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“ ABC4D APPROACH TO HIV/AIDS ADOPTED BY MYRADA ” paper presented at the International Conference on “Micro Finance in the Global strategy for meeting the Millennium Development Goals” hosted by Concern Worldwide, Dublin, Ireland, September 2005 By Dr. Maya Mascarenhas , Myrada, Bangalore, India
India has an estimated 5.1 million people (2004 NACO report), with 10% of the world’s population of people with HIV being Indian. The overwhelming majority of these (89%) are in the age group of 15-44 years. Women constitute 21.4% of known AIDS cases in the country. The six states with the highest prevalence in India are Tamil Nadu, Maharashtra, Karnataka, Andhra Pradesh, Manipur and Nagaland. MYRADA has long since recognized the negative impact of HIV/AIDS on communities and development., with its work in HIV AIDS prevention with the Devadasi groups in Belgaum in 1994. Recently, MYRADA has initiated a large intervention project targeting high-risk groups in four districts of Gulbarga, Chitradurga, Bellary and Kolar in partnership with the Karnataka Health Promotion Trust, with funding from the Bill and Melinda Gates Foundation, and in Chamrajnagar district with KSAPS support. Acknowledging the epidemic nature of this problem, and its ramifications on the health and economic future of the country, MYRADA has expounded its vision and policy on HIV/AIDS interventions within its purview. This has translated into a holistic ABC4D approach to HIV AIDS. (A= awareness, B= behavior change, C4= continence, condoms, community and continuity and D=drugs). It is important to note that there is a logical connection between these components. For example, while we start with Awareness, we know that it is inadequate unless there is Behavioral change. The second link between Behavioral Change and C4 is even more important. This is because C4 describes the strategy that MYRADA adopts to motivate and sustain Behavioral Change. THE ABC4D APPROACH TO HIV/ AIDS PREVENTION A = Awareness B = Behavior change promotion C4 = Continence, Condoms, Community and Continuity D = Drugs AWARENESS Several studies show that the level of awareness about HIV/AIDS is far from adequate in the general population. While 75% of the adult population may have heard of AIDS, less than 50 % had heard of HIV, or know about its method of transmission and prevention. In the rural areas, the picture was even more dismal. Literacy levels correlated very high with the lack of awareness. Awareness was consistently low across gender and place of residence. Knowledge was low among rural females in Karnataka (5.9%) and Tamil Nadu (5.9%). One of the main areas of interventions is to raise the level of awareness of the population about the basics of HIV/ AIDS. It is important that this awareness is given to all segments of the population including the general adult population, youth and women. Methods of awareness creation are as critical as the content of the message. Our experience in Belgaum has taught us that a multi method approach is the most effective. Here, a plethora of methods are used targeting literate and illiterate, urban and rural populations. The common methods used that were found to be very effective were: Mass awareness: Pictorial posters, wall writings, stickers, Street plays Radio shows and TV spots Distribution of pamphlets Targeting youth: School HIV/AIDS education programs Debates and quiz Condom demonstration Targeting rural women Self help group trainings with flip charts Health camps Targeting high risk groups One to one discussion, small group discussions Health camps and STI services Condom demonstration Health care providers: Training on syndromic management of STIs Training on counselling Setting up facilities for HIV testing. BEHAVIOUR CHANGE PROMOTION Awareness creation will ensure that the communities learn the basics of HIV/AIDS. We know that this disease is closely related to high-risk behaviour patterns. The commonest method of transmission in India is through sexual contact (85%). Behaviour change requires a different approach from awareness creation. Here, there is a focus on the behaviour and the challenge is to work on people developing the positive attitudes to enforce a change from high-risk behaviour to a safe behaviour pattern. Given the well known example of how difficult it is to get a smoker to stop smoking even though he is well aware of the relationship between smoking and lung disease, the challenge with behaviour and HIV AIDS is much more, given the stigma associated with discussing about sex. Behaviour change process follows various stages. It is important to know that just by giving information on a topic; the person will not change their behaviour to a safe one unless they go through the different steps outlined below: UNAWARE INFORMED/AWARE CONCERNED KNOWLEDGEABLE and SKILLED MOTIVATED to CHANGE READY TO CHANGE TRIAL ASSESSMENT OF NEW BEHAVIOUR MAINTENANCE/ ADOPTION OF NEW BEHAVIOUR This process will require working with peers and other accepted members of various communities. It also requires interventions targeting high-risk groups such as commercial sex workers, high-risk clients such as truck drivers, vegetable vendors, migrants, etc. One to one discussion and counselling will facilitate this process to a large extent. We have learnt that behaviour change needs to be focused in small groups where the group will exert its own internal pressures on its members to learn and adopt the safe behaviours required to prevent HIV