UN REPORT 1998
DAY 1 SESSION II : Tuesday, 2 June, 1998
FORCE FOR CHANGE: YOUNG PEOPLE AND HIV/AIDS -
KEYNOTE ADDRESS
Rob Moodie, Former Director
Country Support, UNAIDS, Geneva
Shararda Chowardy, Representative
Youth in Asia Pacific
Mr. Moodie introduced this year’s UNAIDS’ World AIDS Campaign by drawing attention to two points:
1. This year’s World AIDS Campaign was intended to be conducted WITH young people rather than FOR or ON young people.
2. The name of the campaign, “LET IT HAPPEN,” suggests to the senior decision makers that young people and their organizations must participate in the planning, implementation, and in the understanding and evaluation of what does and does not work. In short, let the young people be a force for change.
Mr. Moodie pleaded with the participants to learn from previous mistakes. In the past, the issues of sex, drug abuse, discrimination, unfriendly health services, have been left out of discussions, with the mistaken assumption that they are problems for others to deal with. Unless they are dealt with openly, there will be little progress in affecting people’s lives. Mr. Moodie focussed the remainder of his presentation on five major areas:
1. The importance of articulating clearly the impact of HIV on young people. Seven
thousand young people per day around the world contact HIV everyday. It is estimated that 700,000 in Asia Pacific will be infected this year. Of the 2,000 daily infections in this region alone, most do not know that they are infected because HIV is a silent disease, visible only when the infected become sick. He exhorted the participants to have at least a general idea of how many new infections occur in their countries every year/month/day in order to use that information to get the type of help need to combat the disease. Further, in order to help young people begin their sexual activities safely, estimates should be obtained of how many are initiated in sexual activity. The majority of the youth do not have control the first time over their first sexual experience. Young women, in particular, are more vulnerable to HIV because they face more physical and sexual violence. They are also more likely to become victims of the sex industry. This lack of control is also true when young people first experience drug use.
2. Young people are a force for change. They need our support. They know what
they want. Young people do care and they have energy, idealism, skills and commitment that must be used to help change the course of the epidemic. Working with young people helps prevent HIV, because behavioral change is possible. In northern Thailand, for instance, HIV and STD in general has been noticeably reduced among 21-year-old males in part due to the use of condoms. This type of success tends to take place in situations where there is great cooperation between the major players.
3. Young people know what they want, and they have rights that must be protected,
respected and promoted. At this point, Mr. Moodie introduce Miss Chowardy to speak on behalf of the youth. Her comments are summarized below. Mr. Moodie spoke of the rights of young people. These rights, established 50 years ago, are captured in the universal Declaration of Human Rights which was signed by virtually all governments. These inalienable rights include: the right to be yourself, express yourself, make decisions, enjoy sex, to be safe, choose to get married, have family, to know about sexual health, AIDS, STD, to health care -, to be involved (planning, implementation, influencing governments, etc.).
4. Mobilize social and private sectors to form new partnerships. Senior decision makers have an obligation to mobilize new partners. HIV prevention works best when there is a consensus among institutions/parties. These partnerships are absolutely critical so they must be sustained. Of particular usefulness are organizations that are already successful at reaching young people such as MTV, religious organizations, the media, etc. Their methods can be used to reach young people more effectively.
5. We need to LET IT HAPPEN. Once young people and their organizations have been mobilized, we must LET IT HAPPEN. We must ensure that young people are heavily involved. To do this, we have to find out what young people want, help them get it. He emphasized the need to mobilize new organizations, form new partnerships and LET IT HAPPEN. We know how to deal with HIV, but we are losing the battle.
Mr. Moodie summarized the concerns of the youth by quoting the testimony of a 14-year-old girl from Botswana: “There’s a serious problems of communication between parents and their children. There’s a cry from our hearts. Parents, talk to us.” Mr. Moodie added that the word “parents” could be substituted for “administrators”, “adults”, because we all have the responsibility to listen to the concerns of the youth.
Shararda Chowardy: Representative of Youth in Asia Pacific.
We believe that we can help. We the youth have a viewpoint. Plain common sense to involve in decision process will help. HIV is faced mostly by us. Even though elders may have a better perception of the matters, the youth have their own viewpoints. If viewpoints of the youth are ignored, the policies formulated by the current policy makers will be rejected by the policy makers of tomorrow. Youth must be involved in program planning, implementation and evaluation, to make them more relevant to the problems facing them.
Adults fear that sex education will make youth desperate for it. This, however, is not so, for sex education is helpful in making the youth aware about reproductive health and sexuality, physical development, causes and effect of HIV, and so. It is the youth’s right to know, so it is the elders responsibility to inform the youth of those aspects of their well being. The more the youth know, the more careful in the future. They will make responsible decisions and share those messages to our peers. Parents have an important role because they have the responsibility to communicate with their children. She encouraged youth participation on all levels to influence the governments through appropriate means.
SPECIAL REPORT SESSION: ESCAP MEETING, JUNE 1ST 1998
ELIMINATION OF SEXUAL ABUSE AND SEXUAL EXPLOITATION OF CHILDREN AND YOUTH
Reported by:
Ms. Thelma Santos, Director II,
School of Health and Nutrition Center,
Department of Education, Culture and Sports
Psig City, Philippines
Dr. Tia Phalla, Director
National AIDS Program,
Ministry of Health,
Phnom Penh, Cambodia
Prof. Dang Canh Khanh, Director
Youth Research Institute
Vietnam Central Youth Union
Hanoi
The meeting stressed the urgency to address the contemporary problems of today’s children. The following issues are of great importance. They are listed in no particular order and reflect points addressed at the meeting as well as comments made by the three distinguished participants who reported on the meeting.
1. Child abuse and exploitation is becoming a problem of increasing dimensions which has been recognized by both developed and developing countries.
2. This realization has been actualized by conducting local, regional and international meetings with the intent of preparing a global declaration to prevent and control sexual abuse and exploitation of children.
3. Relevant rules and policies are in place but the political wheel need to succeed.
4. Formal and Non-formal education plays an important role in preventing child abuse. In many countries, the education level is very low and there is no sexual education in school to help prevent abuse and prostitution.
5. Close collaboration must be forged between governments, NGOS, parents, church and other society sectors.
6. Spirituality must be enhanced among our youth
7. The participation of the youth is crucial to the successful implementation of programs.
8. Governments show low compliance to their commitments towards prevention and control of child abuse and prostitution.
9. Traditional cultures have some negative practices which exclude women from reintegrating into her community after she has lost her virginity outside of marriage.
10. In addition to economy, culture, society, and other events, the prevention of child abuse and sexual exploitation to the concept of Globalization.
PANEL DISCUSSION
IN AND OUT OF SCHOOL HIV/AIDS EDUCATION/ LIFE SKILLS DEVELOPMENT
WORK OF UNFPA AND UNESCO
FRANCISO ROGUE: (UNFPA, BANGKOK)
I UNFPA ACTIVITIES
Mr. Rogue showed detailed transparencies showing the components of UNFPA’s support in the area of HIV/AIDS. The areas covered were:
1. Country
2. Target groups. These vary from country to country, ranging from individuals to health services.
3. Entry-points for interventions. This area specifies where the assistance is introduced. Included here is a list of the various agencies, institutions and/or events involved in the prevention programs in each country. These are all existing UNFPA projects in each country. Knowing the entry points is valuable because they detail the approaches and mechanisms that have been approved, thus providing valuable information that can be used when requesting funds and support for other programs.
4. Mechanisms and/or approaches used. A wide variety of approaches are practiced in all the countries, ranging from mass media campaign to family-centered approaches.
5. Implementation and cooperating Agency/agencies.
UNFPA supports only specific activities, as opposed to programs, the fall under its mandate. Is has, therefore, not addressed the HIV/AIDS in each country systematically . This assistance provided is sporadic and based on need. UNFPA assistance generally takes the form of integration into existing activities, such as:
1. Training component/curriculum of a particular program.
2. Service component of a particular MC/AIDS reproductive programs.
3. Specific Events like “World Population Day” .
4. Use of NGOs in specific countries, particularly in HIV/AIDS areas considered sensitive by the countries.
There is a growing involvement of young people in the planning, development, monitoring and evaluation of the activities. Most of the target groups, however, are not the youth, so they need to get more involved. Many funded activities happen at specific times, and are integrated into the MCH family planning or reproductive health. Many activities are innovative in getting young people involved. For instance, UNFPA funded two school publications and let the students write articles on matters that concern them.
II UNESCO ACTIVITIES.
There is an ongoing project funded by the Japanese government which started in 1996, which involves in-school education for HIV/AIDS. The project, which will end in December, 1998, focuses on the quality improvement of the curriculum and of teaching/ learning materials. UNESCO, Bangkok, is the executing agency with the participation of six other organizations.
The project is conducted in three phases:
1. National studies are conducted to analyze curriculum, school counseling support and to compile teaching/learning materials.
2. Regional workshops are conducted to develop a common framework for implementing strategies.
3. Implementation of teacher/training activities.
Based on country reports, the preliminary findings in the various areas were:
1. Curriculum and Teaching/Learning Resources
a. Over-crowded school curriculum
b. Poor quality of curriculum
c. Curriculum objectives are not clear/comprehensive
d. Focus is on information rather than attitudes and skills.
e. Inadequate distribution of materials and inappropriate material adaptation.
f. Inadequate policies to support HIV/AIDS prevention education.
g. Lack of teacher confidence/ interest in the use of the participatory skills teaching methods.
h. Inadequate pre- and in service teacher training
2. Other Issues
a. Inadequate coordination of school-based HIV prevention education at the national, regional and local levels.
b. Issue of HIV education is regarded as too controversial.
c. HIV/AIDS competes with other community concerns, thus receiving less support.
d. Lack of coordination of community resources, including human and financial.
e. Lack of availability or access to community resources.
f. Inadequate advocacy to support HIV prevention education
h. Unclear or unbalanced responsibility for school-based HIV prevention education between the health and education sectors. This point is very important because there needs to be clear understanding between the Health and Education ministries, otherwise there will be a lot of confusion.
Mr. Roque proceeded to present the consensus arrived at the 1997 Beijing Workshop:
A. Teacher Development
n Training does not address teachers' needs, particularly in the areas of confidence/skills
n Lack of involvement of teacher's in the implementation training institutions
n Lack of implementation/follow up after the trainers are trained.
B. Curriculum And Teaching/Learning Resources
n Curriculum is overloaded
n Emphasis is on information to the detriment of the attitudinal aspects and skills training
n Materials are underutilized, poorly distributed or inappropriately adapted to the setting.
n Monitoring of curriculum implementation is weak
n Lack of training of curriculum planners and writers
n Inadequate support by policy makers and program implementers at different levels
C. Other Broader Issues
n Strong needs for research on KAP (knowledge/attitudes/skills) including situational analysis to determine the needs of students, teachers, parents and community
n Lack of centers of excellence. There is no specific place where people can be sent for training of HIV/AIDS prevention
n Lack of school-based and community referral agencies for counseling and support services (i.e. community agencies, nurse, guidance officer, school health educator)
Based on the above, Dr. Roque presented the priority areas that must be addressed in the region.
A. Priority Areas For The Region
n Teacher Training Development- Coordination, communication and monitoring of teacher training activities
n Need for research to support HIV/AIDS-related teacher development
n Creation of in-county pool of experts
n Design and implement sustainable and supported teacher training program.
In the area of curriculum and teaching/learning resources, there must be:
n An effective use of existing curriculum frameworks and resources
n The development and implementation of policies on appropriate integration of HIV/AIDS prevention education
WORK OF THE THAI RED CROSS
Greg Carl,
Thai Red Cross, Bangkok
The traditional paradigm of HIV/AIDS Education is that if thorough information is provided, people will automatically want to change their behavior. The Thai population contradicts this assumption, because they a have level high information on HIV/AIDS but are still unable to apply it for behavioral change. Developing prevention and coping skills is more effective because the Health-Belief Model assumes that people have the capacity for decision making, problem solving, and other necessary skills to achieve behavioral change. Thus, what is needed is a program that will assist in developing life planning skills the influence decision making, problem solving skills, which directly influence behavior that will help people respond in an appropriate manner.
Mr. Carl presented a conceptual model that begins with “Knowledge acquisition”. Mr. Carl felt that the word “information” was more accurate because most people have a lot of information about HIV/AIDS/STD but cannot apply it, whereas “Knowledge” is information that can be applied when needed. This “information” needs to be accompanied with “skills building” to develop attitudes and appropriate behavior to achieve positive health behavior and prevention of HIV/STD.
The Thai Red Cross has modified its HIV/AIDS prevention programs over the years. Originally, it concentrated on providing information by showing people in the final stages of AIDS, and pointing out that those at greater risk belonged to “undesirable” groups. This caused discrimination against those were already infected and against certain groups in the society. The issues of non-discrimination, and living with people with HIV/AIDS were added. Because people still looked at the HIV/AIDS as being the problem of a risk group rather than a risk behavior, the issue was personalized by the addition of reproductive health into its program, stressing marriage, family planning. While useful, the approach is not relevant to most young people because they are not yet thinking about family planning when they become aware of their sexuality. They are at an experimental stage and want to have fun.
To address this larger issue, the ‘FACTS FOR LIFE’ campaign was started, based on a booklet by UNICEF/UNESCO/WHO, which addresses HIV/AIDS as part of the general health issues rather than being segregating it from other health concerns. HIV/AIDS is no longer addressed only special occasions. It is brought forward as another issue to which people must react productively in order to prevent it. Individuals, particularly out-of-school youth, must look at their goals and expectations and at the skills they need to reach them. They must prioritize and be realistic. They must also be aware of how to deal with the obstacles that come up on their way to reaching those goals.
In this model, problems and obstacles are looked at in the general sense (e.g. buying a house) before the issues of HIV/AIDS are brought in. People must think about the consequences of actions such as going to a massage parlor and the effects such actions can have on their long-term plans. People are taught not to try and solve all problems at the same time, but to choose a fundamental problem to focus on in order develop the skills required to solve it. This will increase the chance of solving that problem effectively. The advantages and disadvantages of each solution must be carefully weighed before making a decision. Parallel to these skills, people are taught that change is a continual process and that sometimes we need to re-evaluate goals and expectations, either because they are to high or not what is needed.
The Thai Red Cross currently works with the “In-School Youth Programming”, where a lot of time can be spent with the target population. With other youth, the amount of time is limited, so instead of talking about proper attitudes etc, the program beings with developing skills to influence proper behavior and, in so doing, develop proper attitudes at the same time. Other activities of the Thai Red Cross are:
a. Working through the schools to help reach the local communities. This involves coordination with CBO’s, NGO’s , families, community leaders and local health officers to reach out to the youth.
b. Develop camps where in-school youths will trained out-of-school youth.
c. Community theater workshops using the information obtained in the camps
d. For urban youth, the same programs work well, but some of the agencies through which work is done are changed because there is s more structured environment to work in. Currently they work with street youths, factory workers, out-of-school youth in the non-formal sector, restaurants.
Youth is incorporated into the design of the project by doing focus group discussions and in-depth interviews and by also having them conducting community-based service in their own environment. They collect the information and bring it back for further development and fund-seeking. To evaluate life skills, pre- and post-tests questionnaire surveys to determine if the youth have enough information about HIV/STD, and if they have proper attitudes. They work together in a peer review settings, so they talk about the problems, provide support in finding solutions.
WORK IN THE CHIANG RAI PROVINCE IN NORTHERN THAILAND.
Sumalee Wannarat, Teacher
Chiang Rai, Thailand
Sumalee introduced herself as a teacher in a small school in the northern Thai province of Chiang Rai. When she started working she did not know anything about AIDS, and talking the infection was taboo.
As more people contacted and died of AIDS in nearby villages, she learned more about it and wanted to get involved in preventing it. She started working with children by providing information about the infections. The aim was to work with children so they could, in turn, take the information to the villages. Since the perception is that it is unacceptable for children to teach adults, the children staged plays as well as other activities. Initially, she didn’t think the adults would accept these “lessons”, but their pride in watching their children perform made them accept what was being taught.
After two years of working in her own village she felt she had to expand the programs to other villages. Later, experts from outside helped evaluate the programs and helped designed a direction. She was eager to urge the youth volunteers to plan solutions. She started in the schools and, with the help of volunteers, she went to work in the villages as well. She realized that AIDS was not the only problem. Issues like poverty, drug abuse, migration and sex trade were all interrelated and had to be addressed as well.
She found that AIDS affected three main groups:
1. Children who parents died of AIDS, and were thus, left orphaned (orphans)
2. Woman who had been infected by their husbands.
3. Seniors in whose care the orphans were left.
As the community learned of this, funds were set up to help these groups.
At present there are 12 villages in the program, all following the basic idea started in the first village. The current aim is to sustain the work being done and to, eventually, cover all the 20 villages in the area. To do this the sub-district office has been informed of the work and convinced to provide assistance. They have already set up projects and funds to help HIV/AIDS patients. This year they were granted 100,000 Baht. Now she recruits interested teachers as well as students from other schools to help. She has also set up a network among all the seven schools in the sub-district.
Ms. Wannarat stressed that work can start voluntarily from within the community and later outsiders can be brought in to help. It is hard to obtain enough funds, but not impossible. The lesson to be learned here is that community-based work can succeed in the fight against HIV/AIDS.
Nancy Fee added that this was an example of what one committed individual can start and how that individual can mobilize others. Things can happen and can be sustained.
WORK IN DEVELOPING CURRICULUM ON HIV IN SCHOOLS.
DR. TIN MAR AUNG
UNICEF,
MYANMAR
Dr. Tin spoke briefly about how the HIV-inclusive curriculum was developed in Myanmar. The curriculum is called SHAPE (School-based Healthy living & HIV/AIDS Prevention Education program) and had it’s inception in 1996. In the 1998-99 school year it will be introduced in grades 2 - 9 (7 - 16 year-old students). This curriculum replaces an earlier one, which was medically oriented and proved inadequate upon further evaluation.
