Economic, Social and Cultural Rights; and Article 28 of the Convention on the Rights of the Child. The latter two treaties spell out specific, legally binding obligations for states that are parties to those treaties.

31 form of school fees, making the cost of pri- that aim to establish camps in high-risk areas. mary education particularly prohibitive. Each of the camps functions as a shelter for According to a recent report by OXFAM, approximately 30 girls who have been rescued declining household income—along with from traffickers or who are in danger of being contractions in public provision of educa- sold. The camps provide education, vocation- tional resources—sometimes results in chil- al training, and support and counseling. dren being withdrawn from school to reduce Project staff have worked closely with col- pressure on household budgets and generate leges, local pressure groups, village leaders, additional income (Watkins 1999). medical offices, lawyers, and police. Many young people who are out of Evaluation suggests that the Maiti Project has school are compelled to work to support prevented some girls from being sold into themselves or their families. Household sur- brothels in India. In addition, child traffick- veys from a low-income settlement in ers have been exposed and imprisoned as a Lusaka, Zambia found a sharp increase in result of the project’s efforts. The project is child labor following structural adjustment, most remarkable in its integrated approach to with boys being sent out to earn income meeting the needs of young people and in directly in the market and girls taking on the ways it takes account of the complex additional household responsibilities so that social and economic circumstances of vulner- adults—especially mothers—could seek able young people.7 income-generating work (Watkins 1999). Another young population that is highly Children are sometimes compelled to seek vulnerable to HIV and AIDS is street chil- work in mines, motorparks, or plantations, dren. Experts believe their numbers are on and can find themselves in highly vulnerable the rise in the urban slums of the developing circumstances where adults can easily take world, and that this increase can be attributed advantage of them—sometimes sexually. A to reductions in state spending on education, rapid assessment study conducted in several the growth of urban populations generally, motorparks in Nigeria, for instance, revealed and migration fueled by extensive rural pover- that young boys and girls are susceptible to ty. In addition, the HIV/AIDS pandemic has recruitment into informal sexual networks in already created millions of orphans, leaving which adolescent boys serve as “pimps” for them on their own or in the care of relatives girls who provide casual sex for money or and neighbors who may find providing this other goods (Babalola 1997). Reaching additional care extremely difficult. As with employed young people with information other situations where young people find and access to services and technologies to themselves away from the protection of their reduce their risk of and vulnerability to HIV families and communities, girls in these cir- requires interventions that take into account cumstances are often compelled to resort to their particular circumstances and the sup- sex work for survival or protection, which port of their employers. places them at very high risk of contracting In Nepal, the Maiti Project has targeted HIV and STIs. Programs designed to reach young people subjected to sexual exploitation street children and address their particular cir- and abuse, including young women at risk of cumstances need to be mounted with the being sold into prostitution in India. The support of wider community organizations project has undertaken a range of activities that may also have contact with these young

7 More information about the Maiti Project can be found on its Web site, www.maitinepal.org. 32 people. Training with police, juvenile justice help them obtain prompt treatment for STIs courts and facilities, and child welfare services and for opportunistic infections for those is also crucial to the development and sustain- already infected. FOCA also provides basic ability of interventions for reducing vulnera- education and vocational training in such bility among this highly at-risk population. skills as tailoring and carpentry. Some gradu- One NGO that has worked with street ates have gone on to start their own busi- children in Kampala, Uganda is Friends of nesses. One group of children formed an Street Children Association (FOCA), which acrobatics team, and another formed a jazz provides food, recreation, schooling, and group with donated instruments. The acro- vocational training to about 200 children liv- bats and musicians earn money by performing on the streets of Kampala. The children ing at weddings and parties. end up on the streets for different reasons. Most have lost at least one parent, often to Providing Youth-Friendly Reproductive AIDS, and all come from families too poor Health Services to support them and send them to school. Meeting the needs of sexually active young One of FOCA’s counselors recounted, “It’s people is urgent. UNFPA estimates that only not easy working with street children, some- 17 percent of these young people use contra- times they insult us, steal our watches and ceptives. Over 4 million women ages 15–19 bags, even our shoes.” Once on the street, years have abortions every year, 40 percent of many children fall into a risky life of drug which are performed under unsafe condi- abuse, pickpocketing, petty theft, and sex tions (UNFPA 2002). Despite the silence work, all of which contribute to a very high and stigma that surround adult attitudes risk for HIV infection.8 toward young people’s sexuality and sexual Thirty-five of the children who attend behavior in most societies, young people FOCA are girls. All are engaged in some want, need, and have a right to reproductive kind of sex work, and many have already had and sexual health services. However, they children of their own. “They are tougher and face many barriers in accessing these harder to help than the boys,” says one of resources. Services simply may not exist, and the counselors. Street girls are more stigma- establishing them is strongly opposed by tized than street boys and are subject to sexu- adults. Where they do exist, they may be al harassment and rape. Many of them move unaffordable. Stigma may surround youth between odd jobs, such as street vending, services, and concerns over lack of confiden- and enter temporary relationships with men tiality and disrespectful treatment may inhib- who give them shelter, food, clothes, and it young people from using them. other gifts. Half of the babies born to girls at Reproductive health program designers FOCA do not survive their first year. and service providers can offer services for In order to reduce the risk of HIV infec- young people both within and outside the tion among street children, FOCA employs health clinic setting. In the context of about 30 peer educators, all former street HIV/AIDS, access to information and con- children themselves, who distribute condoms should be made available to young doms, encourage the children to seek volun- people in places they routinely gather, such tary counseling and testing for HIV, and as cafés, nightclubs, street vending machines,

8 For more information on FOCA, contact Friends of Street Children Association, Box 10353, Kampala, Uganda. See also Friends of Street Children Association 2001. 33 and vendors. Methods for pregnancy preven- reduction options. In addition, younger tion can be made available through pharma- women are more physiologically susceptible cies or through youth support groups, as to STIs and HIV because of the relative long as staff are properly trained to provide underdevelopment of their reproductive accurate information and methods to young tracts. Men also seek out younger wives, in people. School referrals, workplaces, commu- the hope that they are sexually inexperienced nity or recreation centers, and telephone hot- and free from STIs and HIV. Program lines are other possible entry points. designers and service providers need to devel- Within the clinic setting, young people op and support programs that recognize that may need access to a variety of services, younger women may require different inter- including screening and advice on nutrition ventions than older married women. and other issues related to healthy living; testing for and treatment of STIs, including Innovative Approaches to Reaching Young People voluntary HIV counseling and testing; screening, counseling, and referrals for Advocacy, information dissemination, and youth—especially young women—who youth empowerment experience violence, sexual abuse, and rape; a The Institute of Population Studies at range of options for preventing unwanted Cayetano Heredia University in Peru pregnancy; and antenatal and postpartum designed, implemented, and evaluated a services for young women who are pregnant. community-based program on sexual and The reproductive health needs of young reproductive health for young people in two people differ according to their age, living neighborhoods in Peru (Alarcon and arrangements, education, working status, Gonzalez 1996). Program staff sought to and, particularly, marital status. Reproductive mobilize community resources to improve health service providers should be especially the quality and dissemination of information aware of the circumstances of young married on related issues; create democratic models women’s lives. Early marriage occurs through- for sexual health promotion that respect the out the world, but it is most common in rights of young people; empower young peo- parts of Africa and South Asia. In India and ple to identify and seek solutions to their sex- Niger, the percentage of young women mar- ual and reproductive health problems; and ried by the age of 18 is 50 and 76 percent, motivate local municipalities, education and respectively (UNICEF/UNAIDS/WHO health sectors, youth groups, and communi- 2002). In Nepal, 19 percent of girls are mar- ty-based organizations to direct more ried before they are 15 years old—a number resources toward sexual and reproductive that increases to 60 percent by age 18 health services for young people. (UNICEF/UNAIDS/WHO 2002). Despite Young people gave positive assessments the fact that early marriage may indeed mean of the educational workshops because they that young women are more likely to have were participatory, engaging, and focused on fewer sexual partners, this fact does not pro- their problems and perspectives. Participants tect them from HIV, because their husbands were committed to the program strategy, as are usually older and have been sexually shown by their level of voluntary involve- active for years. In fact, marriage may actually ment as peer promoters. The level of involve- increase women’s vulnerability to HIV infec- ment in and support to the project from key tion because of their inability to successfully members of the community increased signifi- negotiate condom use or adopt other risk- cantly over time. The evaluation concluded 34 that the project’s strategy has high potential Telephone hotlines to improve the sexual and reproductive An AIDS hotline and counseling service health of young people and to become estab- evolved out of a trial telephone counseling lished within the community. service established in Egypt by the Ministry of Health (El-Gawhorg 1998). Similarly, Communications campaigns: Radio, print, UNFPA helped establish telephone hotlines and television for university students in India. The A media campaign aimed at young people National AIDS Control Organization (part was developed via collaboration between the of the Ministry of Health and Family Dominican Republic’s National HIV/STD Welfare of the government of India) estab- Prevention Program and 20 governmental lished similar hotlines for the general public and nongovernmental organizations (“AIDS telephone hotline launched,” The (Academy for Educational Development Hindu 1997). The hotlines provide a way for 2002). Before the media campaign, extensive people to discuss sexuality, condom use, pre- research—including a knowledge, attitudes, marital sex, and homosexuality, all issues that behavior, and practices survey—was carried are rarely addressed in public forums. Even out to establish a profile of the young people with limited advertising, people began to at whom the intervention was aimed. call, and an evident need for the service was Appropriate messages about HIV/AIDS were identified. The objectives of the hotlines are then developed and disseminated through to provide accurate information about radio, television, and print media in three HIV/AIDS to the public, including young phases. The first phase was designed to people, and to provide confidential and increase awareness. The second phase anonymous HIV/AIDS counseling services. attempted to ensure consistency in messages from different sources and included the pro- An Integrated Approach for Life-Skills duction of a manual for teachers and youth Development and Youth-Friendly workers. The third phase concentrated on Reproductive Health Services making young people aware of how to pro- In Mwanza, Tanzania, young people at risk of tect themselves from HIV infection and pro- HIV and other reproductive health problems viding information about where they could have generally lacked access to adequate access services and support. information and reproductive health care. By An evaluation, which involved focus age 19, 1 percent of boys and 5 percent of group discussions with young people, girls are HIV-positive. Since 1999, however, revealed that the messages were perceived as the government of Tanzania, in collaboration well-targeted, creative, and imaginative. with the African Medical and Research Young people reported that the messages had Foundation (AMREF), has been offering a promoted discussion and helped them reflect range of adolescent sexual health services that on aspects of their behavior. However, young are having a dramatic impact on the course of people also reported that more work was the HIV epidemic in the area and should needed in order to encourage better commu- empower young people to lead healthier lives nication between parents and children. The in general (AMREF 2001). The program, overall approach has now been replicated in called MEMA kwa Vijana, includes a school- Guatemala, and other countries in the region based sexual and reproductive health educa- are also considering how the method can be tion program led by teachers and peers that adapted for their use. makes use of drama, stories, and games. The 35 program promotes distribution of condoms Gupta 2002). There is growing recognition to young people by young people themselves. that linking such programs with interven- It also provides education both to local health tions to improve the reproductive health of workers (including those involved in STI young people, including HIV/AIDS preven- treatment) to make them more sensitive to tion, furthers the overall goal of addressing the needs of young people and better able to the socioeconomic determinants of risk for serve those needs, and to parents, teachers, and vulnerability to HIV/AIDS. Worldwide, and community leaders about the importance there are a range of such programs, yet of adolescent reproductive health education. many are small in scale and limited in scope The program is particularly innovative (Population Council/International Center because it is designed to use a combination of for Research on Women 2000). Neverthe- approaches to HIV prevention in a single less, research on the determinants of success community, all of which should reinforce of linking such programs should eventually each other to promote safer behavior. It is provide reproductive health program design- also one of the few HIV prevention programs ers and policymakers with a clearer set of for young people that will be rigorously eval- guidelines for the development of effective uated to determine its effect on the spread of programs. HIV. Early results suggest young people’s knowledge about HIV has improved dramati- References cally, that health care staff are far more Academy for Educational Development. “youth-friendly” than they were before, and, 2002. AcciónSida, 17 January. Santo as a consequence, that far more young people Domingo: AED. seek care from them. African Medical and Research Foundation. 2001. Good Things from Young People: Improving Livelihood Options MEMA kwa Vijana, unpublished report. for Adolescents Mwanza, Tanzania: AMREF. “AIDS telephone hotline launched.” 1997. In the context of the HIV/AIDS epidemic The Hindu, 23 October. and the special needs and vulnerabilities of Alarcon, I. and G.F. Gonzalez. 1996. young people, access to improved livelihood “Attitudes towards sexuality, sexual options can reduce the likelihood that knowledge and behavior in adolescents young people will need to engage in in the cities of Lima, Cusco, and income-generating activities that put them Iquitos,” report. Lima, Peru: Cayetano at greatest risk, especially transactional sexu- Heredia Peruvian University. Babalola, Stella O. 1997. “Sex-related atti- al interactions. Yet adolescents often are not tudes and behaviours among a high-risk seen as “formal” economic agents, and youth population in Nigeria: A study of therefore cannot benefit from programs and four motor parks in Lagos State,” policies that expand economic opportunities unpublished. Lagos: StopAIDS. targeted to adult men and women. Programs El-Gawhorg, K. 1998. “Breaking a social created especially for young people help taboo: AIDS hotline in Cairo,” Middle East Report (spring). them find formal employment opportuni- Friends of Street Children Association. ties, provide credit to help them start or 2001. Baseline Survey Report on Girls expand small-business enterprises, and offer That Live and Work on the Streets of them opportunities to develop basic skills Kampala. Kampala, Uganda: Friends of and training for management positions (Rao Street Children Association.

