What is HIV and AIDS mainstreaming?

1.1 Who is this book for?

It is important that all emergency field staff including engineers, health promoters, managers, and co-ordinators have sufficient knowledge of HIV and AIDS in order to plan and implement a mainstreamed humanitarian programme. This manual is primarily based on Oxfam experiences, and the learning and examples of good practice will be useful for all organisations who have field staff working in humanitarian programmes.

Emergency programmes in areas such as Haiti and Cambodia, where there is a high prevalence of HIV, will have different needs from those in a low-prevalence country such as Guatemala. This means that field staff will of course have to use their discretion about when and how a programme mainstreams HIV and AIDS. Section 3.2 (page 21) contains clear guidelines on how to make an informed choice.

1.2 What is mainstreaming?

Mainstreaming has been defined as 'The application of learning and new behaviours into core activities of organisations.' For example, gender can be mainstreamed into humanitarian programmes by promoting equality for both sexes throughout the life of the programme rather than attempting to run parallel projects for empowering women. Protection issues such as the safety of women and the prevention of rape are mainstreamed into programmes by reshaping the interventions to minimise risks and to increase safety: an example being well-lit sanitation facilities for women and children in refugee camps. So the objective to address the immediate needs of the affected people remains, but the programme is designed to address gender and protection at all stages.

In order to be able to mainstream HIV and AIDS, we need to be clear about two different definitions: HIV and AIDS programming and mainstreaming HIV and AIDS. Holden (2004) has come up with the following differences:

1 The term HIV and AIDS programming refers to HIV prevention and treatment, care and support for people living with HIV and AIDS (PLWHA), or HIV and AIDS-focused interventions that are integrated within broader health and related programming. The goal of HIV and AIDS programming relates specifically to HIV and AIDS.

2 The term mainstreaming HIV and AIDS refers to 'adapting development and humanitarian programmes to ensure they address the underlying causes of vulnerability to HIV infection and the consequences of HIV/AIDS' (Holden 2004: 40). The focus of such programmes, however, remains the original goal (in the case of Oxfam providing water, sanitation, and hygiene promotion as well as livelihoods, for example).

Stembile says:

It's like putting on HIV glasses and viewing your programme from a different angle!

The Sphere Project is used in humanitarian programmes as a gold standard for good programming and it includes HIV and AIDS mainstreaming. According to Sphere, 'action must be taken in the acute stage following the disaster to minimise risk of (HIV) infection' and 'a basic response to any emergency must aim to maintain respect for the individual rights of people with HIV infection or AIDS'.

Within an NGO emergency programme, HIV and AIDS mainstreaming is usually seen as both internal and external:

• Internal – addressing HIV and AIDS with staff through training on self-awareness and community mainstreaming, adapting and changing policy to promote staff welfare

• External – reducing the risk or the impact of HIV and AIDS through the way we interact with communities and deliver our programmes

1.3 HIV and emergencies

Mainstreaming HIV in the second scenario (Box 1) is important because the emergency may increase transmission and thereby susceptibility to disease in people already affected by the crisis. In scenario three, the one emergency (HIV and AIDS crisis) will affect the other emergency (food shortage) and vice versa.

Other issues that must be considered when mainstreaming HIV are gender and protection. Addressing these factors helps to decrease the chances of becoming infected and to mitigate the impacts of the virus. Managers often struggle with the problem of deciding when to intervene and at what level. A Scoring Tool has been developed to help make those decisions – see page 24.

Three primary principles of mainstreaming HIV and AIDS in emergencies are:

1 Prevention of HIV transmission: This can be achieved by promoting health and strengthening food security and livelihood security, with a focus on women and vulnerable groups. This will be important in decreasing behaviour that increases HIV transmission risks (e.g. sex for subsistence as a survival strategy and forced migration in search of employment). Safe blood transfusions will also prevent transmission and even those NGOs not involved in medical services should lobby for safe blood products.

2 Care of both infected and affected: A nutritionally balanced diet mitigates the health impact of AIDS (opportunistic infections), so promoting health and good nutrition is important especially in an emergency. An issue that is often overlooked is support and assistance for carers of chronically ill people. Addressing the special needs of chronically ill people by ensuring that water is easily available, for example, goes a long way in alleviating the burden of those who care for them.