Based on the principle that “Healthy living is essential to prevent HIV/AIDS” SHAPE stresses on teaching students life skills and healthy living. The curriculum includes a comprehensible language that should be used with school-aged children. It is also informative and practical. The curriculum consists of 72 lessons covering 140 teaching periods, for a total of 105 hours. The lessons are integrated into the general curriculum. The Ministry of Education developed the syllabus in a way that it is not necessary for the teachers to plan the lessons. Follow up activities are given to assess the efficacy of the curriculum. The curriculum is being implemented in 30 townships across 13 states. The activities developed for the syllabus are designed so that the teachers can use those that are most appropriate for their areas.
They curriculum is activity-based and contains things like discussions based on the experiences of the children. Materials like cartoon pictures, flow charts, pockets charts are used to discuss not only HIV/AIDS, but also topics like smoking and care during pregnancy. Other activities include demonstrations, descriptive readings, role play, poems, etc.
The curriculum has been tested three times and has been evaluated in the field. It will be used in all basic schools. Short and effective training courses for teachers were developed to ensure familiarity and appropriate implementation of the curriculum. Some basic and essential information is included:
-HIV/AIDS and services in Myanmar.
-UNICEF assisted HIV/AIDS programs
-Overview of SHAPE program
-Health promotion where school can play a role to strengthen existing health activities.
-How to strengthen the roles of community members, and their function in motivating
parents and implementing the SHAPE program
-Life and social skills.
-Effect of changing conditions and of the media on behavior related health problems.
-Role as facilitators in HIV/AIDS
-Counseling and guidance
The training for teachers follows the “cascade model” and has been conducted in 30 townships. Thus far, 16,000 teachers have been trained. Many trainees were initially reluctant but later were enthusiastic about fulfilling the objectives of the program, which include:
1. To lay a sound foundation for the utilization and practice of healthy habits which would have life-long benefits
2. Based on the principles of love and compassion to promote relevant life and social skills which enable one to participate in proper supportive care for one’s fellow human beings.
3. To provide appropriate knowledge, skills and information for the promotion of preventive health.
4. To provide relevant HIV/AIDS health knowledge, skills and information.
5. To promote the awareness that preventive health is more beneficial than curative health.
SHAPE membership will be formed in every township.
GENERAL DISCUSSION ON MORNING TOPICS
n Many countries struggle about teaching sex education to school age children. Changing the curriculum is not easy, and some countries have a very limited amount of time devoted to Health Education. Also, teaching about certain things (e.g. condoms) is considered taboo.
n Giving information is not enough. Skills based work is very important. It is not appropriate to look at the HIV issue narrowly. There is a need to get everyone involved. It is often hard to get help from people in high positions. Decision makers often ignore the requests regarding HIV/AIDS education. There is still the perception that the infection is a problem exclusive to a certain group (e.g. prostitutes) rather than a societal problem.
n A major problem is that there are no real excellence centers to cope with problems. It is also very hard to obtain funds to replicate the pilot materials. Applying a curriculum that relies on a participatory style of learning is difficult because teachers rely on rote, which does not help in developing skills. If the teachers do not use the participatory approach, it will fail. The teachers need to develop skills in the participatory style of teaching. One approach is to afford practice in the participatory method during training sessions so that teachers become familiar with it. This tactic, combined with the design of specific modules within the participatory styles allows the teacher to follow the curriculum without having too prepare too much, yet can still address the issues effectively and appropriately. An important issue is the clash between traditional cultures and a new style of teaching.
n There is a lack of political will among policy makers and a lack of information exchange and communication between people working in the same country.
n Reproductive health and AIDS are interrelated. If reproductive health and HIV/AIDS can be fully integrated into a holistic approach, we stand a better chance to prevent HIV/AIDS.
n Life skills can be incorporated in general health class, so that the students at least have a solid foundation of skills building, decision making, problem solving, communication, etc, which get them ready for when they receive HIV/AIDS prevention education. Education and life skills must be integrated as a multi-sectorial approach (general health, environment, community safety, etc), not just concentrating only AIDS.
14:00
TOPIC: YOUTH FRIENDLY HEALTH SERVICES
AIDS IN THE YOUNG PEOPLE
Wiwat Rojanaphithayakorn, Senior Expert
Preventive Medicine
Department of communicable Disease Control,
Ministry of Public Health, Bangkok
At present, the age group with highest prevalence of AIDS in Thailand is the 20-29 year -old. Since AIDS has a very long incubation period (7-10 years), that means that some of the people were infected during adolescence. Based on surveillance activities in the army conscripts, the prevalence of HIV infection in many Northern provinces were found to be over 10%. Therefore young people are in great danger of HIV infection.
Figures from May 1992 (outdated; included in the handout) in the Northern Region show a high percentage of infection among 21 year-old. A total of 18% were found to be infected with HIV. That is a ratio of 1 in 5/6 young men. They were most likely infected at the age 15 or 16. And in -depth study found that over 50% used drugs; 75% had their first sexual contact with prostitutes; 13% had sexual contact with their peers (with girlfriend; at school, hotels).
Thailand has many important days that have been borrowed from the west. Valentine’s Day is particularly popular among young adults. A “quick and dirty” study found that on that day:
1. There is an increase in the price of red roses;
2. Rental of rooms in short-time hotels;
3. Increased sale of condoms
Other things that people “copy” is the use of narcotics, particularly the injectable drugs. This is of particular concern when the used of drugs is done by leading movie stars because young people tend to want to copy their behavior. Young people are at a high risk because they experience constant peer pressure to try “taboo” behavior. There are many underlying behaviors or conditions of the youth that place them at very high risk of HIV and other social problems:
n Frequent visits to sex establishments
n Sexual promiscuity
n Consumption of narcotic drugs
n Commit crimes for money to buy drugs or sex
n Failure of school education
n No job
n Health problems: drug addiction, STD and HIV
n Unwanted pregnancy; abortion
n Broken family
n No future
Dr. Suporn Koetsawang
Mahidol University
Thailand.
Dr. Suporn talked about the increasing risks and problems of adolescents in Asia. Some of the contributing factors are:
1. Early sexual maturation (MENARCHE). Many girls start at 9 -10, with average age being 10-13 years
2. Longer dependent period, because of the long period of education
3. Increasing gap between adolescent and adults
4. Increasing influence of peer pressure
5. Increasing opportunities for “adult free” time, particularly in broken family situations.
6. Declining influence of cultural/religious values
7. Increase in premarital sex. 60-70% of the boys and 10-20% of the girls in Thailand have sex at the age of 16 -17.
8. Moving toward industrialization in this area, resulting in the young migrating to the cities to work which takes them away from their parents
9. Expanding commercial influence
10. Increasing power of the media
The last two issues have a lot of impact on the adolescents. The adolescents nowadays are very different from when their parents were adolescents. We must, therefore, have a lot of empathy and understanding for our adolescents.
The risk for STD among young adults is quite high because of behavioral susceptibility. Behavioral aspects that place them at high risk are:
n Feelings of invulnerability
n Condoms are not used consistently or correctly
n Multiple partners or partners who have multiple partners
n Drug and alcohol use
n For young women, there is biological susceptibility because Cervical ectopy makes it easier to get STD.
Young women do not carry condoms because of the stigma attached. They will branded as being “spoiled” or promiscuous. For males, wearing condoms is often equated with personal devaluation. Because there is still no vaccine to cure AIDS, prevention strategies for the adolescents are essential. Dr. Soporn showed disturbing figures which indicate that over 70% of the HIV infected mothers at SIRIRAJ HOSPITAL (1991-1997) were under 25 years of age.
The spread of HIV in Thailand started in 1984. Up to 1988 it was found in mainly in male homosexuals, bisexuals and IV drug users. In 1989 it had spread to sex workers, mostly female. By 1990 it had moved on to the heterosexual male (single or married). From 1991 onwards these males spread the disease to their wives or women with whom they had sexual encounters, and, by extension, to infants.
Dr. Soporn then introduced the Thai Multisectorial AIDS program, started in 1987. Because of the 3 - 4 year delay in implementing the program, the spread of the disease was rampant throughout the country. He warned other countries not to delay actions.
The Thai Multisectorial program involves ministries, non-governmental organizations, multilateral donors, and the private sectors. The program focuses on public information, education and prevention. In addition, there was a mass media campaign promoting 100% condom use, as well as the implementation of HIV testing facilities in all government hospitals. In 1989, a systematic screening of blood and blood transfusion was started. The program also focuses on human rights and social support. In 1990 a counseling plan was implemented as well as recommendations against discrimination, and the promotion of anonymous testing. The program promotes research to guide intervention and policies such as Biannual Sero Surveillance Survey.
In 1995 the Government assigned $60 million USD for AIDS prevention, and an additional. $8 million dollars for ANTIRETROVIRAL/OI treatment. The most effective treatment is the prevention of transmission from mothers to infants.
Young Adults need information, skills and access to services. Providers need to know how and where to reach youth and what contraceptives and STD services are needed. Dr. Suporn emphasized the point that programs by adolescents for adolescents should be organized, and that they must be involved in the design, plan, implementation and evaluation of such programs.
The last portion was devoted to the characteristics that youth health services should have. These are:
1. Convenient location and time.
2. Using peers as communicators so they can talk to their friends.
3. Privacy and confidentiality
4. No red tape
5. Service should be free or provided at a nominal cost.
6. The staff should have a positive attitude
7. Personalized, brotherly, non-judgmental environment/approach
8. Minimization of embarrassment during examination
9. Advice on appropriate contraceptive should be available.
The last point can be controversial. In Thailand the distribution of condoms is acceptable but contraceptive pills for young women is not.
A slide on HIV prevalence in royal Thai army conscripts was shown indicated that from 1990 to 1993, the prevalence increased from 1.6% to 4%. It then shown a consistent decrease to a current 2.2% thanks largely to the education campaign. If a concerted effort is made to work the youth adolescents, there is hope. They must, however, participate in the programs.
SOCIAL MARKETING OF CONDOMS
Steven Honeyman, Country Representative,
Population Services International, Yangon
What Is Social Marketing?
Social marketing is a methodology that uses modern marketing techniques from the private sector and applies them in the public sector. It aims at the distribution of needed health products, in this case condoms, to low income and marginalized groups at an affordable price. Social marketing uses the existing local commercial infrastructure and innovative communications campaigns.
Why Is Social Marketing Needed?
1. Many people in both developed and developing countries do not have access to or
cannot afford needed health products.
2. Government clinics often provide insufficient coverage
3. Generic health products that are free-of-charge are not valued/under-used
How Does PSI Market Health Products ?
1. Procures products locally or internationally. PSI purchases 500 million condoms per year.
2. Sets up a distribution system by working with local wholesalers and retailers. The particular method is determined by the circumstances of the country.
3. Creates and advertises brand-name product for the particular markets
4. Designs and implements powerful communications campaigns to encourage
healthful behaviors
5. Sells product at an affordable price.
Why Does PSI Sell Products ?
1. Purchased products are more highly valued than "give-aways"
2. Profit margin on resale encourages widespread commercial distribution.
3. Revenues can be used to offset program costs. Also, everyone selling-chain (from wholesaler to buyer) gets a small profit. It is that profit that acts as a motivator for the program to continue successfully.
WHO DOES PSI TARGET?
-General public -Urban/rural ;
-Males/females -Young adults
-Children/youth -Service providers
-Media -Opinion leaders
-Transient populations -High risk populations
*commercial sex workers/miners/
truck drivers
Because each group is different, different techniques/messages must be used to effectively reach every group.
Why Is Social Communications Needed?:
1. It promotes behavior change
2. It increases knowledge, attitudes and practices
3. Effective campaigns successfully overcome "resistance points" of target groups, resulting an in increased demand for condoms
PSI and Social Communications Methods
1. Mass Media
- Television and radio
- Print materials
- Music/songs
- Mobile video units
2. Interpersonal communication
- Peer Counseling and education
- Training of service providers
- On-site: workplace, schools and markets
- Journalists
Each program is designed appropriately for each country. In some countries, PSI does not have access to mass media, so the interpersonal campaign approach is used. Mr. Honeyman showed examples of the types of campaigns used in different countries. Both modern and traditional methods are used, ranging from videos, radio shows, songs, dances, stories, puppet shows, etc., to communicate HIV, and promote prevention and condom use. The youth are employed to run some of the programs. Before designing appropriate campaigns for the youth, a lot of research is conducted to find out what they find attractive. Young people also help in the distribution of condoms.
Advantages of Social Marketing Projects;
1. Produces impact quickly. For example, two million condoms were sold in six months in Myanmar.
2. Creates behavior change and awareness increases.
3. Condoms are made available and affordable
4. Promotes innovation and creativity.
5. Social marketing reaches all social levels, because those who cannot afford to buy condoms, can get them for free.
6. Bridges the gap between private and public sectors.
7. Consumers can remain anonymous, avoiding embarrassment.
8. Targets high-risk groups.
9. Develops non-traditional outlets for the distribution of condoms (e.g. taxi drivers)
10. Takes into account the cultural context.
Disadvantages of Social Marketing Projects:
1. A long term focus is needed to have impact (10-15 years to see effect)
2. Hard to find people with expertise in both private and public sectors to do marketing
3. Social marketing is expensive, so raising funds is difficult
4. Takes a long time before countries adopt social marketing.
5. Even though It gets people to use condoms, it does not train people on life skills.
6. It reflects changing cultural values, which is hard for people to accept.
7. It opens doors to corruption
8. Access is to mass media depends on the policy of each country
9. There are still gaps in the groups of people which don not fall under the PSI categories for free issuing of condoms
10. Social marketing also runs into the problem of “indifference” in many countries, where the attitude is that the HIV/AIDS is “someone else’s problem.”
11. stigmatization of condoms, because it is seen only as a commercial sex product.
Social Marketing should be seen within the context of country’s response to HIV/AIDS. It is only one component. It is powerful but limited.
14:35 RESULTS OF SMALL GROUPS DISCUSSIONS.
TOPIC
Both Life Skills and Youth Friendly Health Services are important, essential and complex
programs. How can we build successful partnerships to plan and implement these
programs?
Please consider the role and contributions of:
· the health sector
· the education sector
· NGOs
· Communities, including parents
· Young people themselves
· others
GROUP 1
LIFE SKILLS
Life skills education are divided into formal and non-formal. Formal education can contribute by having master trainers, providing technical input, integration into MCH and reproductive health and coordination, peer training and counseling. They can also train through school health and physical education classes. There should be teachers’ training, both in and pre service, and an integration of the issues into the existing local curriculum. The inclusion of needs assessments and extracurricular activities would also play a role. The community can also be part of the programs including parents, religious leaders. The community can also be part of the programs including parents, religious leaders. Young people can become peer educators through role play and youth groups community.
Non-formal education can take the form of information as well as entertainment. Peer training can take place as well as the development of manuals for literate and illiterate people. NGO should start research, give technical assistance, develop other activities like needs assessment; training and capacity building. Also counseling including anonymous Counseling over the phone. In addition, the community can be involved in activities such as family day events. The counseling can be done by both the parents and the religious leaders. The youth can become involved in the design, implementation and evaluation of the programs.
Different countries have different entities and not all have the same functions from country to country. In the formal sector, policy making is very important, especially the ministries. The donor agencies can be organizing key players and provide technical and financial assistance. Political commitment is extremely important as well. These issues apply to the non-formal sector as well.
GROUP 2
YOUTH FRIENDLY HEALTH SERVICES
There must policy decision, and political and social will, as described in the conference. What should these services provide?
-Preventive Service. This means: promotion; specific protection; early diagnosis and treatment; recurring healing and reintegration. They should also provide STD and HIV management, pregnancy and abortion treatment, family planning methods. They should also stress on relationships; social and religious values; counseling, etc.
The approach should be holistic rather than limited to HIV/AIDS.
The health care system should provide this services and they must include Robert Moodie’s 9 points. Teachers have an important role and can be involved in the first 8 of the 9 points. NGOs should also be involved in all aspects, excluding those that are purely medical.
Each country should decide on the best approach. For any approach to succeed there must be organization development and capacity building. All parties involved should be mobilized. Further, there must be cross - postings so that qualified people provide assistance in various places. (e.g. assign counselors to schools to deal with these important health issues affecting the youth). Finally, there should be study tours for the youth to see how others are working.
GENERAL DISCUSSION: Sessions I & II
QUESTION: In what grades should we have condom promotion? How should it be conducted so that we overcome the resistance by parents, teachers, etc?
ANSWER: UNAIDS Geneva released a summary of the results on the topic of whether education on human sexuality promoted promiscuity. Findings negate the idea of early initiation. Of the 65 international studies, all but 5 showed NO positive relationship. If we tell youths about sex, they will not be promiscuous. If children are exposed to information since pre-school, they’ll begin to form their notions at that early age. Young people can handle honest, comprehensive information and they can use it constructively. All the studies are from industrialized countries, however, which may or may not be similar to what is true in the developing countries.
Regarding how to best introduce condoms to young people, various approaches were mentioned. In some of Thailand’s vocational colleges, self-help AIDS education clubs have been formed and have been supported by some sources with condoms, educational materials and money to run the activities. It has been very effective in raising awareness among peers. Condoms were available to a degree, but not widely because the school administrators were sensitive to the issue. Younger students seem to have an awareness of the effectiveness of condoms. Other approaches are to have health workers, rather than the teachers, provide instruction on proper condom use. The use of leaflets, containing all the pertinent information, as another technique used to teach correct condom use. In some countries, after-school activities on the subject seem to work well with peer education, where the older students learn and pass the information on to the younger ones. In countries with a social marketing approach, it would be worthwhile to open a dialogue with the parents so that the issue of values is introduced, so the youth can develop the proper attitude and not just look at condoms as a mere commodity.