36 Glynn, J.R., M. Carael, B. Auvert, M. Latin America and the Caribbean, Kahindo, and J. Chege. 2001. “Why do unpublished draft. young women have a much higher UNAIDS. 1997. Impact of HIV and Sexual prevalence of HIV than young men? A Health Education on the Sexual Behavior study in Kisumu, Kenya and Ndola, of Young People: A Review Update, docu- Zambia,” AIDS 15(suppl 4): S51–S60. ment UNAIDS/97.4. Geneva: UNAIDS. Gregson, S. et al. 2001. “School education ———. 2002. Report on the Global and HIV control in sub-Saharan Africa: HIV/AIDS Epidemic 2000. Geneva: From discord to harmony?” Journal of UNAIDS. International Development 13: 467–485. UNFPA. 2002. “Providing services that Hargreaves, J.R. and J.R. Glynn. 2002. young people want and need,” www. “Educational attainment and HIV-1 unfpa.org/adolescents/page02.htm. infection in developing countries: A sys- UNICEF/UNAIDS/WHO. 2002. Young tematic review,” Tropical Medicine and People and HIV/AIDS: Opportunity in International Health 7(6): 489–498. Crisis. New York and Geneva: UNICEF/ King, E.M. and M.A. Hill. 1993. “Women’s UNAIDS/WHO. education in developing countries: An Wasserheit, Judith N. 1992. “Epidemio- overview,” in E.M. King and M.A. Hill logical synergy: Interrelationships (eds.), Women’s Education in Developing between human immunodeficiency virus Countries: Barriers, Benefits, and Policies. infection and other sexually transmitted Baltimore: Johns Hopkins University diseases,” Sexually Transmitted Diseases Press, pp. 1–50. 19(2): 61–77. Kinsman, J. et al. 2001. “Evaluation of a Watkins, Kevin. 1999. Education Now: Break comprehensive school-based AIDS edu- the Cycle of Poverty. London: Oxfam. cation programme in rural Masaka, Weiss, Ellen, Daniel Whelan, and Geeta Rao Uganda,” Health Education Research Gupta. 1996. Vulnerability and 16(11): 85–100. Opportunity: Adolescents and HIV/AIDS Levine, C., D. Michaels, and S.D. Back. 1996. in the Developing World. Washington, “Orphans of the HIV/AIDS pandemic,” DC: ICRW. in Jonathan Mann and Daniel Tarantola WHO. 1999. Preventing HIV/AIDS/STI and (eds.), AIDS in the World II. New York: Related Discrimination: An Important Oxford University Press, pp. 278–286. Responsibility of Health Promoting Schools, Population Council/International Center for WHO Information Series on School Research on Women. 2000. Adolescent Health, document 6. Geneva: WHO. Girls’ Livelihoods—Essential Questions, WHO/UNESCO. 1995. School Health Essential Tools: A Report on a Workshop. Education to Prevent AIDS and Sexually New York and Washington, DC: Transmitted Diseases: A Resource Package Population Council and ICRW. for Curriculum Planners, document Rao Gupta, Geeta. 2002. Vulnerability and WHO/UNESCO/GPA/94/1.2.3. Resilience: Gender and HIV/AIDS in Geneva: WHO.

37 Chapter 4 HIV Prevention Among Pregnant Women and Newborns

Pregnancy and motherhood are among the their newborns (WHO 1999). Until recent- most important gender roles fulfilled by ly, the only interventions available to reduce women throughout the world. It is unfortu- the likelihood of mother-to-child transmis- nate, however, that pregnancy and childbirth sion were alterations in infant feeding habits. may be the only events that bring women However, recent breakthroughs in treatment into sustained contact with the health care have been shown to dramatically reduce the system in any number of developing coun- likelihood of mother-to-child transmission, tries. Maternal and child health (MCH) pro- although these “short-course” regimens grams (i.e., antenatal, delivery, and postpar- themselves have had no measurable impact tum services) therefore provide a unique on slowing the progress of HIV/AIDS in opportunity to reach women at risk or other- women (WHO 2002a). Many questions wise vulnerable to HIV infection with criti- about preventing HIV in pregnant women cal information, technologies, and services. and newborns remain unanswered, but inter- As with the basic family planning and repro- vention research is ongoing. Service providers ductive health services discussed earlier, must be mindful of the issues related to the MCH services can provide pregnant women integration of new treatments and services and new mothers with vital information into existing programs. In addition, they about HIV/AIDS and its transmission, HIV must be aware of the many contextual fac- testing and counseling, and referrals to other tors—including, most importantly, those services for women regardless of their related to gender—that influence the success serostatus. of interventions designed to prevent HIV It is important to note that in almost all transmission from mother to child and to parts of the world the majority of pregnant ensure the highest-quality care available for women are HIV-negative (UNAIDS 2002). the continued health of mothers and their Even in the urban areas of sub-Saharan newborn children. Africa where prevalence of HIV infection among pregnant women is the highest in the Voluntary HIV Counseling and Testing world, rates of infection remain below 50 in Antenatal Clinics percent. This does not detract from the Chapter 2 described the benefits of voluntary sobering fact that in some of these areas, counseling and testing for HIV not only in more than one pregnant woman in three is providing vital information to those who are HIV-positive. Furthermore, research has HIV-positive or -negative, but also in allow- shown that in the absence of targeted inter- ing people who are HIV-positive to access ventions, as many as 40 percent of HIV- treatments and services that can assist them infected mothers will transmit the virus to in managing and coping with their illness. 38 This is particularly important for pregnant women because a diagnosis of HIV infection BASIC REQUIREMENTS OF HIV PREVENTION PROGRAMS FOR PREGNANT WOMEN is the only way to ensure access to the growing number of interventions designed to pre- • Antenatal, delivery, and postpartum care services that are adequate vent the transmission of the virus to their and accessible. newly born children, including access to • Information campaigns and community-based efforts to increase drug therapies such as zidovudine (AZT) acceptance of prevention programs in the community. and nevirapine. Another important reason to • Adequate voluntary counseling and testing services, including reliable tests and trained HIV counselors, for all women who are pregnant or integrate voluntary counseling and testing are thinking of becoming pregnant and their male partners. programs into antenatal clinics is the oppor- • Post-test counseling for both HIV-positive and HIV-negative women, as tunity it provides for reaching husbands and an essential part of all voluntary counseling and testing programs. male partners of pregnant women. Research • Adequate supplies of male and female condoms. has shown that pregnancy can increase • Safe delivery services and a referral system in case of complications. men’s—and, subsequently, women’s—vulner- • An affordable, feasible antiretroviral drug regimen that has been ability to STIs and HIV. Because cultural proven to reduce the likelihood of mother-to-child-transmission of HIV. and other factors and social stigmas limit • Counseling about breastfeeding, including information on alternative sexual activity between couples during preg- infant feeding regimens such as infant formula or a short period of nancy and the postpartum period, men are exclusive breastfeeding and abrupt weaning for HIV-positive mothers. more likely to seek outside partners during • Monitoring to ensure that programs that work in theory do so in practice as well. that time (e.g, for data on Nigeria, see •Follow-up of all women, children, and their families to help them deal Lawoyin and Larsen 2002). Counseling men with issues such as nutrition and pregnancy-related problems. in the context of expecting a new child pro- • Referral to other HIV support and prevention programs and to care vides an opportunity to encourage men to and treatment programs for adults with HIV, where available. practice safer sex by using condoms and limiting the number of outside partners, or to promote HIV prevention messages that emphasize a man’s responsibility to protect There are many ways to encourage the health of his wife/partner and his future women who attend antenatal clinics to enroll family. in voluntary counseling and testing services. Ideally, voluntary counseling and test- Some projects use videos or group counseling in antenatal clinics should be available ing, or they include HIV counseling as part to all who want it, and increasingly it is of the midwife’s first interview (Susan Allen, becoming standard practice for pregnant personal communication). The goal of such women in many parts of the world. services for pregnant women is to enable However, service providers should be aware those who are HIV-negative to remain so, of instances in which a male partner coerces and those who are positive to make informed his partner into being tested. A pregnant decisions about their current pregnancy— woman who is offered an HIV test as part especially with regard to the prevention of of antenatal care is often the first in the mother-to-child transmission—and to take household to receive a positive test result, care of their own health. Counseling HIV- and in some cases she is blamed by her positive women should also include provid- male partner for “bringing the virus into ing them with information about avoiding the house.” Testing both partners simulta- reinfection with HIV and prevention of neously may help prevent such problems. other STIs, and teaching them how to 39 Counseling should also make it clear that a REACHING MALE PARTNERS OF PREGNANT woman’s exposure to HIV during pregnancy WOMEN ENROLLED IN A VOLUNTARY can dramatically increase the likelihood of COUNSELING AND TESTING PROGRAM mother-to-child transmission, because HIV ounselor Sostain Moyo of the Zimbabwe AIDS Prevention Project virus levels rise significantly in the days C describes his work: immediately following infection (WHO “One of our biggest mistakes at first was not to have male counselors. 1999). We are now recruiting men, and it should make a big difference. The Post-test counseling for HIV-positive point was raised by the husbands of women who came for counseling pregnant women and testing. They felt we weren’t addressing their concerns. But we also In counseling women who receive a positive realized male counselors can help increase use of prevention services by HIV test result, service providers should pregnant women, especially those who feel they cannot take an HIV test keep a number of important issues in mind. without their husband’s permission, and they can also make a big contri- Even though many women who believe they bution to prevention activities in general. are HIV-positive have their suspicions con- “A sizable number of women are not willing to tell their husbands about firmed by a positive test result, actually their status, because they fear divorce. Many of the women who test posi- receiving the news can come as a shock and tive have not had sex with anyone other than their husbands, so they result in stress and depression. Counselors expect a negative result. For many of those who turn out to be positive, therefore need to be careful not to overload the result is a big surprise. We are trying to find ways to make it easier newly diagnosed women with information. for women to tell their husbands, but it is hard. In many cases, whoever is As Laura Guay, a doctor at Johns Hopkins tested first is seen as the one who brought the disease. ‘Why did you get University who runs an HIV prevention tested? Why were you expecting that?’ the husbands want to know. But project for pregnant women at Mulago since women are counseled in antenatal and family planning clinics, they are often the ones to receive the information first. We have quite a Hospital in Kampala, Uganda puts it, number of pregnant women going through the program who have not told “There is a real risk that a woman will drop their husbands, but this makes it hard for the women to use protection out of the program if she is overwhelmed and plan for the future.” with information at the first visit. After a woman finds she is positive, she tends to shut out everything else for a while, so we obtain care and support. Counselors should just deal with that and give counseling about assist each woman in determining why she antiretrovirals, breastfeeding, and so on at a wishes to be tested, yet allow her to make up follow-up visit.” her own mind about whether and how to Post-test counseling for HIV-positive proceed. pregnant women should be carried out in Pretest counseling for pregnant women much the same way as it is for any HIV- should include information about HIV trans- positive person. Counselors should discuss mission and AIDS, and how to prevent trans- the patient’s immediate concerns, encourage mission to partners and reduce the risks of her to ask questions, and help her decide transmission to newborns. With regard to the whom she might tell about her status. latter, counseling should make it clear that Counselors should provide information not all babies born to HIV-positive women about healthy lifestyles, where to obtain contract the virus, and that there are ways to medical care if necessary, and how to contact reduce the risk of transmission in utero, dur- support groups for people living with ing delivery, and during nursing (many of HIV/AIDS. Counselors should also explain which are described in this publication). that while pregnancy does not hasten the