transmission. CONTINENCE, CONDOMS, COMMUNITY AND CONTINUITY Each of the Cs listed above is of critical importance to any programme being successful in the sphere of HIV AIDS. CONTINENCE This process follows behaviour change where the focus is on promoting self-restraint and permanent adoption of safe behaviour. This requires continued education and counselling focused on high-risk groups. Continence is ensured when the behaviour change in the community is long lasting, and spills over into the next generation. It requires extensive community participation and this will only come about after the community has been made aware, and given the skills to change their behaviour and/ or cope with adverse situations that force them into risky behaviour. Working with small groups is effective as they assume responsibility to ensure that their members adopt safe behaviours in the long term. CONDOMS It has been well established that no HIV AIDS intervention can be completed without ensuring condom promotion as a preventive method. Condom promotions go beyond distribution of condoms. It involves establishing a regular supply, demystifying and destigmatising the idea of using condoms, and setting up outlets to make condoms available within easy distance of every person. It is also important to include demonstrations whereby the correct use of condoms is explained and demonstrated. In our HIV/AIDS projects, condoms are also distributed through the Government outlets and private enterprises such as Population Services International (PSI), which does social marketing of condoms through their registered outlets. COMMUNITY The community is the focal point of any programme in MYRADA. All our activities work very closely with the communities, from the development of concepts, through to planning, implementation, monitoring and evaluation. In fact, MYRADA works solely on the principle of participation, and devolving projects to the community. The recent establishment of Community Managed Resource Centres is a classic example of our commitment to empowering the community to own responsibility for their own well-being. In the context of HIV/ AIDS, the community refers to all sections of the population. It cannot be restricted to the high-risk groups only. Now that the general population is affected with this virus, one needs to involve all types of communities at various levels. Involvement of the community embraces their active participation in the planning of programmes, empowering them with the knowledge and skills to take the program forwards, and linking them with available resources to fulfil their needs. It also requires the community to assume the responsibility of monitoring and evaluating the programme from all perspectives, including financial monitoring. In order for the community to be effective in their involvement, it is important to invest in training and development of core groups of persons such as “community resource persons”, who will then further train their own local communities. These resource persons should also be appointed and managed by the community itself so that there is total accountability to the local people. The community managed resource centre can take over this role and provide services to the people through these community resource persons. Established institutions in the community such as the gram sabha are crucial stakeholders in the success of any programme. Besides representing a large section of the rural communities, these bodies can play a significant role in encouraging and ensuring behaviour changes in their local areas. CONTINUITY Sustainability is the key word to any worthwhile programme or vision. In MYRADA, the driving force behind any project is its sustainability beyond the funding period. This issue needs to be spelled out at the inception of the project so that appropriate mechanisms can be put in place through the project period. In the context of HIV/AIDS, continuity refers to the sustained availability and provision of awareness, behaviour change promotion and services to the community so that HIV prevention activities carry on uninterrupted. In order to ensure continuity, one must look at every possible source, including the creation of financial buffers, which will provide this continuity. Building appropriate people’s institutions is MYRADA’s way of ensuring effective ownership and continuity of programmes. Here, this would require different types of institutions to address various issues. Some examples would include self affinity groups, high risk group associations, district level resource persons groups and community managed resource groups. Other established groups such as the gram sabha, gram panchayats, existing self help groups and so on need to be strengthened and empowered to take on the role of community level resource groups. DRUGS Medical treatment and psychosocial support are essential for people with HIV/AIDS. The range of services includes treatment and follow-up of sexually transmitted infections, palliative care to relieve pain and discomfort, and highly active antiretroviral therapy. While we know that there is no known cure, it is important to understand the benefit of antiretroviral therapy in improving the quality of life of a person with HIV/AIDS. Given the large numbers of persons who are HIV positive on one side, and the prohibitive costs of the drugs that need to be taken life long on the other, it will be important to devolve an effective strategy to address this issue. Other medical support such as treatment of opportunistic infections, nutrition support and improving the quality of life of the infected person is well within the reach of our organization. Treatment of sexually transmitted infections and palliative care and support are available at a relatively lower cost, and MYRADA will need to establish strong linkages between the community and these services. MYRADA’S EXPERIENCE WITH HIV AIDS PREVENTION MYRADA has been involved in the subject of HIV prevention since 1994, and continues to do so through several projects. 