In some places, teaching about condoms is not accepted by the society and government, because it is viewed as promoting sexual activity. People must be encouraged to understand that such programs are aimed at changing risky behavior and teaching sexual responsibility. This includes discussing the advantages and disadvantages of sexual intercourse before marriage. If they realize that generally there are few advantages to pre-marital sex, they will be less likely to do so. However, they should know how to protect themselves in case they do engage in pre-marital sex. Realistically, adolescents cannot be stopped from going to brothels. It may be possible to get them to visit such places less often, thus altering their behavior, if only somewhat.
In Indonesia, condoms are advertised as a means for family planning, but not as preventive STD measures. Sex education was attempted five years ago, but people responded negatively to the name, so the name was changed to “Adolescent and Productive Health Education”. The use of condoms will be included “silently” in the package developed with the help of Family Health International.
The promotion of condoms in both primary and secondary schools can be done in a more indirect manner. In Thailand, the majority of Health Teachers are single females. If they promote the use of condoms, they are looked at with suspicion. However, if the assistance of married teachers is engaged, matters can be more easily handled. Also, the use of condoms and other contraceptives can be introduced within the context of activities aimed at educating the young people within the context of building relationships. Activities like “101 Ways to say I love you without having sex,” in which men and women write their ideas separately, and then compare them, are extremely valuable ways of dealing with the subject. This is followed by “101 ways to tell us they love us.” The males answers to the first activity are compared to the females answers to the second activity, and vice versa. This is an eye opener because they realize that men and women think differently. Men are more into releasing sexual tensions, whereas women are looking for a more emotional bond.
Teachers can have a supply of condoms to give to kids when needed. Generally, in all schools there are teachers that the students look up to. Those teachers can keep a condom supply without creating uncomfortable assumptions about them. Schools can act as referral services. In some areas there are “condom points” appointed for the distribution of condoms any time of the day or night.
A complimentary strategy to condom promotion is the school system is the use of mass media. In many countries the use of condoms are advertised on TV but the ads are designed to avoid offending the sensibilities of the community at large. One strategy is to advertised condoms without using the word “condom”. This seems to be completely acceptable to the community. In Thailand, for instance, condom is referred to as “healthy rubber sack”. The word “healthy” makes people feel better.
In Singapore’s sex education texts, the word “condom” is nowhere to be found, even though the sex education program has been in place for five years. It concentrates on discouraging pre-marital sex, multiple partners and the use of needles. By introducing sex education in stages, an uproar from the community is avoided. They have time to get used to the fact that sex education is part of the curriculum.
Although the approach of introducing sex education in stages was seen as valid, some people expressed concern that it was too slow and that at this stage it was imperative that sex education programs dealt openly with the issues if prevention was to have an real chance at succeeding. It is extremely important for the youth to learn to protect themselves. Teachers, administrators, etc. have to open up their minds and allow the education to proceed.
When looking at formal curriculum and educational programs, we have to be mindful of the ethnic variety in each country. Even countries that describe themselves as homogeneous, really are heterogeneous. These differences must be taken into account when developing prevention and education programs, in order to reach every single group within each country.
END OF DAY ONE
DAY 2 SESSION II : Wednesday, 3 June, 1998
Summary of the First Day’s Topics
Nancy Fee
Rob Moodie, identified five key themes, which were further highlighted and developed during the day. Rob noted that the course of-the HIV epidemic is being determined by young people, as over 50%, of new HIV infections occur in that group. Yet: the behavior change observed in countries like Thailand, indicate that there is still a potential for change is among young people. With skills, knowledge, and a protective social environment, young people can learn to protect themselves, thereby to change the course of the epidemic.
The importance of involving young people in all elements of the work was highlighted. The World AIDS Campaign this year is "with", not "for" young people. Shararda Chowardy, speaking for the youth of Asia. was a living example of this. "We want to be consulted, we want to be consulted-', she emphasized. Both speakers emphasized that young people have both rights and responsibilities.
Mr. Moodie opened the theme of partnerships, noting that the successful HIV programs have all been partnerships - within communities, between governments and NGO's, with the media, and business communities. This idea was further developed during the with practical examples of successful programs.
Mr. Moodie’s last theme was that once we have developed our work, have involved
young people, and have built partnerships, then we need to step back, and "let it happen". The implication is that if we attempt retain too tight a control over the programs, we will be sacrificing real participation, the energy and enthusiasm of our young participants, and perhaps limit the achievements of our work. Once we have done a good, professional job, we need to give space for others, and for our aims to be achieved.
Following Mr. Moddie’s speech, three participants reported on the previous day's work, which centered around everyone’s attendance at the ESCAP meeting on the elimination of sexual abuse and sexual exploitation of children and youth. All three noted, the day was a real "eye opener", and showed us the depth and complexity of the problem, along with the need for urgent and comprehensive action.
The Panel Session on In and Out of School HIV/AIDS Education: Life Skills Develop- ment took forward a number of the key themes that Rob and Shararda had already identified. Briefing the participants the work of UNFPA and UNESCO in the region, Mr. Francisco Rogue outlined the integration of work with young people into the broader approaches of reproductive health, which links together sexual health issues in a way that makes sense to young people.
Mr. Greg Carl noted that in the work of the Thai Red Cross with out of school youth in
Thailand and some of the surrounding countries, it was realized that a life skills approach
was needed, which supported young people in identifying their life goals and expectations, and in developing the skills that they needed to work towards achieving these goals. These skills include decision making, problem solving· communication.. and
HIV prevention This framework ensures that young people are able to apply what they
learn to their lives in a holistic and realistic manner.
Sumalee Wannarat from Chiang Rai showed the power of the committed individual,
and of communities that are mobilized to fight HIV infection. She described her work
with youth volunteers to reach and educate the community - and the process to develop a supportive environment for behavior change. Her work also provides a practical example on the importance of partnerships and of letting things happen.
The last panelist in the morning was Thin Mar Aung, Who told us about the development
of the school curriculum and teacher training in Myanmar. Careful development, building
of` teams, and pre-testing, has all led to the development of an effective curriculum, which will be implemented from the primary level upwards.
After the morning panel session, we had a short time for discussion. The problems of get ting commitment for action in low HIV prevalence countries was noted, along with
difficulties in finding time for life skills education in over-packed curriculum. A number of participants noted their experience in integrating HIV issues into the curriculum, in
working with extra curriculum activities, and in taking broader approaches. such as the
"health promoting schools" approach, which enable the integration of HIV issues.
The afternoon session was on Youth Friendly Health Services. Professor Suporn
highlighted changes which have put young people at increased risk of HIV infection, and
other reproductive health problems, including pregnancy and STD infections. He noted
increasing adolescent sexual problem, the behavioral and biological susceptibility of young people to reproductive health problems. In noting the requirements of a youth
friendly health service, he emphasized Save us a list of key requirements, including: a
convenient time and location; youth as communicators to promote the services; privacy
and confidentiality; no "red tape" procedures; services provided for free, or at nominal
cost; a personal, brotherly and non-judgmental approach; positive staff attitudes,
minimizing embarrassment during exams, and appropriate contraceptive advice. From
discussions after the session, I know that many of us found the Professor's brief
presentation to be inspiring.
Steven Honeyman gave a good briefing about social marketing, and the place of social marketing in providing young people with effective access to condoms. He explained the concept of social marketing, the experiences in the region and globally, and the advantages, disadvantages and limitations of social marketing.
At the end of the day, there was a discussion on the role and contribution of the various sectors to the development and implementation of Life Skills Development, and Youth Friendly Health Services. Discussion by the groups identified a range of approaches, and some common themes. Many of these issues reflected back again to Mr. Moodie’s key themes for the day: young people as a priority, partnerships, and working with rather than for young people.
SESSION II (continued)
TOPIC: DRUG USE AND HIV/AIDS VULNERABILITY
Dr. Jennifer Gray: Principal Policy Officer
Illicit Drug and Health Units
North Sydney, Australia
Among the hilltribe people in the northern Thai province of Chiang Rai there has been a quick shift from opium smoking to heroine injecting. In 1989-1990 the Hill tribe people smoked opium. Within two years, 50% of them had shifted to heroine use. Of this group, half of them had shifted to injecting heroine. Heroine injecting could reach epidemic proportions soon. The Thai part of the Golden triangle is where major UN crops substitution programs have taken place successfully. The hilltribe people no longer had opium to use for medicinal or for recreational purposes, thus becoming dependant upon the supply of opium from Myanmar. However, in the Chang state of Myanmar the production of opium switched to the processing of heroine, so what crosses border now is injectible heroine. In 1992, 60% were daily heroine users, with half of those using the injectible kind. Altogether, about 50% of the male population and 30% of the female population became addicted. This series of events has unleashed tragic consequences, including:
n Young women going into the sex industry because they need money to purchase heroine, which is a more expensive drug. Six years later, HIV was present in 35% of the injecting drug users and 70% of those in the sex industry.
n There are a large number of babies with AIDS.
n Young children see their parents injecting heroine into their bodies and assume that this is a normal part of life. They will emulate that behavior.
To begin the education process, the first step was to employ young people as primary health care workers. The needs of the community required staff employed on a full time basis to do HIV care, run the drug prevention and drug treatment programs. Young people were deliberately selected because it was important to develop leadership among young people so that they, as the next generation of village leaders, would train and have access to skills building. Formal education was not a critical factor in the selection. The program is going into its fourth year. The primary care health workers work very close with the youth of the village. The strategies used are both direct and indirect. Most successful strategy involves sports, which Dr. Grey labels as an indirect strategy. Sports helped deal with two important factors:
1. Finding things for young people to do in their free time.
2. Assist the youth of the villages, who increasingly want to be more like their city counterparts, in developing life skills to deal with urban vs. Rural differences.
Through sports, the following has been achieved:
1. The young are playing a lot of sports together
2. They play sports with Thai people in the lowlands (more urban areas), thus learning how to positively deal with urban life.
3. A strong bond has been created among the youth of the village. At their own initiative, they have formed youth groups. They plan things ranging from team uniforms to the growing of vegetables.
The results are encouraging. From the 60% of male adults who used drugs when the project started, only 2% in the under-25 year old age group are still addicted. Of the female population, 80% used to join the sex industry. Now, none do. The primary health care workers have become strong peer leaders and are now going to other hilltribe sites as well as to Thai villages to talk about their activities. Another positive outcome is that the members of the community see people from their own ethnic background in positions of leadership. This helps influences the choices they make. There has been, for instances, an increase in the number of people who want to go to school to get a formal education. Even though the community works with other agencies and with NGO’s, it is people from within that keep the project alive and successful. An important function of the policy makers, then is to provide a catalyst so that community keep doing it. There are five policy approaches, which are applicable at both national and local levels:.
1. Prevention: life skills education, sports, leadership training.
2. Early intervention and treatment. Needles and syringes exchange, methadone maintenance programs. These have limited the spread of HIV through needle exchange. Methadone maintenance has allowed the family to keep some money for more important needs, like food. Nearly 50% of drug addiction has stopped. It has decreased the need for girls to go into the sex industry. Also, children see that their parents can stop using drugs.
3. Partnerships: Most government departments should be involved in developing policies regarding drugs.
4. Community and family involvement.
5. Monitoring, evaluation and surveillance.
DRUG USE AND HIV/AIDS
Adrian Reynolds, Former WHO Consultant
Queensland
Drug use creates serious problems at the local, national, and international levels. Illicit drugs use have increased as much as cigarettes and alcohol. Unsafe drug preparation and administration practices associated with the transmission of blood diseases is a common feature of illicit drug use in many countries.
Are these risky practices the result of drug policies that severely punish and marginalizes drug use? Do these repressive measure violate the universal declaration of human rights and rights of child? Decisions must be made based on empirical evidence rather than on personal opinion and simplicity of thinking. There are a number of strategies that, based on empirical data, can be effective or ineffective in a wide set of cultural settings.
1. Importance of paying attention to empirical evidence. Too many decisions are made that fail the test of consistency. Politics, inadequate research, naivete are but some of the issues that prevent a decision making process that should be based on empirical facts, and careful implementation and practical experience.
2. Primacy of Public Policy. It reflects and directs the patterns of social behavior. Decision makers must pay close attention to the policy dimensions of their decisions before investing resources into implementation into individual and collective behavioral change strategies. Public policy must enable, support and facilitate changes that serve to protect and promote health.
3. Oppressive drug policy. Empirical evidence (mostly western) suggests that extremely punitive policies do more harm than good policy to support health. People respond best to positive behavioral management (encouragement) than to negative behavioral management (admonition). A lot of human tragedy is created when repressive measures are practiced to eliminate drug use. None of them have resulted in the reduction of drug-related harm.
4. Role of school and community drug education. The belief that we can prevent and deal effectively with drug problems principally through school and community drug education is, empirically, more about unfounded hope and idealism than about realized outcomes. The role of education, however, is:
a. to question many current approaches to health education and other uni-dimensional or simplistic;
b. to challenge governments, non-government organizations, the private sector, researchers and international aid agencies to think and act in a far more knowledgeable, innovative and courageous manner than often appears to be the case at present;
c. to suggest that nations and societies must first pay more serious attention to public policies, social norms and other factors that shape social behavior.
School education must include:
a. provide honest, balanced and unambiguous health protection information that meets the rights of the people to knowledge about the means by which they may protect and promote their good health
b. equip people with the necessary skills to deal with life risks (including those associated with alcohol, tobacco and other drug consumption and to sexual activity).
c. provide is access to the practical means to protect themselves, for example, condoms and sterile or clean injection equipment.
Social and Health prevention programs that ignore the fact that people enjoy taking drugs are less likely to succeed.
Drug Treatment
Abstinence treatments are not necessarily the only options that ought to be available. Often, detoxification followed by rehabilitation in its various forms results in very high and rapid relapse rates due to feelings of hopelessness, helplessness, client-blaming among health care workers and policy makers, and with nihilism and loss of faith in human service providers among those seeking help for their drug problems.
Drug-free oriented treatment and rehabilitation should be available to those who are ready, motivated and in possession of the necessary personal skills and environmental support. “Respite” oriented or “palliative” care may be more beneficial to those who: do not meet the above; who are realistically unable to remain drug-free.
Drug-free treatments are usually expensive in terms of their capital and operating costs. They are successful in attracting people but retain only a very small proportion of the in need population because of the long stays that are commonly prescribed. They also have a high and rapid relapse rate. Involuntary treatments bring with them additional problems and may, thus, no be the solution to drug problems at a population level.
Harm Reduction - What is it?
"The concept of "harm reduction" refers to policies, strategies and activities that are
aimed most importantly at limiting or reducing the extent and severity of problems or harms which occur in any society as a result of drugs and drug use. This approach is based on a realistic acknowledgment that there are no known interventions for completely eliminating drug use or drug related problems in any country, society or community."
Harm reduction strategies that have been found to result in worthwhile size effects related to drug-related harm include:
1. Needle and syringe exchange and availability schemes, with or without ancillary services;
2. Opioid substitution maintenance treatments such as methadone, bupre-morphine and LAAM;
3. Outreach work to promote safer drug use & safer sexual behavior, targeting otherwise difficult-to-reach people who inject drugs
4. Peer support and peer education programs;
5. User self-organizations that are funded, protected and otherwise supported by governments;
6. Condom free supply and cost subsidization programs;
7. Legislation and public policies that enable, support and facilitate harm reduction strategies and activities. (e.g. legislation that legally permits possession of clean injection equipment, regardless of the intended purpose of their use);
8. School and community-based education about safer sexual practices.
NATURE OF DRUGS PROBLEM IN ASIA PREVENTION; VISION OF YOUTH.
Wayne Bazant, Demand Reduction Adviser,
Regional Center for East Asia, UNDCOP
Bangkok
UNDCP agenda is interested in two main aspects of drug abuse.
1. Prevention of onset
2. Reducing adverse effects.
These points are reflected in the challenges and guiding principles in the draft declaration on drug demand reduction. The call for action recognizes de need for effective, relevant and accessible programs for the groups most at risk, taking into account the differences in gender, culture and education. It also focuses on the need to pay special attention to the youth
The current trend of the drug problem in Asia is a move from opium to heroine, increasing injection practices, increase in use of amphetamine-type stimulants and codeine based substances. Many of the users are males, aged 15-30. There is a developing problem of inhalant abuse related to poor communities and young people, often in rural areas. In the case of cannabis, the reduction in its use in some countries has resulted by an increase in the use of substitute drugs like ATS.
The impact is profound in terms of adverse effect on health, upsurges in anti-social behaviors such as crime and violence, draining of human and financial resources, and the destruction of individual’s family.
There is a dynamic relation between the use of drugs and the result of that use. This includes: physical health, social dysfunction, disconnection from accepted social norms,
resorting to unacceptable behavior leading to legal problems, arrests, etc. Young drug users are exposed to high risk situations including injecting drug use, and unsolicited and unprotected sexual intercourse with a consequent exposure to HIV, leading to AIDS.
The intervention projects going on share three features:
1. Collecting up-to-date quantitative and qualitative information on drug abuse patterns and trends among young people. Also, obtaining information on how young people perceive drugs prior to using them is essential, but still lacking.
2. Raising awareness among young people, policy makers and the general public of the risks, costs and consequences of drug abuse.
3. Establishing good practice in drug abuse prevention among young people.
“The Vision from Banff” is a program that provides a very useful strategic context for both prevention and treatment of drug abuse among youth. This was the result of a gathering of 150 young people representing 30 innovative youth programs active in all regions. They compared notes on the impact of drug abuse on their communities and shared ideas for countering the growing drug problem. The main aspect of the vision are:
1. Youth participation
2. Cultural sensitivity
3. Gender issues. Some problems, like forced prostitution, affect mostly women.
4. Proper Education Methods - for school and out of school youth. The issue of life
skills is an important part of this. Drug education should be fact-based
5. Access to alternative activities such as sports and other healthy activities that are fun.
6. Access to Treatment/Health Service
7. Media. The youth would like to be portrayed more positively by it.
8. Information Sharing/Network
9. Evaluation. Drug users need to be given a second chance.
10. Conventions, Policies and Rights Nations and youth should join together in taking
action to prevent drug abuse among young people, to treat addiction, stop traffickers
from violating the right to live without drugs .