40 progression of AIDS, HIV has been associated properly referred for treatment for these with such pregnancy complications as pre- conditions. When counselors discuss treat- mature delivery and spontaneous abortion ments for opportunistic infections (WHO 1999). Women should be alert to (although they may not actually administer the signs of these and other complications treatment themselves), they should keep in and should be prepared to seek care immedi- mind that some drugs, including the tuber- ately if they arise. culosis medications streptomycin and HIV-positive women should be referred pyrazinomide, as well as several other to programs that aim to prevent mother-to- antibiotics, should not be used during preg- child transmission with the use of therapeu- nancy. Furthermore, HIV-positive people tic regimens (see below). Counselors should should not take certain drugs—such as also discuss the risks of transmission through thioacetazone for the treatment of tubercu- breastmilk, alternative feeding options, losis. HIV-positive pregnant women (and choices for contraception (see Chapter 2), all pregnant women) should be routinely and the implications of women’s HIV status screened for STIs/RTIs, including syphilis on future reproductive decisions. Studies and genital herpes—serious infections that have found that while some women are more may also adversely affect birth outcomes. likely to use birth control if they know they Routine antenatal care for all pregnant are HIV-positive, for many others an HIV- women, including those with HIV, should positive diagnosis has no effect on future include treatment for worms, malaria, and reproductive decisions, because society places other infections when necessary. so much emphasis on fertility and mother- Although research suggests that vitamin hood (Feldman et al. 2002). In addition, the A supplementation has no effect on mother- promising results of successful mother-to- to-child transmission, the use of multi- child transmission prevention interventions vitamins has been shown to reduce the risks have in some cases translated into increases of low birthweight and preterm births, and in fertility due to the improved prospects of to increase CD4 cell counts in HIV-positive giving birth to a healthy child. women (Dreyfuss and Fawzi 2002). While The effects of HIV and associated illnesses there are at present no official guidelines on on pregnancy provision of vitamins and minerals in ante- Pregnancy does not exacerbate HIV infec- natal clinics, UNICEF is conducting pilot tion or accelerate the progression of AIDS, studies to investigate the feasibility and but HIV infection is associated with greater logistics of making vitamin and mineral risk of certain pregnancy complications, supplements, including iron for anemia, a including spontaneous abortion, premature routine part of antenatal care in developing birth, and intrauterine growth retardation countries. (WHO 1999). Just as important, while Finally, the risk of perinatal HIV trans- most HIV-positive women are healthy at mission increases whenever manipulative the time of diagnosis, others may suffer techniques are used that raise the likelihood from opportunistic infections such as tuber- of fetal contact with maternal blood. For this culosis, other respiratory infections, diar- reason, invasive procedures such as amnio- rhea, and candidiasis (vaginal yeast infec- centesis or chorionic villus sampling should tion or thrush). MCH counselors are in an be avoided in women who are known to be ideal position to ensure that clients are HIV-positive.

41 The Use of Antiretroviral Drugs reduction in mother-to-child transmission in the Prevention of Mother-to-Child (Dabis et al. 1999; Wiktor et al. 1999). Transmission of HIV Other clinical trials have shown that short- The administration of various antiretroviral course ARV regimens using the combination (ARV) drugs has been shown to reduce the AZT and lamivudine (Gray 2000) or nevi- likelihood that an HIV-positive pregnant rapine alone (Guay et al. 1999) also sub- woman will transmit the virus to her child. stantially decrease the risk of HIV transmis- Where no drugs are administered and the sion. All of these regimens include adminis- baby is predominantly breastfed for about 24 tration of ARVs during labor, with varying months postpartum, the probability of trans- duration of antenatal and/or postpartum mission is generally around 30–35 percent prophylaxis. A single-dose nevirapine regi- (Rutstein 2001). This figure drops to around men provided during labor to the mother 20 percent in cases where there is no ARV and postpartum to the infant has also been therapy and the infant is not breastfed by her shown to be effective—reducing transmis- HIV-positive mother. Research has demon- sion by as much as 42 percent—and thus strated that introduction of ARV drugs may be more practical in certain resource- decreases the mother-to-child transmission poor settings (WHO 2001). Subsequent rate by 50 percent (WHO 2002a). breastfeeding may partially offset this risk Since 1994 remarkable reductions in reduction, but studies are underway to pediatric HIV infection rates have been determine whether daily nevirapine given to observed in industrialized countries that have breastfeeding mothers and their children for adopted the Pediatric AIDS Clinical Trials one to six weeks after birth combined with Group protocol 076, which showed that exclusive breastfeeding may reduce or elimi- administration of AZT to women from the nate the risk of transmission during breast- 14th week of pregnancy and during labor feeding. Although these short-course regi- and to the newborn decreased the risk of mens are not as effective as the longer cours- mother-to-child transmission by nearly 70 es of treatment that are currently the stan- percent in the absence of breastfeeding dard in the developed world (which also (Connor et al. 1994). Unfortunately, issues include replacement feeding and cesarean surrounding the cost and complexities of delivery), they have been deemed feasible for administering this regimen—such as the fact adoption in developing countries. Many that many women do not seek antenatal care such programs are being introduced until well beyond the 14th week of pregnan- throughout Africa, Asia, and Latin America cy—have created significant obstacles to their and the Caribbean. practical adoption in resource-poor settings. Nevertheless, a randomized controlled Concerns about ARV use for prevention of study conducted in Thailand in 1998, mother-to-child transmission of HIV which tested a short-course AZT regimen A number of concerns about the use of anti- starting from the 36th week of pregnancy, retroviral drugs during pregnancy have been was shown to reduce the risk of transmission raised. These include the risk that women of HIV at six months postpartum by 50 may acquire drug resistance if they take nevi- percent in a nonbreastfeeding population rapine during pregnancy, that they or their (Shaffer et al. 1999). Similar trials conduct- infants may experience toxicity, or that the ed among breastfeeding women in Burkina effects of ARV treatment will be reduced Faso and Côte d’Ivoire yielded a 37 percent because of HIV transmission during breast- 42 feeding. None of the short-course ARV regimens, including administration of nevirapine, DONATIONS OF NEVIRAPINE TO DEVELOPING COUNTRIES has been associated with severe side effects to mothers or infants. Drug-resistant viral ecently, the pharmaceutical company Boehringer Ingelheim agreed to strains have been detected in mothers on R donate nevirapine for the prevention of perinatal HIV transmission long-course regimens, and occasionally in for five years, free of charge, to public maternity services in all developing mothers taking a short course of treatment, countries. While this donation offers enormous hope for the prevention of but it is believed that these resistant strains mother-to-child transmission, it relieves only the cost burden of the drug soon die out and are replaced by susceptible itself, which represents a small proportion of the overall costs of imple- ones (Nolan et al. 2002). Research is under- menting an effective and comprehensive prevention program. In order for health centers to participate in the donation program, the company way to determine whether resistance acquired requires that nevirapine be registered in the country and that participat- during one pregnancy reduces the effect of ing groups submit a proposal to their ministry of health. In addition, cur- drugs administered in subsequent pregnan- rent protocols require adequate testing and counseling services by skilled cies. While these concerns are important, the staff. A trial study is underway in Zambia to determine the cost-effective- World Health Organization recommends that ness of administering short-course nevirapine to all women who request they should not be used as reasons to delay it without requiring an HIV test. If successful, such a strategy would only the implementation of programs using ARV be appropriate in settings where HIV prevalence is high. drugs to reduce mother-to-child transmission of HIV (WHO 2002a).