3 Mitigation of impact of the emergency on the HIV and AIDS profile: This impact can be mitigated by alleviating labour loss and shortages, supporting livelihoods during the emergency-induced economic crisis, arresting agricultural disruption, and preventing sexual exploitation and rape (both male and female). Access to health services and antiretrovirals should also be considered, by humanitarian NGOs who have expertise in those areas.

1.4 What mainstreaming is not

• Working only with HIV-positive groups

• Running training courses on HIV prevention without using the knowledge to change the way we programme

• Doing mass condom distribution in isolation

• Changing the focus of the humanitarian response to HIV prevention

As Holden has stated: 'Mainstreaming is not concerned with completely changing an organisation's or sector's core functions and responsibilities, but with viewing them from a different perspective' (2004: 42). See Box 2 for an example of HIV mainstreaming.

Stembile says:

To sum it up – mainstreaming is thinking about HIV and AIDS in all programmes (and considering both staff and beneficiaries).

When considering any response you should ask yourself two key questions:

1) How will HIV and AIDS affect the programme?

2) How will the programme affect HIV and AIDS prevalence?

Why mainstream HIV and AIDS in emergencies?

2.1 Why get involved?

It is only in the past four or five years that it has become apparent that even in emergencies, programmes must consider HIV and AIDS. HIV and AIDS has not generally had a high profile in humanitarian programming. The reasons for this are:

• It is difficult to measure – due to poor surveillance and therefore poor data, few testing sites, and a mobile population.

• It is difficult to prevent transmission in a crisis – rape and sexual attack are more common, condoms may not be available, people use sex to barter for necessities, and prevention programmes are disrupted.

• It has been seen as a medical issue rather than a public health issue which affects sectors such as education, community, and livelihoods.

• It has been seen as a development and not an emergency issue; the increased risk of transmission linked to the presence of military, and an increase in rape cases have not often been considered in first-phase responses.

• It has not been seen as an immediately life-threatening disease such as malaria or cholera.

Nonetheless it is now recognised that HIV and AIDS can and must be mainstreamed into any emergency analysis and response. There is no point in saving lives in the short term if we fail to address the factors that may increase transmission (and thereby mortality rates) in emergencies. As one villager said during an assessment in Zimbabwe:

'We don't want to die with our bellies full.'

2.2 How emergencies can result in spreading HIV

Even before an emergency occurs, poverty, income inequality, gender inequity, poor public services, and low literacy all increase susceptibility to HIV infection, which in turn leads to a rise in opportunistic infections and death in the economically productive population (15–45 year olds). This then leads to decreased production; the cycle of poverty. Any emergency, whether due to natural disaster or conflict,will only worsen the situation.

Although conflict, poverty, food shortages, and displacement make people vulnerable, there is evidence to show that this vulnerability will not automatically result in increased HIV susceptibility. There have been cases when conflict has actually hindered the spread of HIV. Figure 1 on page 11 illustrates how, in a conflict and/or displaced persons situation, while some factors may increase the risk of transmission, others will hinder the spread.

In all emergencies there is the potential for increased susceptibility to infection with HIV and increased vulnerability to the impacts of the HIV and AIDS epidemic. This is due to the following factors:

• Breakdown of family and social values and networks, with increased vulnerability and susceptibility especially of women and children

• Increase in rape cases often by military or paramilitary personnel

• International military and sometimes international aid workers visiting local sex workers

• Breakdown in supply chain for condoms leading to more unprotected sex

• Poor IDP/refugee camp facilities, with latrines and washing areas for women unlit and far from the household, thus increasing the possibility of rape

• Breakdown in health services providing treatment for sexually transmitted infections (STIs) and other diseases

• No/limited access to antiretrovirals

• Tendency for men to seek work away from home in times of drought, leaving women and children to fend for themselves

• Tendency for migrant workers to visit commercial sex workers if they are forced to live far from their families

• Less disposable income, sometimes forcing women into sex for subsistence

• Coercion by aid workers distributing food or goods – workers asking for sexual favours or money in exchange for the food being distributed, or simply in exchange for registration for assistance

• Increased blood transfusions due to large numbers of injured people in both conflict and natural disasters, in countries where there are poor blood screening facilities

• Interaction with host communities where transmission rates are higher than in the affected community

Box 3 on page 12 gives examples of the impact of emergencies on HIV prevalence.