11. Resources and Funding for youth programs and centers.
12. The Vision. The message is passed to the United Nations, member states and
others, including young people who
want to do something about drug abuse. teachers and parents. Much
can be achieved if we have the chance to join hands with national
organizations.
Paul Deaney, Executive Officer of AHN
CHIAN MAI, Thailand
Mr. Deany stressed the seriousness of the spreading of HIV. Slides showing the spread and sustainability in various country stressed the fact that the battle against HIV is being lost. However, there are many things that can still be done to prevent and reduce the risk of infection.
I Global Snapshot : HIV and Injecting Drug Use (IDU)
n Global consumption of Heroin and other illicit drugs increasing despite concerted efforts
n Estimated 6 Million IDUs in the world
n IDUs in 120 countries: HIV among IDUs a problem in 80 countries
n IDU and HIV spreading to new countries and populations
n Recent spread of HIV among IDUs most obvious in developing countries
II Factors Leading to Increased HIV among IDUs
n Needle Sharing
n Drug use seen as legal and not a public health problem
n We have a “war on drugs” but no corresponding war on HIV among drug users
n Failure to see that IDU’s are a vector for the spread of HIV to the community
n Failure to understand political and social dimensions of the problem
n Economic instability
n Lack of political will
n Failure to plan for our future and that of our children
n Denial: hoping the problem will just go away
Harm reduction is reducing the harmful consequences of drug use. The question facing us now is: Which is the bigger problem - drug use or HIV/AIDS? HIV prevention among IDUs involves a balance between public health, law enforcement, community attitudes and political imperatives. Harm reduction programs among IDU include:
n Education and counseling
n Drug Substitution
n Abstinence
n Needle Syringe Exchange programs
n Increasing Needle syringe accessibility
n Seat belts in cars
n Condoms/safer sex
n “If you can’t be good/safe, be careful”
Other Approaches to IDU are:
a) Demand Reduction through education, counseling, abstinence, and drug substitution (e.g. methadone)
b) Supply Reduction through, policing, customs and border controls, crop eradication, National legislation and policies, Interdiction (penalties/prison), UN conventions
There are many barriers faced by harm reduction programs in Asia. Some of these are:
n Stigma surrounding Injecting Drug Use
n Programs are often in isolated areas
n Little information and few resources
n Lack of research on problem and responses
n Shortage of skills relating to program design, implementation and evaluation
n Little opportunity for sharing skills and experiences
n Few treatment and prevention programs
n slow Government and International responses
n Little support for NGO responses
n No recognition that HIV epidemics among IDUs are preventable
The Asian Harm Reduction Network (AHRN) was formed in 1996 formed by nine countries to reduce the harms associated with injecting drug use in Asia, especially HIV infection, through a process of networking, information sharing, advocacy, and program and policy development. The objectives of AHRN are:
1. To establish a sustainable Harm Reduction Network, based eventually in Asia;
2. To develop more comprehensive understanding of patterns of injecting drug use and associated harms (especially HIV infections) in Asian countries;
3. To provide a forum which will encourage communication and information exchange between individuals, organizations and countries participating in the network;
4. To provide training and support of individuals and organizations in Asia, sharing core skills and a coherent philosophy which can underpin their work;
5. To facilitate policy and program development at NGO, government, regional and international levels; and
6. To promote national harm reduction networks and programs.
Since 1996 AHR has grown from a membership of 46 people in 9 countries, to 1,100 people and programs in 48 countries by 1998. By the year 2000 it expected that the membership will have no limits and hope that it will be based only on need.
DISCUSSION SESSION
1. Has Dr. Grey’s program been tried in big cities? What would be the differences?
Even in big cities you need to have community help. Dr. Grey used Sydney to
illustrated that even in large cities there are communities formed around drug users.
When they move, the form new groups. Individuals have family, friends, so in city
center we have to find what constitutes their particular community. The program is
transferable to most communities, whether urban or rural. The whole idea of the
program is to have a reproducible model and much work has been done in
conjunction with the government to achieve that.
2. Regarding IV use, are there any studies relating new cases of drug users to new
cases of people infecting with HIV?
At the beginning of the program, the HIV infection was 35%. Currently it is down to
15%. The incidence rate is 2% from a previous 11% in Thailand as a whole, and 22%
in the north.
Education through Entertainment for Youth
The Mirror Group
The participants were treated to a performance by the Mirror Group theater group. All of the skits dealt with STD prevention and actively promote the use of condoms as. The group’s performance was very colorful, active and full of music and humor, but the seriousness of the message was in no way underplayed or minimized by the histrionics.
The Mirror Group follows a variety of guidelines when using the media for educational purposes with the youth. A summary of these guidelines is included below.
At the end of the performance, a lively discussion ensued. Some participants shared experiences from their countries and said that due to gestures deemed unseemly, the performances were not allowed. In Thailand, the group has encountered some resistance but, overall, have been able to carry their message. Their main purposes is to make the youth, and the public in general, aware safe sexual practices because, as one of the panelists pointed out, they really cannot stop people from engaging in sex.
Media. Different types of media are suitable for different target groups and have different effects on their information processing due to the media's own limitation. In addition, different age group learns and processes information differently. Therefore, choosing the right media for the right target group is crucial for effective campaigns because it affect the target groups' learning behavior and, thus, the effectiveness of the messages conveyed.
Youth. This age group needs extra excitement and colorful materials to trigger their curiosity in order to learn new information. Innovative educational materials can do the job better than traditional ones. Based on our past experience, we are certain that informal, lively, interesting and entertaining media not only are crucially useful in conveying the messages and accessing the target group but also create enjoying learning experience for them.
Plays. Theater is unique in its style because it is colorful , informal, easy to understand It is visual and the pictures can clarify ideas to make them easy to learn and memorable. Plays have a dimension that promotes direct interaction between the conveyor and receiver of the message. In addition, the plays portray factual human behaviors based on the target group's daily lives. They can relate to and empathize with the characters, thus having the desired impact on them.
All types of media have limitations but with proper control and management they can prove to be lively and effective in providing the audience time to stop and think. The whole process is, therefore, a valuable learning experience.
DISCUSSION OF MORNING SESSION
1. Since the use of condoms has been successful in Thailand, has there been attitude change from traditional to a more casual view of sex?
The answer seems to be “yes” based on information that Dr. Grey has obtained of studies conducted with university students in the north of Thailand. There has been an increase in casual sex.
2. Does the Thai government conduct evaluations on the sexual behavior of the youth?
There is sentinel surveillance for the prevention of HIV. At first, the focus was on people in the sex industry. Official figures show that now 97% of people in the sex industry do use condoms. Casual sex has increased but it seems that the use of condom is not as prevalent as it is when the sexual activity involves someone working in the sex industry. The use of condoms among the youth is somewhere between 10 and 20%, which is very low.
OVERVIEW OF HIV/ AIDS VULNERABILITY
Sawitree Suwansatit,
Deputy Permanent Secretary,
Ministry of Education, BKK
Mrs. Sawitree presented figures based on the reported 78,000 cases of HIV infection, noting that the 25 - 29 age group was the most affected, accounting for 28.7% of the infected. The 20-24 age group accounted for 12.9% of the infections, which indicated that the disease had probably been contacted during their teens. Mrs. Sawitree stressed that education was an important factor in reducing the potential infections among the younger population. In order to succeed, education must take advantage of the youth’s natural desire to learn and experiment with new things. Education, thus, cannot be limited to just teaching knowledge and conveying information, but also help the students in the process learning to learn, to be, to do, and to live together with mutual respect.
In order to promote awareness and understanding, the educational response to AIDS must develop personal skills to maintain good health; develop the ability to seek access to treatment; and develop an active role in self care. To that end, Thailand has integrated HIV/AIDS and life skills into the curriculum, starting at the primary school level. This educational approach involves the training of teachers and administrators; the production of quality education material; the promotion of a safe and peaceful learning environment; and extracurricular activities. Of great importance is the existence of close cooperation between the schools and the communities they serve. Further, the involvement of the youth in these education and prevention programs is of crucial importance as well. Youth volunteers and student leaders are instrumental in peer group education.
The importance of a thorough educational program cannot be stressed enough. It has been found, for instance, that the knowledge about sexually transmitted diseases and even the reproductive system are poorly understood by the Thai youth. Attitudes about AIDS are also erroneous among all age groups and education levels. The infection is still viewed by many as a problem exclusive to certain high risk groups, rather than of the society as whole.
The great challenge is to keep updating knowledge in order that the teachers and the youth are constantly aware of the situation and realize that AIDS is a threat to the society as whole. No one is completely safe, so education and awareness on this issue must be an ongoing activity.
In the question and answer session, Mrs. Sawitree made the following points:
1. The program is done in all schools, but schools with higher risks of infections have to develop their own intensive programs. Risk reduction, however, is not as effective as it had been hoped.
2. The relation between AIDS and drug, sex, and alcohol is stressed by the teachers. There are different campaigns against drugs, but all are related and should be integrated when teaching life skills. It is important to empower the youth to make decisions that will help them get away from the problems.
3. There is a systematic program in teacher training. Students leaders are also trained because they are an important part of the program.
4. The program is supported by the Ministry of Health.
5.
It is
impossible to train all 600,000 teachers in Thailand. Teachers of certain
subjects are targeted, such as Health, and they go back and train their
colleagues. However, training of youth is important because they normally
turn to each other in times of trouble rather than to their parents or
teachers. For the youth to feel comfortable about discussing some problems
with their teachers, the attitude of the teachers must change first.
SESSION III . TOPIC: HEALTH CARE SYSTEM SUPPOR
ADOLESCENT REPRODUCTIVE HEALTH
Dr. Takashi Wagatsuma, Senior Medical Advisor,
JICWELS, Tokyo
The concept of Reproductive Health encompasses four main elements:
1. People can reproduce and regulate fertility.
2. Woman are able to go through pregnancy and childbirth safely
3. Outcome of pregnancy is successful
4. Couples should be able to have sex free of fear of STD and unwanted pregnancies.
WHO defines health as the state of complete physical, mental and social well-being. Reproductive health was redefined as a condition in which the reproductive process is accomplished in a state of complete physical, mental and social well-being, stressing the four points mentioned above.
In a humorous, yet informative style, Dr. Takashi said that organizations like WHO estimates that 100 million acts of sexual intercourse take place everyday around the world resulting in 910,000 conceptions, 50% of which are unplanned pregnancies. Of these 25% are unwanted pregnancies, resulting in 150,000 induced abortion per day. One third of the abortions are performed under unsafe conditions leading to 500 deaths per day.
When STD’s are factored into the equation, the figures boggle the mind. Close to forty thousand children die each die before reaching the age of five. The death rates among infants is highest. Lack of access to fertility regulation is another issue that further compounds the problem.
The Adolescent Reproductive Health exhibit four characteristics.
1. Early childbearing; unsafe abortion; STD; threatened adolescence health
2. Teen parent face social and economic barriers
3. Sex education helps adolescents make responsible choices
4. Sexually active adolescent should choose protective methods to avoid pregnancy and STD, including special counseling on the selection of the appropriate protective/preventive methods.
Three patterns of Sexual and Reproductive patterns are found in adolescent sexual behavior:
1. Early sexual experience and late marriage (mostly in developed countries). It occurs in mid to late teens, exhibits a low use of contraceptives; a high incidence of unmarried/unwanted pregnancies; high incidence of abortion.
2. Early marriage and child bearing (primarily in Southwestern Asia). Marriage takes place at an age close to menarche (menstruation); early and frequent child bearing; Premarital sex/pregnancies are uncommon; abortion is illegal/unsafe.
3. A transitional stage between these two patterns (mostly in urban settings). For women especially, traditional restraints become less effective.
The Japan Statistical survey by the Population Program Research Council shows that since 1990 the sexual behavior of unmarried women in Japan has changed considerably over the years, with current figures showing that 30% of them engage in pre-marital sex, an all-time high. It further shows that Japanese unmarried women who engage in premarital sex have their first experience somewhere between the ages of 15 - 20. The peak age is 17 years old. It should be noted that the 1998 survey is the first one in which this particular information was asked, so there really is no basis for comparison as to how the behavior of unmarried Japanese women has changed over the years.
Information from other sources, notably the ESCAP meeting attended by the participants of the seminar, show that senior high school girls engage in casual sex with middle-aged man for money that they use to buy for personal goods and luxury, not for survival reasons. To what extent this is true remains to be seen. However the official figures published by the Research Council would appear to lend validity to this observation. However, even though the spread of HIV in Japan is not as serious as in other countries, the potential for it to become a more serious problem is there.
Worldwide, adolescents can face serious physical, economic and social consequences from pregnancies and sexually transmitted diseases. Sexuality education makes adolescents make responsible choices.
ACCESS TO DRUGS
Dr. Chaiyos Kunanusorn
Aids Division, Ministry Of Public Health
Bangkok
Dr, Chaiyos thanked the various people and institutions who have helped him with his investigation and studies on Anti retroviral issues. Dr. Chaiyos presentation was divided into five parts.
1. Development of HIV/AIDS related drugs. The first cases of AIDS were identified in 1981. Two years later the medical community identified pathologic agent, namely the HIV virus. In 1987 the use of AZT was started. In 1992 there was a global move from Monotherapy to double, triple and now, quadruple therapy. Dr. Chaiyos proceeded to explain in brief detail the physical progress of the virus in the human body.
2. Medical supply for opportunistic therapy . There are about a dozen anti retro virus the inhibit the progress such as AZT, IDDC, etc. Another group is currently being developed, called Immune modulator, which helps boost the number immune cells. Several companies are developing drugs to intervene viral life cycle. The number of HIV-related medicines have been on the increase and now there are close to 60 in the market. In Thailand the cost of treating and AIDS patient in 1995 was about 20 thousand Thai Baht (around US$800 at the exchange rate at the time). The price will very likely double in 1998. The 1996 the requirement for medicine cost in Thailand was 1.4 to 1.5 Billion Baht. By the year 2000 the cost is expected to be 2 billion Baht.
3. Mother to child and health workers prophylaxis - In this section, Dr. Chaiyos presented evidence of the positive effect that various intervention programs and medication have to prevent the transmission of HIV/AIDS from mother to unborn child. The ACTG 076 (SEDOVIDINE MONOTHERAPY), in particular, shows a significant success in this area. Not all the patients, all of whom were HIV positive, underwent the full treatment. The patients who were more likely to undergo the full, six- week treatment were those who did not experience adverse reaction (nausea and vomit). Conversely, those who did experience adverse reactions were less likely to complete the treatment.
4. Thai evolution for HIV/AIDS medical supply - Financially, the anti retroviral program was quite unaffordable, so the strategies to provide treatment had to change based on further research. A six-month evaluation of 1000 cases were used to compare SEDOVIDINE and DDI versus SEDOVIDINE and DDC. The results were positive with few adverse reactions. At present there are 50 hospital all over Thailand participating in the study. An important result is that the treatments are no longer viewed in terms of anti retroviral medication exclusively, but has expanded into other aspects of medical supplies such as Immune modulator which helps boost immune cell; cleansing of vaginal canal to prevent transmission from Mother to child is done. Modern technology and studies from western countries must be adapted to fit the needs in Thailand. Also, new technology must be developed that is be suited to Thailand.
5. Specific issues for youths - a) Access to drugs should be decreased and Thailand already has some programs in place. b) Access to HIV testing should be stressed
c) Post sexual exposure should be accidental not for pleasure. d) Divert the strong
feelings of youth to be used in more constructive forces.
Drug development is rapid, but the cost is high. The Thai system is not ready to undertake chronic care for HIV. Prevention is the key to fight it.
HOME BASED CARE FOR HIV
Dr. Eric Van Praag - WHO, Geneva
Referring to Dr. Chaiyos comment that “the system is not ready”, Dr. Van Praag stressed that while that it is true, we must make it ready, even if the necessary tools are costly and difficult to implement. The numerical consequences of HIV among Young People are truly staggering. By the end of 1997 there were over a million children under the age of 15 living with AIDS in the world. Over half of them were infected in 1997, the majority in Africa. Nearly half a million deaths occurred in 1997 as a result of AIDS. AIDS does not only affect the children who are infected by it but also those who are orphaned as a result of losing their parents to the disease. The cumulative number of deaths due to AIDS thus far is nearly 3 million people, leaving more than 8 million children orphaned.
The epidemic is extremely dynamic. If the 15-25 age group is added, the number of people living with HIV increases to 1.6 million within for people up to the age of 25. The problem is increasing in developing countries. In one day alone there are 16,000 new HIV infections. Over 90% are in developing countries; 14,000 adults, half are in 15-24 age group. In Asia, 700,000 young people in the 10-24 age group are infected every year.
In order for young children living with HIV to reach the health system to get support they must face a number of difficult factors that make it hard for them to seek assistance. They must face problems related to drugs, violence, alcohol, loneliness, lack of food and shelter, and discrimination. The health systems are also under an enormous amount of pressure that make it difficult to obtain the necessary funds. For us to respond better, we must overcome all the aforementioned obstacles. In addition, it is imperative that we realize that young people have different needs from those of adults in terms of health information and services. In many countries young people with health problems are unable or unwilling to reach and/pr used the available health services. Some of the problems are related to time and distance, but in other instances, the children may not be allowed to seek help. Often the clinics providing treatment are very judgmental of the children and make them feel very uncomfortable, which makes them reluctant to seek help. This reluctance is further entrenched in their attitude because of lack of confidentiality. Confidentiality is often not practiced with the youth in the same way as it is with adults. In many countries it is illegal to provide certain services to the youth and/or the youth need parental consent prior to seeking the needed service. It is important to address these attitudinal issues.
Dr. Van Praag stressed that it is important for health care workers to find a way to communicate with young people, particularly when the results show that a young person has been infected. Because the counseling skills of the health care worker are quite poor, the bad news are not conveyed directly. This leads to a “serostatus”. The patient doesn’t really know if he/she is infected so nothing can be revealed to others. Thus, no support can be really created because of this “conspiracy of silence”, which is further aggravated by the fear and neglect in the hospital community.