HIV Prevention During Labor important factor than the duration of labor and Delivery itself (Kuhn et al. 1999). For this reason, Assuming that one-third of children born to membranes should not be ruptured artificial- HIV-positive mothers will contract HIV in ly if labor is progressing normally. Also, the absence of any kind of intervention, it is manipulative procedures—such as attempting estimated that the majority of those infec- to turn breech babies around—should not be tions—50 percent—will occur during deliv- performed. Procedures that may break the ery as opposed to in utero (17 percent) or baby’s skin or increases the infant’s contact through breastfeeding (33 percent) with the mother’s blood—such as scalp blood (UNAIDS 1999). Clearly, all women should sampling or the application of scalp elec- have access to safe delivery services, whether trodes—should also be avoided. or not they are HIV-positive. A trained Studies have shown that cesarean deliv- attendant should be present at all births. ery reduces the likelihood of perinatal trans- Sepsis should be prevented. Attendants mission of HIV (WHO 1999). However, should endeavor to prevent vaginal and cer- health facilities in developing countries where vical tears and should avoid performing epi- HIV prevalence is high are typically poorly siotomies unless absolutely necessary (WHO equipped, and referral systems are generally 1999). These recommendations are particu- weak. Therefore, the number of cesarean larly crucial for HIV-positive women to deliveries in such settings is low. Even where lower the overall risk of mother-to-child cesareans are performed, surgical staff may be transmission during labor and delivery. reluctant to operate on women they know to Unnecessary interventions and proce- be HIV-positive for fear of infection. dures should be avoided. The risk of perinatal Cesarean deliveries for HIV-positive women HIV transmission increases with the duration are therefore usually only indicated for other of membrane rupture, which is a much more medical reasons, such as obstructed labor, and 43 not as a public health intervention to reduce Exclusive versus mixed infant feeding perinatal HIV transmission in poor countries. In settings where replacement feeding is not When cesareans are performed, clinicians practical or can be dangerous, exclusive breast- should administer prophylactic antibiotics to feeding for a period of three to six months reduce the risk of postpartum infections to provides immunological and nutritional which HIV-positive women are more likely advantages over replacement feeding, and to be susceptible (WHO 1999). Finally, a seems to be associated with only a small risk trial in Malawi found that vaginal cleansing of HIV transmission to the child (WHO with chlorhexidine during delivery reduced 2002a). Furthermore, in communities where the risk of both neonatal and puerperal sep- women who replacement feed are stigmatized sis, and it seemed to reduce the risk of peri- because it is believed that they may be HIV- natal HIV transmission, but only in cases positive, exclusive breastfeeding would help where membranes had been ruptured for women avoid the negative social consequences more than four hours (Taha et al. 1997). that might result from replacement feeding. Further research on vaginal lavage with Recent studies have shown that mixed chlorhexidine or benzalkonium chloride indi- breast- and replacement feeding should be cated that it did not have any effect on ante- avoided as much as possible, because it great- natal transmission (Mandelbrot et al. 2002). ly increases the risk that the child will become infected through breastmilk, com- Infant Feeding and HIV Prevention pared to exclusive replacement feeding or It is believed that about 20 percent of chil- exclusive breastfeeding (WHO 2002a). dren born to HIV-positive women acquire Nevertheless, mixed feeding is the norm in HIV through breastfeeding, depending on many places, because exclusive breastfeeding duration of breastfeeding and other factors is often difficult, even for very young babies. (WHO 2002a). Whereas in developed coun- Women in research studies say that they tries all HIV-positive mothers are advised to sometimes experience pressure from family use infant formula, women in many develop- members to give their infants other foods, ing countries lack access to clean water, with such as formula or porridge even in the first the result that the formula they prepare may few months of life (WHO 2002b). In any transmit deadly infections to babies as well as event, MCH counselors should advise contribute to malnutrition. Other issues women that mixed feeding reduces the pro- include the social stigma of not breastfeeding tective value of breastmilk and is associated and the cost of alternative feeding options. with greatly increased risk to the infant of Currently UNICEF and the World Health HIV infection, as well as other illnesses. Organization recommend that health work- It is not known why mixed feeding is so ers counsel each HIV-positive woman about much more dangerous than exclusive feeding all infant feeding methods, and then allow with either formula or breastmilk. One theo- the mother to make her own informed deci- ry is that infant foods other than breastmilk sion. UNICEF regularly updates training can cause intestinal infections if they are not materials for breastfeeding counselors; coun- prepared properly, and these infections can selors should therefore try to obtain the latest cause lesions that provide conduits for HIV material from the local UNICEF office.9 transmission when the child subsequently

9 For the most recent version see WHO/UNAIDS/UNICEF 2000.

44 consumes breastmilk. Another theory is that South Africa, however, showed no significant women who breastfeed only on occasion are correlation between breastfeeding and prema- more prone to breast inflammation (masti- ture maternal mortality from HIV/AIDS tis), which seems to be associated with high- (Coutsoudis et al. 2001). However, since the er risk of HIV transmission. two studies are not entirely comparable or Further research is underway to deter- considered to be definitive, further studies are mine the risks and benefits of exclusive underway to investigate the effects of breast- breastfeeding for the first three to six months feeding on maternal mortality due to postpartum, and also the best ways to help HIV/AIDS. women in developing countries achieve this While breastfeeding is often the preferred (Dabis et al. 2002). One concern is about method of feeding in most developing coun- the weaning period, which may have to be tries, health workers must avoid making rec- very short in order to avoid prolonged peri- ommendations that might not be in the best ods of mixed feeding as the child becomes interests of the mother and child based on accustomed to other foods. However, very their own biased preference for breastfeeding. abrupt weaning may be difficult—both Counselors should provide all available infor- physically and emotionally—for both the mation accurately and responsibly so that mother and the child. Until issues such as women can make informed decisions based this are resolved, breastfeeding counselors on their own circumstances. Further, health face a difficult dilemma—one that requires a workers should support those decisions and, careful assessment of each client’s particular in the event a new mother chooses not to circumstances. Currently, clinical trials are breastfeed, provide access to cheap or free underway to determine whether postpartum infant formula and clean water. Researchers administration of antiretrovirals to HIV-pos- at the University of Natal, South Africa itive mothers and/or their babies improves found that the best way to help women make the safety of breastfeeding. The results of informed choices about infant feeding was to these studies, combined with wider access to clearly explain the risks and benefits of each these drugs, will influence future recommen- method rather than issue directives about dations. In any case, project administrators what to do. As a result, a significant number should consult the latest recommendation of women chose to breast- or bottlefeed from UNAIDS and UNICEF. exclusively (Bland et al. 2002). Another common concern involves the effects of breastfeeding on the overall health What About the Mothers (and Fathers)? of HIV-positive mothers. A recent study from Most of this chapter has been devoted to the Kenya found that HIV-positive women who prevention of mother-to-child transmission of breastfed exclusively had a significantly higher HIV. Critics have pointed out—and rightful- risk of death during the first two years post- ly so—that the imperative of preventing pedi- partum than HIV-positive women who used atric HIV infection, while not necessarily at formula exclusively (Nduati et al. 2001). This the expense of mothers, infringes on women’s has raised concern that the nutritional status dignity and rights by treating them only of some HIV-positive women may not be instrumentally in order to “save” children. adequate to sustain prolonged breastfeeding, Furthermore, all who work in reproductive and that this may accelerate the progression health settings, from the national to the local of AIDS in some cases. A similar study in level, are in a position to advocate for one of