1. AIDSCAP Project (AIDS Control and Prevention) – BelgaumThis 4-year intervention focussed on HIV AIDS Prevention activities targeting rural communities in 4 taluks of Belgaum District. This project was the first time any NGO attempted HIV/AIDS/STD awareness with rural populations on such a large scale. It was also the first time that MYRADA had systematically addressed the issues of HIV AIDS and STDs. Key learning’s from the project were:
This five-year project, initiated in four districts of Karnataka in February 2004 is in partnership with Karnataka Health Promotion Trust with funding from the Bill and Melinda Gates Foundation. MYRADA decided to take it up in four districts as it recognised that HIV AIDS was an issue that was closely linked to the vulnerable populations. This project has a very specific focus in preventing transmission of HIV in high-risk women (commercial sex workers) and high-risk men (men who have sex with men and clients). This focus works on the premise that reducing the prevalence of STIs and HIV in these groups will correlate with an overall reduction in HIV prevalence across the district. The interventions are planned to reduce HIV prevalence, and include condom promotion, STI treatment with counselling and awareness on HIV/STIs to these high-risk groups. MYRADA has adopted the ABC4D approach in this project. While awareness programs are directed at the larger community to provide an enabling environment, behaviour change promotion is targeted at the high-risk groups through institution building and provision of services. This project has over 40 dedicated staff who work along with community facilitators and the high-risk community represented in the form of around 200 peer educators. In the first year we worked in 28 urban locations across the districts with a total of around 10000 high-risk group persons. In the second year, (2005-2006), we have expanded to 2 more urban locations involving a total of 12000 high-risk group members. Almost 7500 men and women from the high-risk community have been successfully treated for STIs in the last 6 months, and will be followed up on a regular basis.
With the support of UNDP, this project looks at the issue of women’s vulnerabilities to HIV AIDS, and how we can reduce these. The two main approaches are increasing women’s awareness and capacity to assert their rights, and to create a supportive environment that will address their needs and help reduce their vulnerabilities. This project is focused on women in the rural areas and urban slums, and works in collaboration with other NGOs through established community organizations such as self help groups. Using the 5 CHARCA pillars of awareness, capacity building, creating support structure, strengthening health services and creating an enabling environment, MYRADA has a dedicated staff of nine persons and 35 community resource persons devoted to this project, covering 105 villages and 20 slums of Bellary, Sirugupa, Hospet and Sandur taluks in Bellary district in the first year.
This project, with the support of Karnataka State AIDS Control Society (KSAPS), is a three year targeted intervention project that looks at reducing HIV transmission in sex workers in all the four taluks of Chamarajanagar. Initiated in September 2004, this project has already been able to provide regular services to more than 350 of the 700 estimated sex workers. The overall goal of the project is to establish and provide focus prevention services (awareness, condoms and STI treatment) to the high risk groups, and to provide an enabling environment in the community. The team consists of a project coordinator, 6 outreach workers, a counsellor and 15 peer educators. The unique features of this district is the large proportion of homosexuals (estimated at 30% of the high risk group), and its proximity to Mysore city.
One of the areas of focus in the child centred programme of MYRADA Plan International is health promotion, which includes HIV AIDS prevention. These projects are located in three different areas: Dharmapuri district of Tamil Nadu, Madakasira of Andhra Pradesh and H. D. Kote of Mysore District. Over 700 villages are covered under this project involving the rural populations. 4. HIV/AIDS Prevention Programs: – Kadiri, Huthur and GermalamThrough core funding from NOVIB and German Agro Action, these three projects conduct HIV ADIS awareness and trainings for its key staff; community resource persons and the self help groups. Conclusion We are still learning from our experiences. So far, we know that HIV AIDS is not only a medical or public health problem, but permeates all sectors of development. We are in the process of understanding and studying how to mainstream HIV AIDS into our development work as well as integrate the ABC4D approach in all our work. This includes setting up a workplace policy for our own organization as well as encouraging the community based organizations we work with to understand and adopt the ABC4D approach in their own societies. |
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