In order to address the problems, a very comprehensive care system with all the necessary components is necessary. This system should include.
1. Medical care: antiretroviral treatment; treatment of opportunistic infections; promotion of immunity
2. Nursing care: nutrition; exercise; hygiene/situation; simple treatment; pain and suffering relief; herbal foods and medicine. All treatment must within en emphatic attitude on the part of the nursing staff.
3. Mental/Emotional care: both pre and post test counseling; meditation; spiritual support
4. Social/Economic support: acceptance from the society; income generating activities and marketing; economic supports.
Health services can be made youth friendly by setting up stand alone units that provide such assistance. In addition, there must be a realization that these services can only be provided by building communications systems between all the services: medical, educational, and social. The system must be easily accessible to the youth. This means that hours when such services are provided may have to be adjusted to meet the needs of the young people. The system must also adapt the fees charged to suit the financial situation of the youth; provide confidentiality; enlist the participation of their peers, etc.
Dr. Van Praag proposed the establishment of Voluntary Counseling and testing that would fulfill four important objectives
1. Relive anxiety and/or assist in decision-making and planning for the future
2. Lead to improved clinical care through early HIV detection
3. Grant the patient the right to know his/her serostatus
4. Decrease risk behavior.
This services should be provided
within the clinical setting, free standing voluntary testing sites and services,
and as a “byproduct” of screening procedures such as blood donation, research
projects, etc. The basic procedure to follow when providing these services
would take the form of one pre-test counseling session, followed by an HIV test,
with a subsequent post-counseling session. An HIV/AIDS continuum of care
would be an automatic byproduct. The continuum would include
Voluntary counseling and testing, Health facilities and Community-based care,
all interacting constantly to not only deal with those already infected but to
prevent future infections.
CLINICAL MANAGEMENT
Dr. Shin -ichi Oka,
Director,
AIDS Clinical Center
International Medical Center of Japan, Tokyo
The treatment on HIV in the United States, Europe, and Japan has entered a new era after the introduction of anti-aids drugs, called “Protein Agent Inhibitors”. Dr. Oka’s presentation focused on the HIV therapy currently conducted in Japan, with specific attention to the, prevention of Aids using anti HIV drugs.
The Pathogenesis of HIV infection is very important for the seeking HIV treatment. The three most important areas in this progression are:
1. Viral Load in plasma - This reflects the progression of the disease
2. Turn over HIV in plasma - which is very rapid, only 6 hours.
3. HIV growth in lymph nodes, which destroys them.
If the patient is infected with HIV, the viral load during the primary stage of the infection increases rapidly. After about one month the viral load decreases but does not go down to zero. This is called an immunological set point, which is a more stable phase. This very important point in the progression is a virological set point. If the viral load at this point is very high the disease progresses very fast, but the viral load is very low, the disease progresses very slowly. The viral load at this point is determined by the immunological function. The viral load is the best predictor of disease progression.
Viral kinetic study reveals that turnover of HIV in plasma is very rapid, only 6 hours. The turn over of HIV infected T-cells is very fast, only 1.5 days. The production of new HIV per day is equal or slightly higher than the production if be T-cells, which means that the disease progresses despite the absence of symptoms. HIV destroys the structure of the lymph nodes. Treatment must begin before the destruction of lymph nodes occurs.
In Japan, nine anti-HIV agents are available, of which 5 are reversed transcriptors inhibitors and 4 are Protein Agent Inhibitors. The transmitted inhibitors are divided into 2 groups: this group is actively prorating cells and this group is active in stable cells and protein inhibitors. One from each group is usually chosen.
In 1996, the major strategy for HIV treatment was two-drug combination, usually two reversed transcriptors. This changed to a three-drug combination after the Protein Agent Inhibitors became available in 1997 (AZT+DDCà AZT+DDC+SQV)
In patients treated with AZT, 3DC and Idinavir, the CD4 count increased rapidly and the viral load went down to nearly undetectable levels. Every patient undergoing the three drug combination shows encouraging responses. In order to combat opportunistic infections among patients that had undergone the 3-drug combination, the Hart-Viral and cogtive therapy was started. Hart, along with Protein Agent Inhibitors, helped cut the trend of opportunistic infections by half.
There are several programs of HIV treatment using the 3 combination but the patient has to take many tablets per day. The most popular combination is AZT, 3DC and Indinavir, requiring the patient to take 20 tablets per day, 6 times a day before and after meals. Some of the anti-viral drugs are very toxic and expensive.
The crystal of Indinavir is a very famous side effect of the Protein Inhibitor, affecting about 30% of the Japanese patients who take it. To prevent the side effect, the patients must drink 1.5 liters of water per day. This is new critical symptom in which the lymph node underneath swells 5 weeks after the initiation of Protein Agent Inhibitors. The symptom is very severe, causing a very high fever, pain making it very hard to continue anti lateral-viral treatment.
To combat AIDS effectively we must not wait until it is fully developed and once therapy is started, it must not be stopped even if the patient shows improvement. The HIV treatment must be ongoing.
PEOPLE LIVING WITH AIDS
Samaran Takan
New Life Friends Club,
Chiang Mai,Thailand
Mr. Samran an HIV infected patient. He spoke in Thai. His comments are translated in their entirety below.
“ Good afternoon distinguished guests and participants:
My name is Samran Ta-gan, an HIV infected patient who has an opportunity to share my experience here with you in order to help you develop your AIDS related projects. I realized that I was infected after a blood test in 1989. I regularly fell ill and felt despaired and discouraged. I thought I could not tell a soul for fear that people around me would feel disgusted towards me and could not accept me. I was scared that my own parents would know and would not let me live with them any longer. I was confused and preoccupied. I did not know what to do with my life and I was not well health wise. I wanted to hang myself instead of suffering the facts
I later met a doctor at a TB Control Center. District 10, Chieng Mai, when I was in a very bad shape. I lost my appetite, had chronic fever, and my weight dropped. After receiving treatment at the Center, I got better and began having a glimpse of hope in my life. Being infected with the HIV virus triggers an ignorant villager like me to learn more about it. I joined the group of the HIV infected and learned more about others in similar situations. We hold on to each other for support and encouragement and now I have learned how to cope with being infected with AIDS. I did everything to strengthen my body and to relax because I would fall ill any time I felt stressed. Since I joined the group and shared my experience with other people infected with AIDS, my life has more meaning and my health has improved. It gave spark to my life and I now know myself better. I have tried to learn lead a new life, that of being infected with AIDS. If l cannot do so, I will have more problems and opportunistic infections will flare up. More and more people are being infected. Therefore, I thought I was given a second lease on life. I started to take care of myself by eating foods that are not hazardous to my health and avoiding those that are, like pickled food and alcohol. I know that if I watch what I do, I can live happily with the AIDS virus. From my 5-6 years experience at the Center, I know it can be done. Every member of the group, both men and women, takes care of his/her health and lives a happier life.
My health improved because of several factors: - The society gives me a chance to use my potential to join in solving the problems. The support and assistance from both the government and private sectors, as well as other organizations act as a medicine that help lengthen the lives of the infected so they can live to work for themselves and the society.”
Mr. Samran’s testimonial ended with a slide show of the activities of the New Life Friends Center in the northern Thai province of Chiang Mai. In addition to providing medical and emotional support, the center is involved in educational campaigns in cooperation with the government and other institutions to prevent the spread of the disease as well as to teach people, both the infected and uninfected, how to live productively with AIDS. The Center produces newsletters and magazines on preventive health care. Mr. Samran ended by asking the participants to help find ways to sustain his fellow AIDS patients and to provide them with effective treatments.
GENERAL DISCUSSION OF THE DAY’S
TOPICS
The issues covered throughout the day included:
n How to deal with sex education.
n Policy changes to deal successfully with drug use in the region.
n Reproductive Health
n Reconfigurating Health services for young people.
n Broaden the vision of which government departments are responsible for the various issues.
The following are some of the comments and concerns expressed by the participants.
On the issue on the effectiveness of punitive measures, the representative from Singapore indicated that in addition to such measures, the handling of the drug problems is multi-pronged, not just punitive in nature. The country also has health education, drug rehabilitation, half-way houses in addition to providing opportunities for reintegration into society. There is close monitoring of narcotic abuse in the country and a heightened law enforcement. It is a simplification to say that punitive measures do not work. It all depends on the characteristics of each region, the size of the drug problem, and the socio-political and economic environment. In response to this argument, Mr. Reynolds acknowledged that it’s difficult to generalize on his observation, but that generally, punitive policies were in direct contradiction to the universal declaration of human rights. Even though different countries have a different success rates when applying punitive policies, all countries should be honest in their appraisal and evaluation of the impacts of such policies. He added that any policy should be accepted by both the decision makers and the community. Another point to consider is whether a fixed policy is better than a policy which allows for changes to meet the changing situations.
Another participant brought in the issue of drug trafficking prevention into the region, noting that not enough stress is given to it. However, it was pointed out that a country like the United States has spent billions of dollars in controlling import of drugs, but only 10% of that amounts is poured into demand reduction while the rest goes into supply reduction. This approach has not resulted in less drug usage. Perhaps it is time to pay more attention to ways in which demand for drugs can be reduced. UNDCP is moving towards that approach and away from supply reduction. There is no reliable indicator showing that supply reduction is successful. What it has done, in fact, is to create opportunities for corruption within the police force, customs, public sectors, Mafia organizations.
The discussion turned to health care provision. The health care expenditures are very high and the question was raised as to which sector, private, public or traditional, would be best to serve the needs of AIDS patients. In Myanmmar, for instance, the home-based care project is being piloted. The clinic health system, practiced in Thailand, is followed by it is not fully ready to handle all the cases. People infected with the disease fall into different groups. There is a group that seeks care at private hospitals and cover the costs themselves. The second group fall under the social security system, which receives assistance from the government. The government only pays for AZT and DDI drugs (considered “essential drugs”), but some hospitals do not have the drugs available. The third group fall under the “poor people fund”, which also government dependant. The hospitals have discretionary power over these funds and decide who can benefit from them.
Mr. Samran said that for general maladies, people in upcountry Thailand follow home remedies because most people do not have money for medical care, or have no access to anti retroviral medication. Most district hospitals, however, can treat opportunistic infections. With the hill tribe people, in addition to problems of inaccessibility, cultural considerations are of importance when dealing with anti retroviral medication. Their notions of time make it difficult to follow a fixed, clock-dependant schedule. Also, their cultural ideas of illness and healing are different. When the symptoms go away, they stop taking the medication. The western notions of medication, time, etc., are simply not transferable to many cultures.
The discussion turned into the possible effects of herbal/traditional medicine in combination with modern medications. There is no evidence on the effectiveness of herbal medicines in combination with anti retroviral medication. Herbal medicines are expensive and the regiment system is quite complicated.
The interesting exchange of ideas then shifted to the topic of whether condom promotion encouraged increased sexual activity among the youth. There seemed to be two contradictory pieces of evidence. Mr. Honeyman said that the evidence suggested that it actually delays sexual activity indicating that young people can make appropriate decisions when presented with accurate information. This is a point that must be presented to policy makers when programs are being set up. Condom used should not be associated only with commercial sexual activity because it stigmatizes its used. People are thus reluctant to use them outside of commercial sexual activity, a behavior which takes time to modify. Dr. Grey’s findings appear on the surface to indicate that casual sex in Thailand has increased and that the attitude towards sex, particularly among young women, has changed. She was quick to point out that the change in attitudes is not to be associated with the promotion of condom used, as each phenomenon has developed separately and for different reasons.
Dr. Van Praag mentioned that studies conducted in two countries where sex education is introduced at a young age, Norway and Uganda, actually resulted in the youth postponing their first sexual encounter to a later age. Dr. Wimut quoted a study in Bangkok, 1992-1996, showing similar results.
Miss Amporn challenged the participants to thing clearly about whose needs they were trying to meet: those of their particular departments/institutions of those of the people they claim to serve? Also, she pointed out that the culture frames within which the adults are developing the programs do not always address the needs of the young people.
END OF DAY 2
DAY 3 Friday, 5 June, 1998
The last day of the seminar began with a report on SESSION IV : PROGRAMME ACTIVITIES OFR YOUTH. The participants were divided into three groups for visits to various sites on the previous day. The following is what each group had to say about the study visits.
GROUP 1
The group visited four places:
1. Community project at Bangkoknoi:
n 'Friends Tell Friends' supported by European Union for two years
n Objective of project - to develop a model of social support in the community.
a) Community assessment
b) Safer sex in the community
c) To reduce risky sexual behavior through empowerment of women
through condom use.
d) Increase public understanding and acceptance of people living with HIV/AIDS
The community has a population of 2,000 and 12 volunteers have been selected and trained by Health Nurses. Training is of short duration and repeated with techniques on how to approach the community and information on AIDS epidemiology in the community. They explain the problem in that community. They are easily accessible, as they are in that community itself, unlike government health centers. Twelve volunteers with one of them as chief volunteer have recruited 600 friends in that community.
The community has built a community center where senior citizens are taken care of or take care of themselves. They are also utilized in this project. The volunteers are mainly housewives. Some of them are employed. They contribute two or three hours of their time per day. The center operates on Baht 4,000 (roughly US$100) a month. They are now involved in fund raising activities, as their grant from EU has been ended.
Problems faced: Mainly women have been influenced by the program, with a poor response from the men. Lack of funds.
Success: People infected with HIV/AIDS come forward and declare their status because of sincerity on the part of the volunteers. They are referred to the appropriate Government health facilities.
2. Courtesy call on Deputy-Governor, Dr. Kachit Choopanya, Office of Bangkok Metropolitan Administration.
Deputy-Governor Kachit is a very well informed, experienced leader. The group had a fruitful discussion on HIV/AIDS transmission through sexual activity and drug abuse .
3. Community project by BMA at Soi Pipat 2, Silom Road
This community project is held once a month (depending on requests and availability of staff in various communities) aiming at the elderly, children and vocational training for women of that community. A bus that has been modified to include a VCR, audio and a stage for entertainment and also has games, library for children. It is manned by five staff including a psychologist. The purpose is to gainfully occupy the time of these groups. At the time of our visit, the ladies were practicing hair styles on volunteers from the community for free.
The general impression was that the project was good. Eight more buses are being ordered, at a cost of 2,000,000 Baht each.
4. Street children at Lumpini Park
The
children are mainly from rural areas and most of them work as sex workers in
the PATPONG area and come back to the park
for a bath and rest at about 1:00 - 2:00 a.m. and then go back.
The younger children are given the opportunity to play by BMA (Bangkok
Metropolitan Authority) and develop reading and writing skills. The BMA
also arranges for the children who are without birth certificates to attend
school and the older children are given the opportunity to vocational and
educational training. However, there are no welfare homes where they could
be sent for better care.
GROUP
2
This group visited two places:
I. Samut Prakarn AIDS Prevention Project For Industrial workers (SAM)
n Funded by CARE INTERNATIONAL, SAM is private project with multi-cooperative links with the government, private sector, Labor Union, and Hospitals.
n Samut Prakam is a very large industrial estate in central Bangkok with 5,000 factories and 600,000 workers, the majority of who are migrant workers from up north country.
n Size of problem is 70,000 HTV positive and 700 AIDS cases
n Staffed with 100 volunteers, many are students and 30 PWA.
n Major activities include
1. Training workshop at factories, usually started with trainers and subsequently downwards to peer educators (assisted by hospital staff
2. Vocational training for income generation especially those with AIDS related disabilities
3. Counseling and peer support
4. Support for HIV mothers with free milk powder
Factory visit to- SIAM OCCIDENTAL ELECTROCHEMICAL COMPANY:
n Observed the third training session for 32 participants; mixed genders; age-range 20-39.
n Training using slides, video and interactive quizzes. Of particular interest was HIV transmission by the use of game "Cup of water and syringe"
n Excellent graphic demonstration of condom use by young lady trainer between two male volunteers.
n Enlightened the realities of HIV/AIDS through a PWA volunteer, whose recollection spans from despair, denial and abandonment to acceptance, feeling valuable and having hope, as a greater source of help towards the positive change was from his peers.
2. Thai Red Cross
n Very organized NGO with the patronage of the Royal Family.
n Has a chapter in each of the 76 provinces with 12 additional disaster relieve sections
n Four areas of activities which complement the Department of Public Health- administrative, anonymous clinic, research social and behavioral science and special activities
Anonymous Clinic
n Sees 100 clients for anonymous HIV testing per day. No identification used, except the code numbers to obtain result
n Rapid test results (half an hour / BAHT 220; Regular test result in 3 days/ BAHT 80
n Process involves self evaluation questionnaires, pre/post test counseling and follow up activities
n For HIV+ cases, a range of support services may be initiated e.g. WFC (Wednesday Friend's Club)
n The group observe the AC, consoling room and the lab
Wednesday Friend’s Club (WFC):
n Support group for HIV/PWA. Started out on a Wednesday but now is daily
n Very extensive with their activities and some members reaching popularity status
n Activities include talks and counseling, HIV phone line, "Red Ribbon" newsletter, home visitation programs.
n The group visited the WFC
and met staff both HIV and non HIV. They also contributed to their income
generation activities where they run the shop and sells goods like
T-shirt, shampoo and Red Ribbon pins.
GROUP 3
This group visited two places
1. The Center for Protection of Children's Rights (185/16 Charansanitwong Soi 12, Bangkokyai) and two associated shelters
2. Samutprakarn: The Committee of Community Development - Site for street girls project, to cover also the Worker’s Union head office, a small leather production units at the housing estate, and a slum area where the children need help.
Lessons learned:
1. In trying to understand the nature, magnitude and scale of violation against children rights in the area the following facts come into attention:
n The problems originated from multiple causation, like culture, economic difficulties, lower education, etc.
n It covers also illegal adoption, child abuse, children prostitution, exploitation of children.