45 the most basic human rights, namely univer- fied in MTCT prevention programs. An sal access to treatments, including antiretrovi- essential care package for mothers would rals, that impede the onset of AIDS. include treatment for opportunistic infec- However, a basic fact that has been known tions such as tuberculosis, AIDS-associated for some time bears repeating in the context fungal infections, STIs, and others illnesses. of HIV/AIDS: Even when prevention of The package would also include ARV thera- HIV among newborns is successful, the like- py throughout the life of the mother, child, lihood that a child will survive to the age of and, when possible, the entire family when five when her mother, or father, or both are certain clinical criteria were met. lost to AIDS is quite low. Program planners At first, MTCT-Plus programs will be and policymakers must therefore strive to do tested in countries where HIV prevalence in everything possible within resource-poor set- the general adult population is at least 5 per- tings to ensure the health and longevity of cent and where programs using ARV drugs to HIV-positive mothers, fathers, and all adults. prevent mother-to-child transmission are These concerns should encourage pro- already in place and functioning reasonably gram staff to improve health care for all HIV- well. Such programs should be able to offer positive people, through advocacy and by women voluntary counseling and testing for solidifying the referral links between preven- HIV, as well as standard antenatal care. In tion programs for pregnant women, the pub- addition, a laboratory capable of measuring lic health care system, and networks of people levels of CD4 lymphocytes will be necessary living with HIV/AIDS. Even where the lack for MTCT-Plus. Questions remain about of resources is an obstacle to ARV therapy, how best to implement the program, what prevention and care programs in developing the costs will be, and whether such a program countries can offer an HIV-positive woman can be sustained. Pilot projects should help vital counseling and, at the very least, nutri- resolve these issues and identify best practices. tional support and assistance in planning for MTCT-Plus could provide a means for the children she has, as well as treatment for extending better AIDS patient care to whole the many opportunistic infections associated communities, not just to pregnant women with HIV. and their babies. Eventually, treatment ideally “MTCT-Plus” will be offered to women’s partners and to Programs that offer pregnant HIV-positive other infected children in the family. women ARV drugs to protect their unborn Programs to integrate HIV prevention children offer little help to women suffering into maternal health services are still at an from AIDS. With these ethical concerns in early stage. ARV drugs for the prevention of mind, a group of foundations working mother-to-child HIV transmission are avail- through a Secretariat established at able in only a small number of hospitals and Columbia University recently created a new clinics in the developing world, but already program to help women and babies affected these pilot programs are demonstrating that by HIV. MTCT-Plus, which is providing its there are substantial costs in addition to the first grants in 2002, is designed to link cost of the drugs themselves. Additional mother-to-child transmission (MTCT) pre- resources are necessary to carry out effective, vention efforts to HIV/AIDS treatment ini- sensitive counseling, including increased tiatives in order to increase the chances of space, training, and staff salaries. In addition, survival of infected mothers who are identi- antenatal programs in many developing coun- 46 tries are inadequate. Malaria prophylaxis, involves helping women recognize their own blood grouping, hemoglobin tests, and iron vulnerability, which often has its roots in gen- and folate supplementation should all be rou- der-related discrimination they experience in tine in antenatal care, but they seldom are in their productive as well as reproductive lives. many resource-poor countries. The incorpora- Therefore, an overarching concern of all tion of new services into already existing pro- health workers involved in HIV prevention grams comes with certain costs—and these programs must be to empower women and, if cannot be overlooked. There is little doubt possible, improve their status in society that antenatal care has been less than ideal in through advocacy designed to protect and most settings for decades. However, anecdotal promote the rights—especially reproductive evidence suggests that the introduction of and sexual health rights—of all women. interventions to prevent mother-to-child transmission has boosted morale among serv- References ice providers by empowering them with the Bland, R.M. et al. 2002. “Breastfeeding practices in an area of high HIV preva- appropriate informational and therapeutic lence in rural South Africa,” Acta tools to address the consequences of Paediatrica 91(66): 704–711. HIV/AIDS in their communities. Program Connor, E.M. et al. 1994. “Reduction of designers and policymakers should consider maternal–infant transmission of human the potential positive impact of integration immunodeficiency virus type 1 with on the overall quality of antenatal care servic- zidovudine treatment,” New England Journal of Medicine 331(18): es, rather than assume that the introduction 1173–1180. of MTCT prevention programs will weaken Coutsoudis, A., H. Coovadia, K. Pillay, and already resource-constrained services. L. Kuhn. 2001. “Are HIV-infected Finally, it is important to note that HIV women who breastfeed at increased risk prevention programs for pregnant women of mortality?” AIDS 15: 653–655. will achieve little if women at risk of HIV Dabis, F. et al. 1999. “6-month efficacy, tolerance, and acceptability of a short regi- feel stigmatized and believe that they lack men of oral zidovudine to reduce verti- control over their reproductive lives. In high- cal transmission of HIV in breastfed prevalence regions, all pregnant women— children in Côte d’Ivoire and Burkina whether HIV-positive or -negative—will need Faso: A double-blind placebo-controlled to decide whether or not to take an HIV test multicentre trial,” Lancet 353: 786–792. and whom to tell about the results. If they are ———. 2002. “Improving child health: The HIV-positive, they must decide whether to role of research,” British Medical Journal 324(7351): 1444–1447. take antiretroviral drugs, if available, or Dreyfuss, M.L. and W.W. Fawzi. 2002. undergo other treatments to prevent trans- “Micronutrients and vertical transmis- mission to their babies. They have to make sion of HIV-1,” American Journal of choices about the best options for feeding Clinical Nutrition 75(6): 959–970. their infants. They also must make informed Feldman, R., J. Manchester, and C. decisions about future childbearing. Very Maposhere. 2002. Positive Women: Voices and Choices: Zimbabwe Report. London: often, pressure from partners, families, and International Community of Women communities will prevent women from mak- Living with HIV/AIDS. ing these decisions on their own. Preventing Gray, G. 2000. “Early and late efficacy of HIV transmission involves far more than pro- three short ZDV/3TC combination reg- viding information and condoms. It also imens to prevent mother-to-child trans- 47 mission of HIV-1,” Abstract LbOr5. domised controlled trial,” Lancet 353: XIII International AIDS Conference, 773–780. Durban, South Africa, 9–14 July. Taha, P. et al. 1997. “Effect of cleansing the Guay, L.A. et al. 1999. “Intrapartum and birth canal with antiseptic solution on neonatal single-dose nevirapine com- maternal and newborn morbidity and pared with zidovudine for prevention of mortality in Malawi: Clinical trial” British mother-to-child transmission of HIV-1 Medical Journal 315(7102): 216–219. in Kampala, Uganda: HIVNET 012 UNAIDS. 1999. Large Scale Implementation randomised trial,” Lancet 354: 795–802. for Prevention of Mother-to-Child Kuhn, L. et al. 1999. “Distinct risk factors Transmission of HIV: Issues for Southeast for intrauterine and intrapartum human Asia and the Pacific, Technical Update immunodeficiency virus transmission no. 1. Geneva: UNAIDS. and consequences for disease progression ———. 2002. Report on the Global in infected children,” Journal of HIV/AIDS Epidemic 2002. Geneva: Infectious Diseases 179(1): 52–58. UNAIDS. Lawoyin, T.O. and U. Larsen. 2002. “Male WHO. 1999. HIV in Pregnancy: A Review. sexual behaviour during wife’s pregnancy Geneva: WHO. and postpartum abstinence period in ———. 2001. Effect of Breastfeeding on Oyo State, Nigeria,” Journal of Biosocial Mortality Among HIV-Infected Women, Science 34(1): 51–63. WHO Statement no. 7. Geneva: WHO. Mandelbrot, L. et al. 2002. “15-month fol- ———. 2002a. New Data on the Prevention low-up of African children following of Mother-to-Child Transmission of HIV vaginal cleansing with leuzalkonium chlo- and Their Policy Implications, WHO ride of their HIV-infected mothers dur- Technical Consultation on Behalf of the ing late pregnancy and delivery,” Sexually UNFPA/UNICEF/WHO/ UNAIDS Transmitted Infections 78(4): 267–270. Inter-Agency Task Team on Mother-to- Nduati, R. et al. 2001. “Effect of breastfeed- Child Transmission of HIV. Geneva: ing on mortality among HIV-1 infected WHO. women: A randomised trial,” Lancet ———. 2002b. Breastfeeding and 357: 1651–1655. Replacement Feeding Practices in the Nolan, M., M.G. Fowler, and L.N. Context of Mother-to-Child Transmission Mofeson. 2002. “Antiretroviral prophy- of HIV: An Assessment Tool for Research. laxis of perinatal HIV transmission and Geneva: WHO. the potential impact of antiretroviral WHO/UNAIDS/UNICEF. 2000. “HIV and resistance,” Journal of Acquired Immune infant feeding counselling: A training Deficiency Syndromes 30(2): 216–229. course,” document WHO/FCH/ Rutstein, R.M. 2001. “Prevention of perina- CAH/00.2. Geneva: WHO. tal HIV infection,” Current Opinion in Wiktor, S.Z. et al. 1999. “Short-course oral Pediatrics 13(5): 408–416. zidovudine for prevention of mother-to- Shaffer, N. et al. 1999. “Short-course child transmission of HIV-1 in Abidjan, zidovudine for perinatal HIV-1 trans- Côte d’Ivoire: A randomized trial,” mission in Bangkok, Thailand: A ran- Lancet 353(9155): 781–785.

48 Chapter 5 HIV Prevention Through Management of Reproductive Tract Infections

Reproductive tract infections (RTIs) com- ulcers, genital warts, abnormal genital tract prise three types of infections that affect the discharge, and lower abdominal pain) but are reproductive tract: sexually transmitted infec- often asymptomatic, particularly in women tions (STIs) caused by viruses (such as herpes (Holmes et al. 1999). Long-term sequelae simplex virus, human papillomavirus, and include infertility in both men and women, HIV), bacteria (such as chlamydia, gonor- cervical cancer, ectopic pregnancy, sponta- rhea, syphilis, and chancroid) or other neous abortion, premature rupture of mem- microorganisms (such as trichomoniasis) that branes, premature delivery and consequent are transmitted through sexual activity with low birthweight, neonatal blindness and an infected partner; endogenous infections infection, and death. Women are more vul- that result from an overgrowth of organisms nerable to STIs and their sequelae than men. normally present in the vagina (bacterial They are more susceptible to infection partly vaginosis and yeast infection); and iatrogenic because semen carrying pathogens stays in infections caused by the introduction of the vagina for some time after sex, and partly microorganisms into the reproductive tract because their reproductive tract consists of through a medical procedure (Population large surface areas that can be exposed to Council 2001).10 Vaginal infection is most infection. In addition, women seek care less commonly caused by endogenous infections often, or delay seeking care, because their but can also be caused by certain STIs (such infections are likely to be asymptomatic, they as trichomoniasis). Cervical infection is most may interpret symptoms such as vaginal dis- commonly caused by STIs (such as chlamy- charge as “normal,” or they do not have dia and gonorrhea), but can be caused by a access to treatment services. The social, psy- variety of pathogens. Both vaginal and cervi- chological, and economic consequences of cal infections can spread to the upper repro- STIs are often devastating (Dallabetta et al. ductive tract, but cervical infections are more 1996). While infections caused by bacterial prone to such progression. Transcervical pro- and protozoal agents have been curable by cedures (such as menstrual regulation, abor- appropriate antibiotics and chemotherapeu- tion, and the insertion of intrauterine tic agents for more than 40 years, at present devices) may facilitate infection of the upper viral infections cannot be cured. reproductive tract. According to World Health Organiza- Sexually transmitted infections can cause tion (WHO) estimates, there are over 340 a wide variety of symptoms (e.g., genital million new cases of curable STIs each year