2.3 How HIV can aggravate the impact of emergencies

The effect of HIV on emergencies will depend on the prevalence in the country before the emergency. In a country with high prevalence there may already be a marked decrease in the number of young healthy workers in the agricultural and the industrial sectors, and in essential-service areas such as education and health. The health system may already be over-burdened and resources may be scarce. Even in a country that is coping, the emergency may be all it takes to turn a low-prevalence into a high-prevalence situation.

HIV can worsen the emergency situation by:

• Reducing resistance to disease in those already affected – through lack of food, lack of medication, and increased stress levels

• Undermining existing positive coping strategies in HIV-affected households, and over-burdening carers

• Placing more demand on resources (such as water supply in camps or shelters) for those who are HIV-positive and showing symptoms of AIDS (chronically ill) and their carers

• Making it difficult to find healthy workers for prevention programmes in camps; carers may not be free to take up volunteer posts or participate in cash for work programmes

• Causing the host community or other cultures and ethnic groups to discriminate against PLWHA in the new environment

• Increasing the vulnerability of orphans and other vulnerable children affected by HIV (OVCs), old people, and child-headed households, due to the fact that they may have difficulty in getting food, may be last in the line to receive scarce rations, and may not be able to collect water and firewood

Stembile says:

Be prepared! You need to know about the pre-emergency situation in your country. How did HIV affect the population before the emergency?

2.4 Vulnerable groups

In a humanitarian emergency there will be certain factors such as age, gender, social disability, and HIV status that affect vulnerability and people's ability to cope with the disaster. The Sphere Project defines key vulnerable groups as women, children, older people, disabled people, PLWHA, and ethnic minorities. These same groups have been used here for consistency. First we review the susceptibility of these groups to HIV infection and then we look at how an emergency situation can make this worse for each group.

2.4.1 Women and girls

These are the factors that increase the susceptibility of women and girls to HIV infection:

• Physiological: the virus is found in greater concentration in semen than in vaginal secretions so women are more likely to get infected by men than men are by women. In addition, tearing and bleeding during intercourse, whether from rough sex, rape, or prior genital mutilation (female circumcision), increases infection risk.

• Social: In many countries, women are often not in a position to negotiate when it comes to sexual matters, and there may be stereotyping of 'loose women' (the assumption that because a woman agrees to sex once, she is immoral or is therefore a commercial sex worker). Many societies tolerate multiple partners in men but not in women. Young girls may be brought up with little sexual or reproductive health knowledge, making them even more vulnerable to infections.

• Economic: Women who lack economic resources may be more accepting of violent sexual behaviour if they fear that their partner may abandon them if they refuse. The phenomenon of 'sugar daddies' where older men pay young girls for sex (often in kind) occurs in many developing countries. (See Box 4.)

2.4.2 Young males

These are the factors that increase the susceptibility of men and especially young boys to HIV infection:

• Social norms that reinforce their lack of understanding of sexual health issues and their toleration of promiscuity

• Substance abuse such as drugs or alcohol, which may lead to prostitution or simply sex for subsistence (sex tourism)

• Sex for subsistence (without substance abuse), which may be an alternative in times of hardship

• Types of work that can entail mobility and family disruption (migrant labour, truck driving, fishing, and military service)

2.4.3 Effect of an emergency on women and girls and young males

• In conflict there is increased risk of rape, sexual abuse, or pressure to engage in sexual favours by armed forces and displaced men

• In conflict there may be forced recruitment of child soldiers (both male and female)

• In times of drought or deprivation, sex for subsistence may increase

• Boredom in camps may lead to increased drug and alcohol abuse with possible unprotected sex as a consequence

• A lack of role models and family support may lead to more promiscuity and unprotected sex

Box 5 gives an example of one way to work with young people.

2.4.4 The elderly, the disabled, and ethnic minorities

There are a growing number of elderly people taking care of small children either due to the death of a parent or because parents have migrated to seek work. In a high-prevalence country, there may be no grown-up children to care for elderly parents, who are left to fend for themselves. An elderly carer who was already looking after a disabled person may suddenly find themselves caring for orphans as well.