2. CPRC which was founded in 1981 provide the following services:
n protection of children's rights violation victims
n temporary shelter and care
n rescue operations
n public education
n legal advocacy and assistance
n rehabilitation
n family substitution
n coordination with other organization and country of origin
3. The project and activities mainly done and concentrate on NGO, followed by local/community organizations recognized by the authority. Real support received is still very limited. Only very small number of children can be accommodated.
4. The project gives indirect support to HIV/AIDS prevention and care but could change the community and the government’s attitude toward children rights violation
5. Child labor and street children could be the target groups that need better support if social welfare in general is to be elevated.
Conditions
1. Programs on children's rights protection in this region is still in the beginning stage and needs to be further developed technically as well as financially.
2. At this stage, the success of the project depends on dedicated volunteers.
3. The programs and their capacity is very limited in comparison with the problems.
4. Technical difficulties are still to be anticipated.
5. Public support also has to be developed.
SESSION V: TOPIC REGIONAL COOPERATION - YOUTH AND HIV/AIDS
PROMOTING A SAFER YOUNG GENERATION
Eric Van Praag - WHO, Geneva
Although organizations such as WHO are strong in providing bilateral cooperation, they have not provided as much assistance in promoting cooperation between countries. International organizations must stimulate countries to learn from each other. So far there is not much happening in these areas and good opportunities are being lost because the countries do not practice what they have learned or neglect to implement what has proved to be successful in neighboring countries. While meetings such as this one are of great value, often they do not result in the expected out come - to actually initiate practices that will lead to fundamental, and productive, changes in each country.
WHO provides specific technical advice and supports countries in the areas of STD control; surveillance for HIV, AID case reporting, STD; HIV testing and counseling; strengthening reproductive health services; tuberculosis control; and drugs. Any assistance can be obtained by simply contacting the Regional WHO support offices. The organization provides some support in the areas of care; drug use and HIV; and developing user-friendly health services. WHO, however, is weak in the area of human rights; social and developmental sectors; impact of the HIV/AIDS epidemic on society. Dr. Van Praag pleaded with the representatives of international organizations to honestly asses their strengths and weaknesses as well so that each could provide the assistance for which they are best equipped.
WHO has started the Regional Collaborating Center and is
in the process of developing a training center for the clinical, care, and
counseling aspects of HIV, based in Thailand, in cooperation with the
country’s Ministry of Health. The idea is to provide training to the
people in the region who wish to develop skills in this area.
SHIV KHARE, Executive
Director
Asian Forum of Parliamentarians on Population and Development
For almost eighteen years the AFPPD has been working to involve parliamentarians in population, family planning, reproductive health and other related development issues. HIV/AIDS is one of the of these issues. With the help of UNFPA funding the AFPPD now has programs in seventeen countries. AFPPD's international department works globally providing support and helping to develop national committees of parliamentarians on population and development worldwide. The International Medical Parliamentarians Organization (IMPO) has support from WHO. IMPO aims to mobilize parliamentarians with a medical or public health background to review and monitor health related legislation and programs. With the support of South East Asian Regional Office of WHO, parliamentarians from South Asia met in Nepal on 13-15-May 1998 to discuss HIVAIDS related issues.
The aim of these meetings is to educate and motivate policy makers on various aspects of HIV/AIDS, to stress its seriousness and to promote the need for so called 'representatives of the people' to wake up and do something about it. Parliamentarians have been instrumental in resource mobilization for population related areas and they can do the same for HIV/AIDS programs. As law makers, parliamentarians can:
n Help review and enact necessary legislation
n Work towards the elimination of discrimination of HIV/AIDS affected people
n Work with their constituency in advocacy programs aimed at HIV/AIDS awareness and prevention including encouraging safe sex campaigns
n Monitor the work of the government especially in regards to care and treatment.
Parliamentarians are of the view that they can do the following for youth:
National Level
n Highlight the involvement of youth for youth in HIV/AIDS prevention programs.
n Work through the health committees of parliaments to influence government departments to focus on young people especially young women.
n Encourage youth wings of political parties to include HIV/AIDS prevention and care as part of their program.
n Speak about HIV/AIDS at public forums.
Constituency Level
n Call a meeting of youth leaders, representatives of youth organizations, youth wings of political parties and women's groups to motivate them to push for HIV/AIDS prevention programs. These programs should include safe sex campaigns, ensuring a safe blood supply and programs timed at the prevention of intravenous drug abuse.
n Talk openly about the transmission mode of the HIV/AIDS so as to educate and remove fear and discrimination.
Youth organizations must be involved
at a national and regional level. Organizations such as the Asian Youth Council,
regional branches of Boy Scouts, Girl Guides, YMCA and YWCA and religious youth
groups are well suited because of their direct contact with young people.
Events should be organized involving large numbers of young people talking about
HIV/ AIDS. By generating mass-media coverage such events would
greatly increase public awareness thus encouraging informed discussion of
HIV/AIDS related issues. Proper discussion of HIV/AIDS has to
be conducted openly if we are going to destroy the myths and stigma surrounding
the disease.
JAPAN’S HIV/AIDS
ACTIVITIES
Ministry of Health and Welfare, Japan
Dr. Kansaku
Japan’s efforts in HIV/AIDS activities fall under a complicated scheme. There are four types:
n Grant Aid - The Japanese Inter Corporation Agency (JICA) handles 99% of this type of aid.
n Loan Aid - OBASHI handles 100% of this type of aid.
n Technical corporation - 30% of the budget is granted by Japanese ODA. Of this, 50% is conducted by JICA and the other 50% is handled by other organizations and ministries.
n Contributions to UN or international organizations.
In Japan, each ministry has an implementing agency under its control which conducts training programs, seminars, workshops, research projects etc. To obtain assistance from ODA, for example, the aid must be requested through diplomatic channels, such as the Japanese Embassy. The request is then sent to the Ministry of Foreign Affairs which, in turn, will make the proper recommendations to JICA. JICA then seeks advice from the Ministry of health. Assistance can also be requested directly from the Ministry of Health.
Mr. Kansaku mentioned three important ways in which Japan will provide specific assistance to the region. First, he government of Japan made a commitment to contribute US$3 billion over a six year period (1994-2000) in the field of population, HIV/AIDS related programs. Second, Japan and the United States are discussing possible collaboration on assistance projects in the HIV/AIDS area. Japan would be responsible for implementing the project in 14 countries, primarily in Asia, while the United States would implement the program in African and South American countries. Third, the initiative for caring, proposed by Prime Minister Hashimoto, includes programs in the areas of HIV-Aids issues, population issues, parasite issues, and Social Welfare issues. All basic human related issues are included. The programs are conducted by JICA and implementing agencies.
Dr. Kansaku then introduced the Technical Cooperation Project. This project invites technicians or professional experts or administrators to Japan to be trained, as well as sending Japanese experts overseas. This project integrates the good points from the Grant Aid and technical cooperation. This project will be planned and implemented over a five-year period.
The Ministry of heal and Welfare in Japan provides support to JICA’s activities by determining projects in certain countries or by setting objectives from a professional’s point of view. In addition to the assistance to JICA, the Ministry has a budget which it shares with programs supporting regional cooperation including programs such as the present workshop. Other seminars will be held on various Asian countries. There is also and HIV-AIDS seminar held in Tokyo annually.
A STRATEGY FOR HIV/AIDS PREVENTION AND CARE IN THE MEKONG SUB-REGION 1998 - 2000
Ellen Shipley, Director
Health Section, AusAID
The strategy for HIV/AIDS prevention and care in the Mekong sub-region has as its primary goal to increase the effectiveness of the response to HIV/AIDS across the sub-region (Cambodia, Laos, Myanmar, Thailand, Vietnam, Yunnan Province, PRC) through better collaboration among countries and donors, and through urgent action. It identifies population priorities giving primary attention to programs aimed at those who are most vulnerable to HIV and STD across and between the countries of the sub-region. Included in the “most vulnerable” group are: women and youth; sex workers and their clients; injecting drug users; mobile populations.
The critical factors which contribute to the sub-region’s epidemic are:
1. Mobility and Migration of sexually active working-age adults exposed to the risk of infection.
2. Less than 50% of the blood transfusions in Asia are routinely screened for HIV.
Migration in the sub-region is the result of trade, search for employment, tourism, armed conflicts, reunion with family, and trafficking of women and children. People risk exposure to HIV/AIDS due to a variety of reasons:
1. Lack of access to services, especially on remote borders.
2. Disrupted social norms.
3. Disposable income and free time.
4. Crime and lawlessness in remote areas.
5. Policies that discriminate against migrant workers.
6. Easy access to commercial sex or casual commercial sex.
7. Easy access to injecting drugs.
The objectives in key areas are:
n Increased access to and use of quality condoms
n Increased access to appropriate STD management, prevention and care.
n Increased access to a minimum package of care and support for affected individuals and communities
n Expanded access to effective education programs for behavior development and change
Various mechanisms for action have been identified. These are:
n Collaborating countries and donors, much in the same way as what Dr. Van Praag mentioned
n Country-level mechanisms for joint planning and programming to continue building on existing mechanisms such as the UNAIDS theme groups. The actions can be tri-partite or multi-partite, taking place at both the national and international levels.
n Criteria for resourcing decisions (access to condoms, STD, behavior development behavior change, etc,) are used to appraise proposals.
n Accountability. Countries and donors must review the progress made against key results areas and plan further priorities for collaborative action
In order to achieve the goals, effective action must take place. Certain enabling conditions are essential across the region:
n Political commitment and appropriate policy environment
n Planning capability across the key sectors in all the countries of the sub-region.
n Implementing capacity across key sectors in all countries of the sub-region.
n Decentralization. Resources and actions must occur at the provincial level as well.
n Scaling up. Sharing successful experiences and taking them to a larger scale.
MULTI-COUNTRY COLLABORATION COMING FORM A SUB-REGIONAL STRATEGY IN SOUTHEAST ASIA
Robert Bennoun,
UNICEF/UNAIDS
Bangkok
MECHANISMS
n A framework which provides practical opportunities for multi-agency collaboration in a number of countries.
n Collaboration in formulation of and action coordinating to Sub-regional strategies.
n Joint planning and funding to support country priorities on a Sub-regional basis.
n Multi-agency Task forces convened by UNAIDS APICT, coordinated by UNAIDS and Unicef.
n Other collaborative arrangements between implementing agencies and donors covering several countries
The following are practical examples of multi-agency action taking place/being planned in a number of countries in the Mekong Sub-region.
EXAMPLE ONE - Seafarers, their families and sexual partners. ASEAN, AusAID, UNDCP, UNAIDS, UNDP, UNICEF, UNAIDS Taskforce on Migration and HIV Vulnerability, NAPs in Myanmar, Thailand, Cambodia and Vietnam, CARE, FHI, PATH in 2-phase collaboration: (1) rapid research, plan of action and interventions to reduce HIV transmission among seafarers, their families and sexual partners; (2) interventions. Country teams coordinated by Taskforce/UNICEF supported by several funding sources channeled through Taskforce.
EXAMPLE TWO - Reduction of vertical transmission (mother-to-child) Multi-country approach to reduction of vertical transmission - Unicef-UNAIDS -NAPs-CDC-SCF-Red Cross-Thai Ministry of Health collaboration and financial support for technical assistance and professional attachment in Thailand and technical assistance to Myanmar, China, Vietnam and Cambodia.
EXAMPLE THREE - In-school Life Skills training. Life Skills approach to in-school STD/HIVIAIDS prevention and care in Mekong Sub-region using one technical assistance (TA) team supported by national officers and INGOs from several countries
n Cambodia -Unicef/Ministry of Education teacher-training and curriculum development; TA from Australia and Lao PDR.
n China - Unicef, National Education Commission, UNAIDS, SCF-UK, Yunnan Red Cross, Australian Red Cross; TA and trainers from Australia and Vietnam collaborate in teacher training and curriculum development.
EXAMPLE FOUR - Youth behavior development and change. Collaboration between National Red Cross and Red Crescent Societies in 14 countries in Asia; collaborating with National and Provincial AIDS Programs; mass organizations, NGOs, Unicef, MOEs and young people, developing training materials and processes to train youth core trainers; technically supported by National Societies from develop countries.
EXAMPLE FIVE - Ethnic minority awareness-raising, prevention and care. Collaboration between Oxfam in Vietnam and China; Unicef in Lao PDR, Vietnam and China; Government agencies in the 3 countries and Thailand responsible for ethnic minority development; and local CBOs in Thailand on technical assistance to integrate STD/HIV/ AIDS prevention and care into village development and poverty alleviation; followed by professional attachment/field visit from the 3 countries to Northern Thailand.
Coordinated by Unicef EAPRO and Oxfam; funded by UNAIDS, Oxfam and Unicef.
EXAMPLE SIX - Behavior Development and Change Communications (BDCC)
Collaboration between SCF, Ford Foundation, Unicef, Red Cross (Thailand, Lao, Australia and Yunnan) and FHI through the UNAIDS Taskforce on Media and Communications to adapt FHI/AIRSPACE BDCC handbooks for translation and use in Lao PDR, China, Mongolia and Thailand. Technical assistance from FHI and funding from Unicef.
EXAMPLE SEVEN - Production of video training package to raise awareness and
support for the key role of people living with HIV/AIDS. Collaboration between Living Films; people living with HIVIAIDS in Thailand, Lao PDR, Mongolia, Vietnam and Cambodia; UNAIDS, Unicef, NAPs and UNDP to film and adapt the video for specific country use; development of handbooks for use with people living with HIV/ADS, family and friends; and service and providers. Funded by Unicef, UNAIDS and UNDP.
EXAMPLE EIGHT - Workplace prevention and care targeting young people/youth
migrant labor. Collaboration between Thai Red Cross, Unicef, UNAIDS, French Development Assistance in Lao PDR, Vietnam and China to modify/develop training materials in local languages and train local organizations to carry out factory-based training. Funded by Unicef and French Development Assistance; technical support from Thai Red Cross.
EXAMPLE NINE - Condom social marketing and distribution. UNAIDS-organized UN trust fund established to allow agencies at national, regional and global levels to contribute funds, technical assistance and condoms. Participation by NAP, PSI, UNAIDS, Unicef, AusAID and NAP. Being implemented in Lao PDR and concept to be replicated in other countries in Asia.
EXAMPLE TEN - Collaboration in strategic planning. UNAIDS cosponsor, other UN agency, bilateral, NGO and NAP collaboration in review of national responses and formulation of national strategic plans. Carried out/planned in Cambodia; Vietnam; Myanmar and Mongolia (Mongolia NAP; UNAIDS cosponsors in Mongolia; UNAIDS/ UNDP Vietnam and Mongolia; WHO-WPRO; Unicef EAPRO, Thailand MOH; Vietnam MOH.) Organized by UNDP and UNAIDS; funded by UNDP, UNAIDS, WHO and Unicef.
EXAMPLE ELEVEN - Multi-country planning and action to reach mobile populations moving between countries. UNAIDS APICT Taskforce on Migrant labor and HIV Vulnerability bringing together UN, INGO, Government and Foundations; preparing guidelines for rapid research and action across countries in Asia and the Pacific.
n Multi-agency rapid study of domestic and cross-border population movements and HIV vulnerability and action plan to reduce this - Lao PDR (current); Yunnan province, China (October)- funded by Unicef, UNAIDS and UNDP.
n Meeting of border province and national level health and HIV/AIDS officers from Yunnan Thailand and Myanmar to discuss continuing low-cost mechanisms for reaching large numbers of highly vulnerable migrant workers and other mobile populations moving between the 3 countries - 8-9 June 1998.
Collaborating with
n CARAM Asia migrant labor network across Asia - from Bangladesh to Vietnam and down to Malaysia and the Philippines; carrying out rapid research on dynamics of population movement; STD/HIV vulnerability and practical options to reduce vulnerability.
n FHI-Care collaboration targeting mobile populations in border areas with high-risk behavior - Vietnam, Cambodia and Lao PDR.
Dr. Abdul Aziz Mahmood, Chairperson
ASEAN Task Force on AIDS
Dr. Aziz, standing in for Mr. Brenan, briefly summarized some of the more salient points that were discussed throughout the meeting. He stressed the rapid spread of AIDS among our youth is very alarming, making the fight against the disease arduous and prolonged. An important task awaiting everyone was how to put into practice everything that had been learned so as to be acceptable and viable within each and every cultural and religious settings. Whatever the outcome, it is clear the any valuable program for the youth must be done with the youth so that they are actively involved in every step of the way.
Equally important is providing the youth with a solid and stable foundation during their formative years. Otherwise, everything else will crumble. The ingredients for a solid foundation are found in the very simple yet important values learned throughout their lives combined with a solid education and healthy practices.
n Strong family values; respect for their elders, their traditions and culture. The adults must be kind to their children. Children are never to be turn into sex objects.
n The elders in every society must act as role models.
n Youth should be taught to value virginity and to save it for marriage and be made aware of the dangers of engaging in sexual activity outside of marriage. Related to this is the importance of faithfulness between marriage partners.
n Any type of opportunistic sex should be avoided.
n The youth should be taught of the dangers of HIV/AIDS
n Their homes should be a haven for the youth.
n Each society must provide play space, such as parks for the youth, so that they can have fun in a safe and sane environment.
n Schools must have extracurricular activities to occupy the lives of the youth in productive endeavors.
Any force for change program needs to give equal emphasis on building a solid foundation for our youth.
Needs Of Participating Countries And Workshop Recommendations
Representatives from each of the participating countries were asked to share their views, concerns and details specific to their countries. The comments are summarized below in the order in which each country’s representative addressed the meeting.
BRUNEI
n HIV/AIDS has been around for 10 - 12 years. It is not a problem to disseminate information. Everything is government based and the education campaigns were started by the Ministry of Education. Interestingly, however, there is no special committee assigned exclusively to deal with HIV/AIDS issues. Since issues are censored, topics like condoms, sexual tools, and safe sex are considered taboo and can only be addressed behind closed doors.
n Religious leaders should play a larger role in helping countries like Brunei, Indonesia and Malaysia overcome this problem. AIDS is a very serious problem which cannot be solved by using traditional religious values alone.