10 For clarity, we use the term “RTI” only when referring to both STIs and endogenous or iatrogenic infections. Otherwise, we use the term STI. 49 syphilis, for example) this risk may be IMPROVING STI TREATMENT IN PRIMARY increased 300-fold (Wasserheit 1992). RTIs HEALTH CARE CLINICS that do not cause ulcers, such as gonorrhea program in Mwanza, Tanzania set out to prove that STI treatment or chlamydia, also increase the risk of HIV A reduces transmission of HIV (Grosskurth et al. 2000, 1995). It did so transmission, although to a lesser degree by improving primary health care services so that they provided effective (Wasserheit 1992). Research is ongoing to syndromic management of STIs. Because the program required no new determine whether bacterial vaginosis— staff or infrastructure, it was highly cost-effective. Primary health care which is present in up to half of all women workers at rural clinics and dispensaries were trained to recognize of reproductive age in many African coun- common RTI syndromes and treat them appropriately. The training was tries—increases the risk of HIV transmission brief—lasting about three weeks—and involved practical experience in as well. RTIs increase both the infectiousness an STI clinic and role-playing, with little emphasis on the etiologies of the of HIV and the susceptibility of an individ- various syndromes. Each patient was examined and a history taken; the ual to HIV infection, so that the risk of patient was then treated and offered condoms and advised how to use transmission is increased if either the HIV- them. Patients were also given notification cards to distribute to their partners, advising them to come to the clinic for treatment. Partners who negative partner or the HIV-positive partner responded were given counseling and treatment, whether or not they has an RTI (Wasserheit 1992). Perhaps the exhibited symptoms of RTIs. About twice a year, on market days, health strongest evidence for the association educators circulated throughout the community with large posters and between the presence of STIs and HIV inci- talked to passers-by about the importance of seeking treatment for RTIs. dence is that after the improvement of STI treatment services in primary health care The program was evaluated over two years, during which time 98 percent of cases that were followed up had been cured. The effective treatment clinics in northern Tanzania, HIV incidence of STIs in the community seemed to reduce the spread of HIV as well, as in the general population fell by approxi- HIV incidence in the general population fell by approximately 40 percent, mately 40 percent (Grosskurth et al. 1995). compared to the incidence in villages where the intervention was intro- The challenges of RTI prevention, diagnosis, duced at the end of the two-year study. and treatment in resource-poor settings An important obstacle to slowing the (170 million cases of trichomoniasis, 89 mil- HIV/AIDS epidemic is the large number of lion cases of chlamydia, 62 million cases of undiagnosed, untreated, or ineffectively gonorrhea, 12 million cases of syphilis, and 7 treated RTIs worldwide (Buve 2001; Paxton million cases of chancroid) (WHO/ et al. 1998). First, many women and some UNAIDS 1997). The largest proportions of men who are infected show no symptoms or new infections are thought to occur in do not recognize them, even in settings with South and Southeast Asia (46 percent), fol- high RTI prevalence. For example, in the lowed by sub-Saharan Africa (20 percent), Rakai Project in Uganda,11 80 percent of all and Latin America and the Caribbean (11 infected people were asymptomatic (Paxton percent). et al. 1998). Second, many people—especial- It has been well documented that both ly women—who know or suspect that they ulcerative and nonulcerative RTIs facilitate are infected never seek care. In the Rakai the transmission of HIV (Wasserheit 1992). Project, only 56 percent of infected people In the absence of RTIs, the risk that HIV with symptoms sought care (Paxton et al. will be transmitted during a single sexual act 1998). Effective RTI management has tradi- is quite low; but if one partner has a genital tionally not been offered as part of public- ulcer (caused by herpes, chancroid, or sector primary health care, family planning,

11 More information about the Rakai Project can be found at www.iavi.org/reports/120/CohortsRakai.htm. 50 or maternal and child health (MCH) servic- promptly treating infected people, should es, and stand-alone public-sector STI clinics include the promotion of health care–seeking are often remotely located and stigmatized. behavior (such as mass media campaigns to Men therefore often seek STI services from increase community awareness and reduce private physicians, but women usually can- stigma); screening to identify asymptomatic not afford the fees charged for private care. infections; effective, accessible, and accept- Third, when people do seek services, they able clinical services; and support and coun- may not be adequately diagnosed or treated, seling services, including partner notification. or they may experience treatment failure. In Integration of RTI services into other the Rakai Project, 33 percent of all infected, reproductive health services symptomatic people who sought care Integrating RTI services into other reproduc- received ineffective treatment (Paxton et al. tive health services (such as family planning 1998). For example, existing laboratory tests and MCH services) is one potential way to for RTIs can be expensive or technically reach more people and improve access to RTI complicated, are often only available in care. However, program designers and service major urban areas, or are inappropriate for providers typically face a number of chal- screening larger populations. In some cases, lenges in their efforts to integrate services the appropriate first-line drugs for treat- (WHO 1999). While the prevalence of ment—or second-line drugs in case of resist- endogenous RTIs among women and STIs ance—may not be available. Finally, sexual among women and men are considered to be partners of people who are diagnosed with “epidemic” overall, their regional or national an RTI may not be notified. In the Rakai prevalence varies widely. This makes it diffi- Project, only 5.7 percent of partners were cult to mount “one-size-fits-all” services in notified (Paxton et al. 1998). every setting. A recent review of the literature Interventions to reduce the prevalence concluded that integration works only if rou- and incidence of RTIs tine consultations are reoriented toward pro- Recommendations aimed at Ministry of tection against the dual risks of unintended Health officials in resource-poor countries on pregnancy and infection, and involve clients the prevention and control of sexually trans- in deciding the outcome of the consultation mitted infections have been published (i.e., a client-centered approach), steps that (WHO/UNAIDS 1997). Because so many would require a substantial adjustment by STIs are undiagnosed or cannot be treated, service providers (Askew and Maggwa 2002). primary prevention of their transmission is Furthermore, managing RTIs effectively is a crucial. Primary prevention strategies include difficult task and may overburden under- reducing exposure to sexually transmitted funded health services that are not already disease pathogens by promoting sexual absti- offering clinical services. Lastly, many nence and a delay in initiating intercourse, attempts to integrate RTI services into other reducing the number of sexual partners, and services have been unsuccessful because of promoting mutually monogamous relation- poorly maintained facilities, inadequately ships. The efficiency of transmission can be trained and equipped staff, and inconsistent reduced by encouraging and enabling safer drug supplies (Mayhew et al. 2000). sex practices, such as nonpenetrative sex and With the possible exception of parts of use of condoms (see Chapter 2). Secondary sub-Saharan Africa, rates of infection among prevention, consisting of shortening the women attending family planning and MCH duration of infectivity by identifying and clinics could well be much lower than in other 51 population groups, thus casting doubt on one tant to ensure that women undergoing these of the most common rationales for integrating procedures are not already infected.12 RTI services within these settings. While The syndromic approach to RTI diagnosis awareness-raising, counseling, and health edu- and treatment cation about RTIs are recommended in all sit- There are at least three ways to diagnose and uations and circumstances, an assessment of make treatment decisions with regard to overall rates of RTIs among women attending symptomatic RTIs: laboratory testing, clini- antenatal clinics should precede the introduc- cal diagnosis, and syndromic management. tion of clinical services into family planning Laboratory testing is clearly the most accu- or MCH settings (WHO 1999). rate method of diagnosing RTIs, but most While these concerns are indeed impor- laboratory procedures require sophisticated tant, the overall benefits of integration of and expensive equipment, well-trained tech- services often far outweigh the drawbacks. nicians, and temperature-controlled storage Since the 1990s, the integration of RTI serv- for specimens and reagents. For example, an ices with other health services has been accurate test for gonorrhea may cost as much encouraged in many places, such as areas as US$15, or may require culture under spe- with widespread HIV epidemics. By integrat- cific conditions. Clinical diagnosis of many ing these services into other services, a larger RTIs is extremely difficult and often impossi- number of people can be educated and ble—few doctors in developing or developed screened for RTIs, and access to RTI care can countries can make accurate diagnoses. be greatly improved, especially for women. Because of the limitations of both laboratory and clinical diagnosis, WHO recommends RTIs and family planning the use of syndromic management for the As discussed in more detail in Chapter 2, diagnosis and treatment of the most com- many contraceptive methods that are effective mon infections, even when laboratory servic- in preventing pregnancy do not prevent RTIs. es are remote and budgets are tight Male and female condoms offer good protec- (Population Council 2001; WHO 2001). tion against most STIs, and research is ongo- Syndromic case management is based on ing to determine whether diaphragms also classifying the main causative agents that give offer some protection. Diaphragms, however, rise to a particular syndrome (genital ulcers in are associated with increased susceptibility to men and women, urethral discharge in men, endogenous and urinary tract infections. vaginal discharge in women, and lower Hormonal contraceptive methods do not pro- abdominal pain in women) using a combina- tect women from STIs, and research is ongo- tion of symptoms reported by the client and ing to assess whether they modify risk for signs observed by the clinician. It then uses HIV. Intrauterine devices (IUDs) and sterili- flowcharts that help the health care provider zation also do not offer protection against reach a diagnosis and decide on treatment. STIs, nor do they significantly increase risk of The recommended treatment is effective for infection, although IUD insertion and surgi- all the pathogens that could have caused the cal sterilization are both associated with some identified syndrome. The syndromic increased risk for iatrogenic infections. IUD approach, sometimes in combination with insertion and surgical sterilization can also risk scoring (see below), has been tested and exacerbate existing infections, so it is impor- implemented in a variety of countries. It was