INDONESIA
n The country’s approach to AIDS/HIV is still very much medically-centered
n UN provided funds to develop educational materials for children, but, once developed, the materials were not used. Some of those materials are used for the materials developed by the government, which must follow the guidelines set by the Department of Religious Affairs.
n University students were trained to be leaders in peer education. They were provided with the outline of the modules. Rather than using the modules, they started preaching at their peers.
n With the current economic situation, more people will be dropping out of school so they will not be exposed the educational material produced for a formal setting. Assistance is need in non-formal education.
n Following the recommendations of “Mega-Country Conference” in Geneva, every aspect of health education should be included into the curriculum, including thinks like cigarette-smoking prevention.
CAMBODIA
n Ninety percent of HIV infections occur through sex.
n Of the 20 to 30 thousand daily sexual acts, 30 to 50 result in HIV infection, partly because condom use is very low. Even in the sex industry, only 60% of the sexual activities are carried out with the use of condoms.
n Even though everyone should carry condoms, the idea has not been as successful is required partly because policy decision makers are not well informed and partly due to lack of funds.
n We need to learn more from neighboring countries.
LAOS
n Laos is going through a rapid transition socially, economically, etc. The youth have started abandoning traditional ways in favor or more modern ones.
n The fight against AIDS is done through community work.
n Laos and its neighboring countries need to work in close collaboration to stop the spread of HIV/AIDS.
VIETNAM
n The number of HIV/AIDS infections has tripled in the last three to five years. More than 60% are found in intravenous drug users. A high incidence is found in sex workers as well. The 20 - 29 age group is the most affected.
n Counseling support is in need of improvement. Care must be provided for HIV/AIDS patients and their families. Innovative approaches to achieve proper handling of the problem through the distribution of clean needles, condom use, behavioral changes, safe blood transfusions, etc.
PHILIPPINES
n There is a strong need for sustained advocacy among policy makers. Every time there is a new government, new policies come into effect, thus starting the process all over again.
n The region should establish an institution so that countries can access information. In the Philippines, the infrastructure is poor because the country is composed of 7 thousand islands. Most of the technology is centered in Manila.
n An executive orders on the National Policy for HIV/AIDS has been signed.
SINGAPORE
n Prevention is the key to reducing HIV/AIDS. It’s only logical the all countries should share and pool their resources to facilitate development.
n Policy makers must be convinced to help and to sustain the programs designed to combat the infection.
THAILAND
n We must pursue regional cooperation. It is of utmost importance to share information and skills at all levels of society: governmental, NGOs, private sectors, community.
n Correlative actions are needed to address the needs of groups like mobile laborers, seafarers, refugees, etc.
n Foreign assistance is of great importance.
Workshop Recommendations
After a lengthy and fruitful discussion, the participants agreed upon the following recommendations:
1. Bearing in mind that all of our countries are parties to the Convention on the Rights of the Child, we agree to mobilize our respective agencies and members of civil society in combating the exploitation and sexual abuse of children and youth.
2. We agree to strengthen our efforts to implement programs and projects that take into account the best interests of children and youth and promote the protection of their rights, including cross border and inter-country activities which seek the elimination of sexual abuse and sexual exploitation of children and youth.
3. With full political will and commitment, we believe it is essential to develop and support partnerships with young people in planning, implementing, monitoring and evaluation HIV/AIDS/STD prevention and care programs for in and out-of-school youth.
4. We support young people in identifying their life goals expectations and their desire to grow in a supportive environment. We recommend that reproductive health, life and social skills be incorporated into activity-based, child centered, HIV/AIDS/STD curricula through a participatory approach in training of teachers and educators.
5. We recommend that government policy and programming reflect the view that condoms are a normal, healthy and safe option for both birth-spacing and reducing the risk of transmission of sexually transmitted diseases, including HIV/AIDS. Programs should simultaneously promote the use of condoms both as one of many effective means for birth-spacing and as an effective means of STD transmission prevention for those engaging in sexual activity.
6. Bearing in mind that social marketing programs should consider social, economic, religious, ethnic and cultural sensitivities specific to each country, we recommend social marketing to be incorporated in country programs as one effective mechanism of promoting barrier methods for family planning and STD prevention, including HIV/AIDS prevention as part of a comprehensive response to HIV/AIDS country programming.
7. To help strengthen the political and economic rationale for adopting best practices in HIV/AIDS programs, we recommend additional social and economic impact studies be undertaken, including cost-benefit analysis of various intervention strategies.
8. We recommend that strengthened community-based and school-based programs targeting young people to prevent and reduce drug use be implemented in each of our countries. Emphasis should be placed on leadership building, skills building, and reinforcement of cultural values.
9. We recommend that a balanced approach be adopted between supply reduction and demand reduction as the most effective approach to contain drug use and the harm associated with drug use. We need to sustain supply reduction efforts and strengthen efforts on demand reduction.
10. We recommend that successful models be scaled up and replicated and used as a mechanism to broaden the base of policy and strategic options available to decision makers.
11. Acknowledging the need for supportive political environments, we recommend that every effort be made to strengthen awareness among political leaders, parliamentarians, government personnel and other members of civil society, including youth and non-governmental organizations in the private sectors, about the situation of HIV/AIDS and youth to make them support effective HIV/AIDS policies and programs among relevant health and social services, education and training, and employment sectors.
12. While each country is responsible
for establishing effective national responses to HIV/AIDS, we are committed to
strengthening effective partnerships with the international community including
the ASEAN Task Force on HIV/AIDS
Professor Natth Bhamarapravati,
Mahidol University,
Bangkok
INTERVENTION TECHNOLOGY FOR THE CONTROL AND PREVENTION OF HIV/AIDS
Professor Natth presented four intervention methods for the control and prevention of HIV/AIDS: Barrier Methods such as condoms and virocide; Behavioral Modification; Anti HIV drugs which can may be used for prevention (which are expensive and for which resistance may develop on the part of the infected); and Vaccine.
A preventive vaccine can be of great value to block or downgrade the infection and disease, and to block transmission of the disease from mother to infant. It should meet the criteria of accessibility, affordability, and deployability at the public health level so that the immunity lasts longer, from adolescence to adult, with boosts
Thailand’s national policy for HIV vaccine trials and development is best summarized as follows:
1. HIV vaccine-is considered to be of priority for the prevention and control of AIDS along with barrier methods and behavioral modification.
2. HIV vaccine trial should be facilitated if the vaccine is found to be safe and immunogenic.
3. Assistance to help Thailand build up its capacity to conduct vaccine trials.
4. The presence of Thais as senior researchers/investigators with meaningful involvement in planning, designing, managing, implementing and evaluating.
Upon realizing that there was no consensus on the vaccine concept that provides protective immunity, the testing of Peptide and GP120 vaccines were facilitated. These are based on clade B HIV 1 virus developed in North America.
When it became known that E clade virus is more common in Thailand and probably in the neighboring countries, the development of a vaccine with the E component was encouraged, despite not really knowing if vaccine based on genotype specific for the region was needed or not. The B+E clade HIV-1 vaccine are being tested.
Thai researchers are encouraged to become involved in the pre-clinical development of vaccine with clade E. Japanese NIID and Thai NIH agreement are to jointly develop a BCG based HIV E vaccine.
********************************
JAPANESE AIDS SITUATIONS
6/3/98
Clinical Management by Dr. Shin-ichi OKA (Director of Aids Clinical Center International Medical Center of Japan, Tokyo)
Ladies and Gentlemen. My talk is on Clinical Management of HIV disease so I think I ... it’s out of the agenda for this workshop. I think there is some meaning in it for you on how HIV patients are treated in US or Europe or in Japan. Treatment on HIV in these countries has entered a new decade or a new era after the introduction of anti-aids drugs, called “Protein Agent Inhibitors”. May I have the first slide:
Today my presentation is focused on HIV therapy currently conducted in Japan, especially in Aids Clinical Center, International Medical Center of Japan.
Next: Treatment of HIV disease consists of 2 parts. One is prevention of Aids, prevention of developing to Aids using anti-HIV drugs and the other is the prevention of opportunistic infections and today I will focus on this part, prevention of Aids using anti HIV drugs.
Next: So the first part of my talk, I will discuss about the Pathogenesis of HIV infection which is very important for the seeking HIV treatment. G-3 are the most important and has to be remembered.
n The first one is the Viral Load in plasma reflects disease progression and second one turn over HIV in plasma is very rapid, only 6 hours. Third, HIV growth in lymph nodes and destroys them. I will talk in more detail later.
Next : This slide shows the viral load in the primary stage of infection. So if the patient is infected with HIV, the viral load increases rapidly in a patient. After about one month, however, the viral load again decreases so we call this point a immunological set point. After decreasing but never goes down to zero. So it turns to the stable phase and this point is very important for this is progression. We called this point a virological set point. If the viral load, this point is very high, you can easily imagine that the disease progression is very fast but his viral load is very low at this point. It progresses very slowly and viral load at this point is determined by the immunological function at this point. So these two points are very important for prediction of the disease progression.
Next: So we can predict the viral load at the virological set point. This patient has a low viral load, under 5,000 copies per ml. in plasma. So this patient’s progress of Aids is under 6% after 5 years but the patient has a very high viral load. More than 30,000 copies per ml. More than half the patients progress to AIDS. So viral load is the best predictor of disease progression.
Next: This is the second point. Viral kinetic study reveals that turn over of HIV in plasma is very rapid, only 6 hours. The turn over of HIV infected T-cells is very fast, only 1.5 days. According to this result, the production of a new HIV per day estimated to 10 to the 10th or 10 to the 12th per day. And in time, host produces new T-cells 10 to the 10th per day. So large number of HIV produced per day and infect the new T-cells and so this event occurs every day. So disease progresses despite asymptomatic cell base without therapy. It’s a very important point.
Next: This is a lymph nodes of asymptomatic patient. His CD4 count is more than 500. So you can see red region here. HIV gathers here. We call here germinal center and HIV destroys structure of the lymph nodes. So already destroys here. This slide indicates that we have to start treatment before the destruction of lymph nodes occur.
Next: These are the three important points to think for HIV treatment. Then my talk moves to HIV treatment in Japan. In Japan, nine anti-HIV agents are available but you can see here that only 1996-1997 most are approved, and these top 5 are the reversed transcriptors inhibitors and in these 4 are Protein Agent Inhibitors. We usually use 2 of them and one of them.
(Group A AZT DAT
Group B DDI DDC SQV)
Next: So using these anti-viral drugs. This slide shows the changing of Forensic stage therapy. Before 1996, the best mark of anti-stage therapy is CD4 count so this patient’s CD4 count is below 500, we have to start HIV treatment. I had earlier mentioned, however, that the viral load is very important for detecting the disease progression. So in 1996, we have to think about viral load but in ’97, the viral turn over is very rapid, so we have to think about all HIV positive patient should be treated if the informed consent was obtained.
Next: So how to use these drugs. The transmitted inhibitors are divided into 2 groups: this group is actively prorating cells and this group is active in stable cells and protein inhibitors. So we usually choose one of these from each group.
Next: So I’ll talk about HIV treatment in hospitals. In our clinical center, opened last year, now we have more than 400 patients and this is the root of infection. Half of them are hemophiliac so it is infected through blood products and the remaining half, 2/3 are male homosexuals. These are the background data of my hospital.
Next: So in 1996, major strategy for HIV treatment was two-drug combination so we usually used two reversed transcriptors but after the Protein Agent Inhibitors are available in 1997, the major strategy changed to three combination, (from AZT+DDCà AZT+DDC+SQV)
Next: This slide represents the effect of “Indinavir”. It’s a Protein Agent Inhibitors, the first 30 cases. Of course, these results represent 3 combination using one of them and Indinavir. You can see viral load keeps declining and this means the load, so viral load decrease to two loads and CD4 count elevated more than 100 or 200.
Next: I’ll show you representative case. In this patient, who starts HIV treatment at the low CD4 count here. The CD4 count is in the yellow line and viral load the blue line. So the patient comes down to the hospital and at that time the CD4 was very low, nearly 20, so we started 3 combination, AZT, 3DC and Indinavir. So CD4 count increased rapidly and viral load down to nearly undetectable level.
Next: This is asymptomatic patient that comes down to the hospital and his CD4 count was very high, more than 700, but his viral load is high too. So we tried to start HIV treatment. So first two months, we educated this patient why HIV treatment is necessary and after obtaining the informed consent we started the 3 combination here. After starting the therapy, CD4 count is stable because at the start of the therapy, his CD4 count was very high but viral load down to undetectable level.
Next: This pattern, this patient has already been treated with 2 combination, AZT and DDC but his CD4 count stable but viral load also a little bit high so we changed the therapy to 3 combination. You can see here, AZT is the same but changed these two to the new ones. So viral load went down to undetectable level and CD4 count increased.
Next: This is the fourth case, this patient has already been treated with 3 combination but CD4 count was low below 200 and viral load is high. So we decided to change to 3 new combination. So we changed to new drugs. After the new combination, CD4 counts jumped up more than 300 and viral load down to undetectable level.
Next: This is the typical clinical course of 3 combination. We called G-3 combination as a highly active anti-lateral viral therapy. So we called Hart-Viral and a cogto therapy. So after the introduction of Hart, these things have opportunistic infections dramatically decreased. So in 1996, these trend of opportunistic infection of nearly a 100 person per year but after introduction of Hart, of Protein Agent Inhibitors, these things decreased to half.
Next: I’ll show you more detail of the opportunistic infection. We can see here Candideassis, Herpes Zoster and CMV disease and micro bacteria AVM complex and the bacteria infections estimated here and all of these are decreased incidents. For example, Candideassis about 1/3 and Herpes Zoster ½ CMV ¼. Things like that. So these are the effect of the three combination.
Next: I’ll show you some representative cases. This patient has very severe fungal infection in the nails. After starting Protein Agent Inhibitors, normal nails grow like this. Of course, this patient is not treated with Anti-fungal agents.
Next: This patient suffers from a very severe herpes. It’s very hard to control this but after introduction of Protein Agent Inhibitors, the herpes improved dramatically. Of course without a cyclopea. This is the effect of Protein Agent Inhibitors.
Next: The next issue is how long these effects last. So this slide represents viral resistance to these anti-viral agents. So if the patient is anti-viral naive so start with 2 of the Harts. We started with Hart, so cogtive therapy. This status viral load resistant mutation in outer region. After 9 months of the therapy. After the 9th month of the therapy, most of the virus is the wild type which means it’s sensitive to the drug. We can say these three patients the blue one is 1-5-4, corresponds to the resistance to 3DCs and this one is 2-1-5 corresponds AZT resistance but the 3 patients have only 1 point mutation so we can estimate that the anti-viral therapy is still active in this group of patients.
Next: This slide, this patient is treated to 3 combination but the pro-therapy is LPI but the PI is worse naive. So change 2 drugs or change 3 drugs, the result is the same. His viral load decreases to under 5,000 here. There are no mutation but we couldn’t decrease the viral load below 5,000. There are so many resistant mutation here. So we have to focus on the reduction of the viral load and the therapy.
Next: There are several programs of HIV treatment using the 3 combination but the patient has to take many tablets per day. If the patient is treated with AZT, 3DC and Indinavir, this combination is the most popular combination. So the patient has to take 20 tablets per day and 6 times a day before and after meals. So it’s very hard to take these tablets. And some of the anti-viral drugs are very toxic and you know they are also expensive.
Next: This is the crystal of Indinavir a very famous side effect of the Protein Agent Inhibitors. Around 30% of Japanese patients get such side effect. So to prevent the side effect, the patients have to take 1.5 liter of water per day. This is a new clinical symptom, the lymph node underneath. This patient, a 29 year-old male, his left neck lymph node is swelling 5 weeks after the initiation of Protein Agent Inhibitors. This one is close to the micro bacteria lymphathenetes. So if your country use Protein Agent Inhibitors, I think so many micro bacteria infections in HIV patients so you have to warn them of this phenomenon. Clinical symptom is very severe, a very high fever, pain and so it’s very hard to continue anti lateral-viral treatment.
Next: And this is the cost of drugs per month in Japan. These are in US dollars. If it’s AZT 265, DDI is 798 USD. The most popular combination, AZT, 3DC and Indinavir cost 1,183 USD. We hope for cheaper drugs in the future. There is a minimum requirement of HIV therapy in Japan but,
First, do not watch and wait for the development of AIDS; so we have to start earlier and do not use any single drug and not to add drugs one by one.
Second, do not stop therapy if the patient show clinical improvement. So patients have to continue HIV treatment.
Next: After introduction of Protein Agent Inhibitors, annual cases of AIDS in the US first down in ’96.
Next: This is the hemophiliac data of Japanese HIV infection in Tokyo area. So also similar, the number of patients are very small but the tendency is the same, down in ’97 because the Protein Agent Inhibitors are introduced in Japan this year. So looking at this result, some young people said that AIDS is far from here but someone is also against safe sex. I think, however, I mention that AIDS is far from its cure. The problem of AIDS is not over. I’ll stop here.
--------------------
Prevention for plants' workers
Name: .............................................. Position: ..............................................
Company: .......................................... Telephone No.: ...................................
Address: ........................................................................................................
Referring to the AIDS Seminar and Workshop on Plans for AIDS Training Activities held by the Samutprakarn Working Committee for AIDS Protection and Control in Industrial Factories as parts of its campaign to educate factory staff on self protection to prepare for the co-existence with their HIV infected colleagues for better working environment; the Committee has visited our factory to follow up on our actions and to offer options and guidelines for joint training, the factory has designed the activity plan for staff training as follows:
a. Number of the attendants ............................, ( ........ men and ........... women). Training will be done .......... rounds, .......... persons per round totalling .......... rounds, using the ......... 2 hour-, .......... 3 hour-, ...... 4 hour-, ........ 5 hour-training course.
b. Training periods for each round:
Round 1 from ................. to ................ of Date: ............................................
Round 2 from ................. to ................ of Date: ............................................
Round 3 from ................. to ................ of Date: ............................................
To contact the Company. the Committee should get in touch with
Mr./ Mrs./Miss ........................... Position: ................... Department: .........................
Tel: ................................. Ext.: .................................... Fax: ...................................
The Company’s meeting room can accommodate up to ................................ people and is equipped with ......... loud speakers ............. overhead projector
.......... slide projector .............. T.V. + Video
Please return by fax
Public Health Dept. Fax: 395-1034, 271-4467 and 756-3592 or call 389-5980 (voice)ext.: 115/120 and 756-3026, 756-3592
AIDS Prevention Project in Samutprakarn Province
The Background
Most industrial factory workers in the Central region migrated from the other regions of the country, particularly the North and the Northeast. These people are propelled by poverty in their hometown and attracted by the Central region’s glittering opportunity to get jobs and earn money. Most of these migrants are young male and female laborers. The Public Health Department’s statistics found that this group of laborers or hired hands is at high risk of being infected with HIV.
As the hub of Thailand’s industries, Samutprakarn boasts 5,000 factories which hire as many as 800,000 laborers, thus the area is naturally the main target for the AIDS Protection Project.
The Objectives
The major objectives of the AIDS Protection Project for Factory Workers to reduce the rate of HIV infection among industrial factory workers are:
+ promote awareness and understanding among factory workers stressing especially on behavioral change to insure zero sexually transmitted infection;
+ promote co-operation among the Project, the workers and the factory to establish an in-house AIDS Protection Project in the factory to promote understanding of HIV infected patients;
+ develop effective training courses and techniques applicable to the factories limited training periods for the best result.
The Project’s Activities
The Project’s major activities are:
+ continue to participate in training future trainers of AIDS in Factories;
+ hold factory staff trainings;
+ hold informative exhibitions and activities at the factory;
+ build a network between related organizations and the factory’s executives to develop a long-term AIDS Protection Activities in the factory.
The Project aims to organize activities in 120 factories involving 100,000 workers during the 2-year project plan.
Participating Organizations
Organizations involved in the Samutprakarn AIDS Prevention Project for Industrial Workers (SAM) are:
- Samutprakarn Public Health Office>
- Samutprakarn Hospital
- Samutprakarn Working Committee on AIDS PPrevention
- The Provincial Office of Industries
- The Provincial Office of Labor Welfare aand Protection
- Thailand Family Planning Association
- Thai Business Anti-AIDS Allies
- Children Welfare Fund, CCF (Thailand)
- American International Assurance (AIA)
- Companies and factories in Samutprakarn area
The Project’s source of Funds
With CARE (Thailand), AIA jointly initiated this Project and provided a majority operating fund. The Project is also subsidized by the Public Health Administration and CARE (USA).
List of the Samutprakarn Working Committee
for
AIDS Protection and Control in Industrial Factories
Samutprakarn Public Health Office:
Khun Nongluk Paw-jareon Khun Juree Kritsanapanu
Khun On-nadda Tantipat Khun Busba Iam-opaat
Samutprakarn Hospital
Khun Kritawan Pongsrikoon Khun Ing-on Kongbanterng
Khun Nareeluk Butmanee
Teparak District Office, Tel: 385-4219
Khun Orapan Keeratiwuttiset
Samutprakarn International CARE Organization (Thailand), Tel 756-3592, 755-3026
Khun Pinyo Weerasuksawat Khun Ladawan Kamalate
Khun Duangrat Kaewkomon
Office of Labor Welfare and Protection, Samutprakarn
Samutprakarn Office of Industries
Khun Utsanee Palasuttikun
The activities for a better Thai society are sponsored by:
AIA-Thailand, The Public Health Administration, Japanese Embassy in Thailand
Summary on Activities Performance,
Samutprakarn AIDS Prevention Project for Industrial Workers (SAM)
Background of the Project
Nov. 94 The Project officially obtained the budget from AIA and began its three-year operation on AIDS Prevention in Industrial Workers, 1995-1996-1997.
Dec. 94 Samutprakarn CARE Organization and the Samutprakarn Public Health Office jointly stipulated guidelines on AIDS operation. The CARE Organization was appointed to be the Provincial Committee, an NGO, sharing an office with the Samutprakarn Public Health Office.
Jan. 95 The NGO and government organization started a joint survey of offices in Samutprakarn and its vicinity in a search for allies for the operation. The GO’s enthusiastic co-operation resulted in a stronger organization, particularly sectors that oversee factory workers, namely, District Office of Industry in the Province (DIP), District Office of Labor Welfare and Protection (DOL), District Office of Planning and Projects (DOI).
The CARE Organization has collected 4,000 factory names and 100were selected to be informed of the Project. Letters and literature on AIDS were forwarded to these factories. In addition, plans were organized to train the first group of their administrators.
Feb. 95 Two more NGOs were granted budget to work on AIDS projects in Samutprakarn area:
1. Thai Business Coallition Association (TBCA), Bangkok, organizes trainings and seminars for factory administrators, excluding workers, on AIDS policy;
2. Parental Planning Association of Thailand (PPAT), Bangkok, organizes trainings and seminars for factory administrators, including workers, on AIDS policy, supplying educational materials on AIDS, i.e., VDO tapes, Training of Trainers (TOT);
3. Social Affairs Group, Samutprakarn, provides services for homeless children and trains factory staff on AIDS prevention.
The Samutprakarn office of CARE Organization through the Project co-ordinator proposed that the Samutparakarn Public Health Office organize meetings for GO and NGO to adjust operating strategies to be consistent with the stipulated plans. The Head of Venereal Desease and AIDS Control, Samutprakarn, suggested establishing the Samutprakarn Working Committee for AIDS Prevention in Industrial Workers which initially include 4 government units and 4 NGOs and later involve a total of 12 government units and NGOs, (refer to the list of Names and addresses and main activities provided for the member factories).
The Committee’s first activity was the First Seminar of Factory Administrators (27-28 February, 1995) which resulted in the resolution to share resources, namely, personnel, properties and budget which add values to the activities organized for 52 factories. To date 12 seminars were held with 274 member factories covering 152,151 workers, (for the first 3 years, please refer to the attached list of factories’ names, addresses and data).
Later the Committee proceeded to concentrate mainly on three activities:
1. Activities to train factories administrators so the factory can set up a clear AIDS policy, understands and effectively solves AIDS related problems among its workers under the supervision of GO and NGO, for example,
the factory is urged to:
+ stipulate AIDS policy in line with the government’s and notify all of its workers;
+ set up a policy to provide in-house AIDS education for its workers;
+ refrain from using the result of blood test for AIDS as parts of job application;
+ refrain from partial treatment towards AIDS infected workers, or applying pressure so they resign, or firing them;
+ provide similar care and treatment for AIDS infected workers to other normal workers.
Tens of factories have established AIDS policy in writing, for eample, the Jardine Groups, MELCO, D.K. Textile Company, Siam Steel Silicate Company.
2. Training for Small group of Workers (main job)
Since the main problem of AIDS infected patients are vague and misunderstanding which resulted in disgust and unacception among their co-workers, particularly those with less education. The Working Committee mainly aims to hold intensive trainings for small groups of workers stressing on being informative, fun, factual, not too formal, as well as repeatedly stressing on:
- attitudes (what will they do incase of bbeing infected. Are they scared or sympathetic? Do not judge others, nobody wants to be infected);
- differences between the HIV infected peoople and AIDS patients;
- risk factors, self-evaluation on the rissk of being HIV infected;
- options for AIDS prevention (skills in uusing condoms/ safe sex);
- life skills (skills in refusing/ negotiaating/ differences between male and female).
The essence of the Project is the training. Therefore, the main activity are to convince factories to see the importance of educating workers. The Working Committee pays a visit to a factory weekly until all are visited. The main objective of such visit is:
1. trigger the factories to lay out a plan for AIDS activities, i.e., organize exhibitions and train workers in small-groups until everyone is included;
2. distribute condoms in the factory, (every factory is provided with a plastic box for such distribution);
3. provide every factory with new AIDS related literature, i.e., newsletters, manuals, risk factor evaluation forms, the latest news on AIDS situation in Samutprakarn area and its vicinity;
4. provide councelling services to factory workers, introduce currently available GO’s and NGO’s services.
3. Supplementary Activities for HIV and PWA infected patients are projects later added in1996 as a response to the increasing number of AIDS patients in Samutprakarn Hospital. Forty-five per cent are factory workers, particularly pregnant ladies, mother and infants. The CARE Organization and Samutprakarn Hospital jointly proposed to the Japanese Ministry of Foreign Affairs (MFAN) to establish a project to assist HIV and PWA infected patients in Samutprakarn Hospital. Up to date, the project has been in operation for three years and stresses mainly on the following activities:
1. train all level of medical personnel in hospitals to adopt positive attitude towards AIDS sufferers;
2. provide physical and mental health counselling services to people who come in to check their blood for AIDS before and after taking their blood, as well as educating them about Terboculosis (TB), home care for patients, diabetes, meditation, field studies;
3. provide special welfare services in case the HIV and PWA victims are poor without money for treatment and medicines, including provide baby formula for infants of HIV+PWA patients;
4. organize activities for AIDS in-patients every Tuesday and Thursday:
- organize discussion groups to exchange iinformation/ discuss problems and provide counselling by experienced HIV infected people;
- provide interested HIV + PWA infected paatients with vocational training --- only skills that are not dangerous to their health, i.e., Japanese traditional textile weaving taught by Japanese volunteers, dress-making;
- assist in finding HIV-PWA infected patieents the jobs that suit their individual skills, i.e., salespersons, factory guards, (motorcycle-taxi riders are not recommended due to its being hazardous to the patients health), finding initial capital for small businesses --- 10,00-20,000 Baht ---, financing job applications and grantinf living expenses while waiting for their first month salaries, including requesting for living expenses from the provincial Public Welfare Office.
The three main activities have succeeded with the support of numerous small projects proposed by the GO, the NGO and the factories, i.e.:
1. Training Project for male and female prostitutes. Provide daily evening visits to all brothels in order to regularly distribute condoms or occasionally treat these workers with Chinese food, train them on living skills and provide them with counselling services;
2. Condom Project for general public: in line with the provincial Public Health physicians. Distribute condoms to people who have reached procreation age, particularly factory workers, with 550 distribution points, namely, at government offices, industrial factories, PTT gas stations, department stores, banks and all hotels;
3. Volunteer Project: recruiting volunteers from workers who are studying the Non-Formal Education Department courses (NFED), organizing training for educational advisers and select students who are interested in being trained as volunteers to help their factory co-workers;
4. Friend Help Friend Volunteer Project at secondary school level and in Samutprakarn Technical Colleges;
5. Seminar Project for leaders of Labor Union Council of Thailand;
6. AIDS Training at Dormitories of Factory Workers Project;
7. Training Project for 10-wheel delivery truck drivers who pick up merchandise from Samutprakarn and deliver to other provinces;
8. Campaign on Public Holidays Project utilizing media to campaign on important holidays, i.e., May Day, World AIDS Day, Valentine’s Day;
9. Training Project for Teparak area Factories which are Rotary Members and Personnel Management Association in Pra-pradaeng/ Teparak areas.
NETWORK
The Samutprakarn CARE Organization have joined hands with the Committee for Private Sector Development Organization (PCDO) to establish a Working Committee for business and labor, Central PCDO, whose 11-organization members jointly held supplementary activities for their members, i.e., seminars for factory administrators, exchange curriculums for activities, including personnel resources, educational materials, exhibition materials and act as an NGO representative to co-ordinate with members of the media --- both TV and radio to inform the public of the HIV+PWA patients requirements.
AIA’s Factory Workers Training Project 1995-96-97 = 3 years
Thai Public Health Administration 1996-97 = 2 years
Japanese Foreign Affairs Ministry 1996-97-98 = 3 years
Japanese Embassy, Thailand 1995- = 1 year
CARE Thailand.
Guidelines in using the right media types with Youth
for educational purposes
Media Different types of media are suitable for different target groups and have different effects on their information processing due to the media’s own limitation. In addition, different age group learns and processes information differently. Therefore, choosing the right media for the right target group is crucial for effective campaigns because it affect the target groups’ learning behavior and, thus, the effectiveness of the messages conveyed.
Youth is the group of people who reach the age that needs extra excitement and colorful materials to trigger their curiosity in order to learn new information. Innovative educational materials can do the job better than traditional ones. Based on our past experience, we are certain that informal, lively, interesting and entertaining media not only are crucially useful in conveying the messages and accessing the target group but also create enjoying learning experience for them.
Plays are a type of entertaining medium. It is unique in its style because it is colorful, informal, easy to understand. It is visual and the pictures can clarify ideas to make them easy to learn and memorable. Plays have a dimension that promotes direct interactions between the receiver of messages and their conveyor. In addition, plays portray factual human behaviors and the target group’s daily lives which they can relate to and empathize with, thus, have the desired impact on them.
All types of media, however, have their limitations but with proper control and management with the factors conveying the desired messages, they can prove to be lively and effective in providing the audience time to stop and think while triggering their curiosity to learn the information throughout the process.
**************************
Good morning/evening distinguished guests and participants:
My name is Samran Ta-gan, an HIV infected patient who has an opportunity to share my experience here with you in order to help you develop your AIDS related projects. I realized that I was infected after a blood test in 1989. I regularly fell ill and felt despair and discouraged. I thought I could not tell a soul for fear that people around me would feel disgusted towards me and could not accept me. I was scared that my own parents would know and would not let me live with them any longer. I was confused and preoccupied. I did not know what to do with my life and also was not well health wise. I wanted to hang myself instead of suffering the facts.
I later met a doctor at a TB Control Center, District 10, Chieng Mai, when I was in a very bad shape. I lost my appetite, had chronic fever, and my weight dropped. After receiving treatment at the Center, I got better and began having a glimse of hope in my life. Being infected with the HIV virus triggers an ignorant villager like me to learn more about it. I joined the group of the HIV infected and got to learn more about others in similar situations. We hold on to each other for support and encouragement and now I learn how to cope with being infected with AIDS. I did everything to strengthen my body and try to relax. I would fall ill any time I felt stressed. Since I joined the group and shared my experience with fellow AIDS infected members, my life has more meaning and my health got a lot better. It gave sparks to my life and I learn to know myself more. I think I should learn to lead a new life, that of being infected with AIDS. If I cannot do so, I will have more problems, the virus in me is lurking to flare up. More and more people are being infected. Therefore, I thought I was given a second leasing on life. I started to take care of my health, eating foods that are not hazardous to my health, i.e., pickled food, alcoholic laced food. I know that if I watch what I do, I can live happily with the AIDS virus in me. From my 5-6 year experience at the Center, everybody can do it. Every member of the group, both men and women can take care of their health and live a happier life.
My health could get better because of several factors. The society gives me a chance to use my potential to join in solving the problems. The support and assistance from both the government and private sectors, as well as other organizations act as a medicine that help lengthen the lives of the infected so they can live to work for themselves and the society.
STEP 4 The process of “expanding his role and the group’s”, returning to one’s original community to instill understanding of the AIDS infected people and co-exist with the infected like oneself.
STEP 3 The process of being “enlightened” which means realizing the importance of assisting other infected patients and live the rest of one’s life consciously and usefully for fellow human beings.
STEP 2 The process of “revealing oneself” and joining others that are out of the closet and improve the group of the infected so the members are stronger spiritually and physically with the support of the main society.
STEP 1 The process of changing attitude. Adjust oneself from being hopeless and desperate to being hopeful to live with the AIDS in one’s body.
AIDS Way of Life
Sumalee Wannarat
AIDS Co-ordinating Center
Mae Kao Tom Sub-District
In the past, many people thought:
- AIDS is something too removed from them// other people’s business;
- AIDS is the doctors’ business;
- the infected - AIDS patients are shunnedd and avoided.
Now, the facts facing us are:
- AIDS is a social problem, requiring everryone to help solve it;
- AIDS situation is increasingly serious aand affects other issues;
- People who are suffering from AIDS are iin fact our friends, colleagues, sibblings, relatives and acquaintances;
- AIDS is around us.
Therefore, AIDS is not any one’s peoblem in particular any longer. AIDS is the problem that everyone in the society needs to help solve.
The initial thing that counts in working on preventing AIDS are analyzing the problems arose in the real community and getting the community to seriously involved in doing so.
AIDS related problems found
in the rural community in Thailand
consist of the following major problems:
From the above chart of problems, it can be seen that the AIDS problems in communities did not occur on their own but derived from several factors, i.e., poverty, lack of income, migration of labors, turn to work in sex trade, drugs addiction, lack of education, accurate data, information, sexual value, etc. These are basic problems in the Thai rural community. These problems do not, however, end with having AIDS patients and death of AIDS in the communities but have other impacts, i.e.,
- orphans of AIDS parents. These chiildren are abandoned without education. If organizations within the community and outside do not step in to help, they will grow up to have a low living quality, poor, migrate to other sites and become drug addicts. These will be an indefinite cycle of AIDS related problems:
- seniors who are left alone to take care of children: when their children died of AIDS, many seniors citizens are obligated to take in and take care of orpahned grandchildren.
- housewives who lost their husband to AIDDS. They are themselves infected by their husband and have to take care of their children in addition to their senior parents. Therefore, there is a high possibility that these women will, spend the rest of their short lives in sex trade which nobody can deny that it can provide them with enough income to do so, as well as have some excess amount for their children’s future. Finally, this turn into the never ending cause for AIDS proliferation.
- the HIV infected and AIDS patients and rrelatives are shunned by people around them. Sometimes it affects the relationship in the family as well as in the community.
The above related problems indicate that solving problems at a certain point does not end any of the problems. The direction to solve problems requires systemetic ideas and activity planning to cover the three types of problems in the form of a comprehensive solution which will lead to a long-term development. The action requires cooperation among the related organizations as well as the government, private sectors.
******************