12 See Population Council 2001 for more information. 52 found to be effective for genital ulcers in men a and women and urethral discharge in men, MAJOR RTI SYNDROMES AND LIKELY CAUSES but less effective for vaginal discharge (partic- Syndrome Likely causes ularly the management of cervical infections) Urethral discharge (male) Gonorrhea, chlamydia, and lower abdominal pain in women (Sloan trichomoniasis et al. 2000; Dallabetta et al. 1998, 1996). Genital ulcer (male and female) Syphilis, chancroid, granuloma The problem with using vaginal discharge as inguinale, genital herpes,b a symptom is that it can be caused by a wide lymphogranuloma venereum range of organisms (see table, “Major RTI Inguinal bubo (male and female) Lymphogranuloma venereum, syndromes and likely causes”). Some condi- chancroid tions, such as bacterial vaginosis, are extreme- Scrotal swelling (male) Gonorrhea, chlamydia ly difficult to cure. In addition, many women Vaginal discharge (female) In many cases, no discernible experience vaginal discharge even in the cause; however, trichomoniasis, absence of any type of infection. Syndromic yeast infection, and/or bacterial management will inevitably miss all infec- vaginosis are possible causes; tions in asymptomatic women and may lead some vaginal discharge may be to the treatment of some clients who do not cervical discharge caused by gonorrhea or chlamydia actually have an STI. Cervical discharge (female) Chlamydia and/or gonorrhea Risk assessments are questions asked of clients by service providers that are used to Lower abdominal pain (female) Pelvic inflammatory disease caused by gonorrhea or chlamydia substantiate clients’ complaints (e.g., vaginal a Regular monitoring by a reference laboratory should accompany all syndromic discharge), to screen for STIs in clients not management programs; small studies of a few hundred patients can determine aware of symptoms (e.g., prior to providing the most prevalent microbes and patterns of drug resistance. contraceptives), or to determine further b Genital herpes is a growing problem, especially in sub-Saharan Africa; there is no counseling needs (Fox et al. 1995). WHO cure for herpes, but acyclovir can reduce symptoms. Although acyclovir is not part of official syndromic management protocols, it may be added in the near future. recommends that they be part of standard family planning and reproductive health practice, whether services are formally inte- development of conditions (such as yeast grated or not (WHO 1999). Systematic risk infections) that result from antibiotic use in assessments aimed at generating a risk score the absence of bacterial infection. In addi- have also been used, for example to improve tion, the potential emotional consequences the performance of syndromic management of overtreatment should not be overlooked. of RTIs. Research indicates that risk assess- If a woman is treated for an infection she ment or risk scoring alone, without any does not have, telling her husband might other method of diagnosis (such as a pelvic cause distress that could have been avoided. exam), is not accurate in predicting the pres- Decisions about how to manage RTIs ence of an STI, especially in distinguishing will depend largely on the local situation. between vaginal and cervical infections (the Before adopting a particular policy, program latter being more serious). Unfortunately, the designers should make every effort to deter- combination of risk assessment or risk scor- mine the prevalence of different STIs and ing with clinical examinations has yielded lit- drug-resistant strains in the area. Reference tle additional accuracy (WHO 1999). labs might conduct a small-scale study to Overtreatment is of increasing concern, find the prevalence of different RTIs in a as the overuse of antibiotics leads to drug- sample of family planning or MCH clients, resistant bacterial strains, as well as to the or they could rely on the results of studies 53 SYPHILIS SCREENING IN PREGNANCY p to 15 percent of women in some developing countries women made their first antenatal visit late in pregnancy, by U have active syphilis, which may cause rashes, headaches, which time syphilis treatment is far less effective in preventing and in severe cases may lead to bone deformities, mental ill- severe birth outcomes. Even when women attended early in ness, and death. Around half of babies born to infected women pregnancy, very few were actually screened for syphilis, and will either fail to survive or will be born prematurely or with those who were diagnosed with syphilis were seldom given low birthweight. A small number of these infants develop con- proper treatment. Their sexual partners were rarely notified genital syphilis, which, like the adult version of the disease, and urged to seek treatment. causes skin rashes, bone deformities, and mental disabilities Doctors at the University Teaching Hospital in Lusaka were (Holmes et al. 1999). determined to improve the antenatal syphilis screening pro- It costs less than US$0.50 to diagnose and cure syphilis, and gram. They began by employing outreach workers to visit antenatal clinics in developing countries are an ideal place to urban shantytowns and encourage pregnant women to come provide infected women and their sexual partners with coun- to the clinic early in their pregnancies for antenatal care. They seling, testing, and treatment. However, a recent survey of ensured that syphilis screening at these clinics was carried out syphilis screening programs in Africa found that 1.6 million properly and that there were adequate supplies of drugs. cases in pregnant women went untreated every year. This num- Infected women were given cards to give to their sexual part- ber included more than a million women who attended antena- ners, advising them to come to the clinic for treatment as well. tal clinics but were not screened. Improving syphilis screening After one year, four times as many women attended the ante- programs in antenatal clinics is therefore a priority for MCH natal clinics early in pregnancy as before, and among women staff. with syphilis the proportion of adverse pregnancy outcomes During the 1980s, a syphilis screening program in Zambia was reduced dramatically—from 72 to 28 percent. demonstrated how effective such programs can be (Hira et al. While the project was successful, there was room for improve- 1990). At the time, around 13 percent of pregnant Zambian ment. More than half of pregnant women failed to seek ante- women were estimated to be infected with syphilis, accounting natal care before the 16th week of their pregnancy, after for 20–30 percent of the total perinatal mortality rate of 50 which it is much more difficult to prevent adverse birth out- per 1,000 births (Hira et al. 1990). While syphilis screening and comes. More-intensive health education within the community treatment were supposed to be part of the national antenatal over a longer period may be necessary to encourage more care program, in practice the system worked poorly. Most women to attend antenatal clinics earlier.

that have already been carried out in the area alternative methods of specimen collection in by the Ministry of Health or independent women that do not require pelvic examina- research groups. The prevalence of HIV and tions, such as self-administered swabs and RTIs may vary considerably from place to tampons, and urine. These alternative meth- place, even within a single country. ods may simplify the logistics of RTI screen- Like rapid tests for HIV, rapid tests for ing in resource-poor settings, and be more other RTIs have the potential to greatly sim- acceptable to women. plify case finding and case management Partner notification, contact tracing, (Mabey et al. 2001). Rapid tests for a variety and gender-related violence of RTIs are currently being developed and/or The primary purpose of partner notification evaluated, with rapid tests for gonorrhea and is to prevent a treated client from becoming chlamydia receiving highest priority. It is re-infected and to prevent transmission to likely that they will be integrated into repro- others. Partner notification can be achieved ductive health services in the near future. by asking index cases to notify their Furthermore, research is ongoing to evaluate partner(s) themselves, or by having public 54 health officials undertake contact tracing (Mathews et al. 2002; Adler et al. 1998). In CHALLENGES FACING RTI PROGRAMS IN DEVELOPING COUNTRIES some settings, index cases are given an additional course of treatment for each partner n many clinical settings in developing countries, the shortage of doc- and are asked to hand these to their I tors means that trained nurses deliver the majority of routine health partner(s) themselves. Partner notification is care services. In order for RTI management programs to run smoothly in voluntary and is sometimes greatly compli- family planning clinics, nurses must be permitted and trained to dispense cated by the possibility of gender-related vio- the drugs to treat these diseases. In Kenya, researchers from the African lence directed against women. Some pro- Population and Health Research Center found that the relevant legislation grams offer to notify the partners of women governing the dispensing of pharmaceuticals did not clarify whether nurses were allowed to do this, and prescription of RTI drugs was, in any who prefer not to do it themselves, but dis- event, not part of nurses’ training. Revising the laws to make it easier for closure through a provider referral system nurses to manage RTIs was complicated by the fact that some doctors must also be done with great caution in saw this as an infringement of their own authority and responsibilities. order to avoid putting women at risk of vio- In Botswana, Kenya, Tanzania, and Uganda, the Population Council also lence. One project in Tanzania used outreach found that many RTI services were dispensing the wrong drugs. Often workers to notify the partners of women this was because treatment guidelines had not been updated or, if they who tested positive for HIV or other STIs, had been, health workers were not aware of them. Sometimes the most but this part of the project had to be aban- effective drugs were out of stock or were not on “Essential Drugs” lists. doned because many of the outreach workers In Tanzania and Uganda, RTI programs were found to be severely under- came from the same communities as the funded and could not afford to dispense the most effective medications. clients, and they felt awkward talking about Source: Miller et al. 1998. sexual risk and disease with the clients’ partners. In Zimbabwe, almost 30 percent of people attending an STI clinic gave false REQUIREMENTS FOR AN EFFECTIVE FAMILY names and addresses when asked who their PLANNING/RTI PREVENTION PROGRAM most recent sexual partners were (Winfield and Latif 1985). Taking these realities into • Reliable running water and electricity for sterilization and other surgical procedures; account, service providers should allow • Contraceptives, including male and female condoms; clients to decide whether and how a partner or partners should be notified. While partner • Counselors trained in syndromic management of RTIs and in conducting risk assessments; notification is theoretically an important • Information, education, and communication materials dealing with public health intervention, in practice disclo- HIV/RTI prevention, including leaflets, comic books, and posters; sure may not always produce its intended • Drugs for STIs; consequence—namely STI diagnosis and • HIV test kits; treatment for the partner. • Information about a referral lab for RTI diagnosis (or, eventually, rapid diagnostics onsite); and References • Equipment for pelvic exams. Adler, M. et al. 1998. Sexual Health and Health Care: Sexually Transmitted Infections—Guidelines for Prevention and Treatment, Health and Population and management with family planning Occasional Paper. London: Department and antenatal care in sub-Saharan for International Development. Africa: What more do we need to Askew, Ian and Ndugga Baker Maggwa. know?” International Family Planning 2002. “Integration of STI prevention Perspectives 28(2): 77–86. 55 Buve, A. 2001. “How many patients with a Mayhew, S.H. et al. 2000. “Implementing sexually transmitted infection are cured the integration of component services by health services? A study from for reproductive health,” Studies in Mwanza region, Tanzania,” Tropical Family Planning 31(2): 151–162. Medicine and International Health 6(12): Miller, K., H. Jones, and M.C. Horn. 1998. 971–979. “Indicators of readiness and quality: Dallabetta, G.A., A.C. Gerbase, and K.K. Basic findings,” in K. Miller et al. (eds.), Holmes. 1998. “Problems, solutions and Clinic-Based Family Planning and challenges in syndromic management of Reproductive Health Services in Africa: sexually transmitted diseases,” Sexually Findings from Situation Analysis Studies. Transmitted Infections 74(suppl 1): New York: Population Council, pp. S1–S11. 29–85. Dallabetta, G.A., M. Laga, and P. Lamptey. Paxton, L.A. et al. 1998. “Community-based 1996. Control of Sexually Transmitted study of treatment seeking among sub- Diseases: A Handbook for the Design and jects with symptoms of sexually trans- Management of Programs. Arlington, VA: mitted disease in rural Uganda,” British AIDSCAP/Family Health International. Medical Journal 317(7173): 1630–1631. Fox, L.J. et al. 1995. “Improving reproduc- Population Council. 2001. Reproductive tive health: Integrating STD and contra- Tract Infection Fact Sheets. New York: ceptive services,” Journal of the American Population Council, www. Medical Women’s Association 50: popcouncil.org/rhfp/rti_fact_sheets/ 129–136. index.html. Grosskurth, H. et al. 1995. “Impact of Sloan, N.L. et al. 2000. “Screening and syn- improved treatment of sexually transmit- dromic approaches to identify gonorrhea ted diseases on HIV infection in rural and chlamydial infection among Tanzania: Randomised controlled trial,” women,” Studies in Family Planning Lancet 346: 530–536. 31(1): 55–68. ———. 2000. “Operational performance of Wasserheit, Judith N. 1992. “Epidemio- an STD control programme in Mwanza logical synergy: Interrelationships Region, Tanzania,” Sexually Transmitted between human immunodeficiency virus Infections 76: 426–436. infection and other sexually transmitted Hira, S.K. et al. 1990. “Syphilis intervention diseases,” Sexually Transmitted Diseases in pregnancy: Zambia demonstration 19(2): 61–77. project,” Genitourinary Medicine 66(3): WHO. 1999. Integrating STI Management 159–164. into Family Planning Services: What Are Holmes, K.K. et al. 1999. Sexually the Benefits? Geneva: WHO. Transmitted Diseases, ed. 3. New York: ———. 2001. Guidelines for the McGraw-Hill. Management of STIs, document Mabey, D., R.W. Peeling, and M.D. Perkins. WHO/HIV_AIDS/2001.01, 2001. “Rapid and simple point of care WHO/RHR/01.10. Geneva: WHO. diagnostics for STIs,” Sexually WHO/UNAIDS. 1997. Sexually Transmitted Transmitted Infections 77: 397–401. Diseases: Policies and Principles for Mathews, C. et al. 2002. “A systematic Prevention and Care, Best Practice review of strategies for partner notifica- Collection. Geneva: WHO/UNAIDS. tion for sexually transmitted diseases, Winfield, S. and A.S. Latif. 1985. “Tracing including HIV/AIDS,” International contacts of sexually transmitted diseases Journal of STD and AIDS 13(5): in a developing country,” Sexually 285–300. Transmitted Diseases 12(1): 5–7.

56 Chapter 6 HIV Prevention Among Refugees and Other Displaced Persons

Refugee agencies have long recognized the emergencies include the conditions of social health needs of people displaced by war and disassociation and uncertainty of displace- natural disasters, including clean water, sani- ment and demobilization, or social norms tation, and vaccination. Until the 1990s, that translate into disregard for the rights of HIV/STI prevention was not seen as a prior- women and children, heightened alcohol and ity in emergencies; however, it is now known drug abuse, and the disintegration of tradi- that displaced people are at great risk of tional social sanctions that might otherwise HIV. If the refugees come from regions discourage such behavior. In addition, sexual where HIV and STIs are already common, violence in war and afterward often has a there is an even greater danger that the dislo- political motive, so that women from one cation, chaos, poverty, and boredom of ethnic group or political faction are targeted refugee life—in addition to the inadequate by men from the opposing side. This was the health care coverage in general and poor case during the wars in Bosnia and Rwanda, quality of HIV prevention, care, and support for example (Peterson and Runyan 1999; programs—will increase the spread of these Nikoli´c-Ristanovi´c 1996). During periods of infections. Because HIV surveillance is not a conflict, men gain greater control over goods priority in emergencies, there are few reliable and services that women and children need. statistics on the incidence and prevalence of Soldiers and camp leaders may demand sexu- HIV among displaced persons. Even so, the al favors in return for such goods as food and incidence of rape in emergencies is believed access to water, and bandits and border to be very high, and the poverty and social guards may see fleeing women and children disruption of war are believed to make com- as easy targets. mercial sex more common. Once an emergency situation is reason- While not all cases of HIV infection dur- ably stable, nongovernmental organizations ing and after emergencies are believed to be (NGOs) working in refugee camps and with the result of rape and violence, health work- other displaced groups should be encouraged ers who assist refugee and internally displaced to carry out a comprehensive HIV preven- populations should consider ways to reduce tion campaign. Because of the unique cir- violence, in addition to carrying out more cumstances, contingencies, and resource con- routine HIV prevention activities. The causes straints associated with the management of of sexual violence during conflict are not well refugees and internally displaced people, understood. Factors that are believed to con- there are several redundant elements of a tribute to increased rape and abuse of women comprehensive HIV/AIDS intervention pro- and young people before, during, and after gram that are critical.

57 HIV PREVENTION FOR REFUGEES: A CASE STUDY FROM NGARA, TANZANIA

n 1994 approximately 300,000 refugees crossed into antenatal clinics. Program staff trained members of the I Tanzania from Rwanda after the war and genocide there. refugee community to work as peer educators in the promotion The refugees settled in three camps in Ngara. It was not of safer sex and condom use among the clients of bars and known how many refugees were HIV-positive at the time, but brothels. Some of these outreach workers were themselves there were concerns that an epidemic might occur, both in the sex workers or bar owners. Teams of health educators from refugee community and among the impoverished local popula- the refugee community were given large posters with cartoons tion. The refugees greatly swelled the population of the local depicting scenes from an STI clinic or a romantic encounter. area, and before long migrant traders from other parts of The teams set up the posters in places where people gathered Tanzania established an informal market outside the camps. (e.g., in the informal markets), and the posters attracted atten- Sex workers also established premises around the camps. tion. After a small crowd had gathered, health educators would A consortium of 13 NGOs, coordinated by the U.N. High discuss the scenes in the cartoons and convey important mes- Commissioner for Refugees (UNHCR) and with technical guid- sages such as what HIV is, how it is and is not transmitted, ance from the African Medical and Research Foundation and and how people can protect themselves from HIV. funding from UNFPA and UNHCR, quickly established an Even though HIV infection rates were not measured, there HIV/STI prevention program in the Ngara camps (Mayaud et were many indications that the program was successful in lim- al. 1997). As the program was being established, the team con- iting the spread of HIV and STIs. As soon as people realized ducted rapid surveys of a few hundred refugees, both men and that improved services were available to treat STIs, the case- women, to determine existing rates of RTIs as well as knowl- load at health posts rose nearly tenfold. The contacts of about edge, attitudes, and practices regarding sex. The researchers a third of these cases were treated as well—a reasonably were unable to measure rates of HIV infection because some high number considering the difficulties surrounding partner of the NGOs expressed concern that if the information became notification (see Chapter 5). The refugees remained in Tanzania widely known, it might further stigmatize people in the camps; for two years, during which time rates of syphilis, urethritis, but researchers did determine that rates of certain RTIs, espe- and cervical and vaginal infections fell by at least 50 percent. cially vaginal infections, were quite high. At the same time, however, there was evidence that commer- They also identified and helped strengthen local resources in cial sex and sexual violence continued to occur. After the the camps and the surrounding communities for HIV and RTI refugees returned to Rwanda in 1996, an HIV-prevalence sur- prevention and treatment. At the same time, the teams organ- vey was carried out among returnees who had been housed in ized a condom marketing campaign and trained doctors and camps in Burundi, Tanzania, and Zaire, as well as among the nurses at outpatient clinics to use syndromic management to internally displaced. The results indicated that returnees from diagnose and treat RTIs (see Chapter 5). In addition, a syphilis the Tanzanian camps had lower HIV infection rates than those screening program for pregnant women was established in who had been displaced elsewhere.

Basic HIV Prevention Services for women and children vulnerable to coercion, Refugees and Internally Displaced Persons sexual abuse, or rape. In addition, the lack of 1. Camp design. Health workers should bear privacy characteristic of camps can also foster in mind that the design of camps can provide the necessity for quickness and lack of inti- an environment that may be conducive to macy in sexual interactions. This in turn can sexual violence. For example, isolated latrines discourage the negotiation and use of con- and sources of water and firewood can make doms or other risk-reduction behaviors.

58 2. Rapid assessments. Small surveys to and should not be mishandled during ship- determine RTI infection rates and patterns of ping and distribution. It is especially impor- antibiotic resistance can greatly aid the design tant that condoms be kept out of direct sun- of interventions aimed at reducing the preva- light and heat and away from sources of lence of these infections, as well as HIV (for water—both of which will compromise their more information, see Chapter 5 and box). effectiveness. 3. Dedicated reproductive health services. 6. HIV/AIDS educators and counselors. A Often reproductive health services for dis- team of HIV/AIDS educators and counselors placed people, if they exist at all, are com- can work both as peer educators—advising bined with services to treat conflict-related displaced populations about sexual health casualties and other health problems. risks and distributing condoms—and as an However, specialized reproductive health outreach referral system—locating men and services have the advantage of being able to women in need of reproductive health servic- focus on the special health and emotional es and helping them gain access to diagnosis needs of people suffering from STIs, and treatment. HIV/AIDS educators should HIV/AIDS, or the consequences of sexual come from the displaced community itself, abuse and rape. Such services should include so that they know the language and customs treatment for STIs as well as training of of the people. They should then be properly health care workers in syndromic manage- trained to promote condoms and offer ment, a system to ensure that essential drugs advice to people who think they may have for the most common STIs are available, and an STI or who have been subject to abuse. a monitoring system to identify the most 7. Media campaigns. The use of con- common infections and their resistance pat- doms can also be promoted through educa- terns. Lab services to accurately diagnose tional activities and the media. Radio spots every case of infection are unlikely to be fea- can be particularly effective for promoting sible in most emergency situations. condom use in emergencies because many 4. HIV counseling and testing. Available people listen to the radio to follow political resources for HIV testing should be devoted developments. first and foremost to ensuring the safety of 8. Counseling, care, and treatment for vic- blood supplies for transfusion. A voluntary tims of sexual coercion and violence. In emer- counseling and testing program is a lower gencies, HIV/AIDS counselors and health priority in refugee situations, but should not care workers are likely to encounter women be ruled out if resources are available in the and children who they suspect have been host county or in the country of origin. sexually abused. The United Nations High Mandatory HIV testing among refugees, Commissioner for Refugees recommends with the single exception of testing blood for that counselors be of the same sex as the sus- transfusion, is not justified. pected victim, and that counseling sessions 5. Condom promotion. Male and female be conducted in private (UNHCR 1995). If condoms and other contraceptives should be the victim agrees to discuss the case, he or as widely and easily accessible as possible. she should be encouraged to report it to the UNAIDS recommends that for a population authorities. The victim should be advised of of 10,000 displaced people, 25,000 con- what to expect if he or she decides to make a doms are needed every month (UNAIDS report to the police. Cases of domestic abuse, 1999). Condoms should be of high quality in particular, must be handled carefully. If a

59 woman is raped, she should be offered emer- References gency contraception to prevent pregnancy. If Mayaud, P. et al. 1997. “STD rapid assess- HIV infection is common in the area, health ment in Rwandan refugee camps in Tanzania,” Genitourinary Medicine workers should be prepared to offer HIV 73(1): 33–38. prophylaxis using antiretroviral drugs. These Nikoli´c-Ristanovi´c, Vesna. 1996. “War and drugs must be administered within 72 hours violence against women,” in Jennifer after the rape in order to have the greatest Turpin and Lois Ann Lorentzen (eds.), chance of preventing infection. The Gendered New World Order: 9. Support groups and work programs. Militarism, Development and the Refugees often experience powerlessness, Environment. New York: Routledge, pp. 195–210. frustration, fear, anger, and boredom due to Peterson, V. Spike and Anne Sisson Runyan. the unfamiliar and difficult conditions in 1999. Global Gender Issues, ed. 2. which they are placed. These feelings can Boulder: Westview Press. inflame violence, including sexual violence. UNAIDS. 1999. Guidelines for HIV It is important to reconstruct, as far as possi- Prevention in Emergency Settings. ble, the routines and social ties that have Geneva: UNAIDS. United Nations High Commissioner for been disrupted by the emergency and to Refugees. 1995. Sexual Violence Against restore the self-respect of displaced persons. Refugees: Guidelines on Prevention and Toward this end, groups working with Response. Geneva: UNHCR. refugees advocate the formation of support groups and work programs for refugees.