Gender Power Dynamics in Marriage and HIV Sero-discordant Relationships

Regional Technical Meeting on

Responding to the Feminization of AIDS:

Gender Power Dynamics in Marriage and Sero-discordant Relationships

Implications for Practice

Workshop Report

18 – 20 February 2009

Dusit Thani Hotel, Bangkok, Thailand

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Report prepared for UNIFEM

Jo Kaybryn – Plurpol Consulting

[email protected]

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Contents

About this report ........................................................................................................................................................ 5

Background ................................................................................................................................................................ 5

Context ....................................................................................................................................................................... 6

Objectives of the workshop ....................................................................................................................................... 6

Project strategy and objectives .................................................................................................................................. 7

Participants ................................................................................................................................................................ 7

Expected outcomes .................................................................................................................................................... 8

Session 1: Opening address by Dr Jean D’Cunha, UNIFEM Regional Director, South East Asia ................................ 9

Session 2: Setting the scene ..................................................................................................................................... 10

Setting the scene and progress to date – Karabi Baruah, Focal point- Gender and HIV Programme UNIFEM-

ESEARO ................................................................................................................................................................ 10

Overview of “Gender dynamics in the epidemiology of HIV in the Asia Pacific Region” – Caitlin Wiesen-

Antin, UNDP Practice Leader .............................................................................................................................. 11

Session 3: Presentations from India and Cambodia followed by discussion ........................................................... 14

Cambodia: Jenne Roberts, Consultant ................................................................................................................ 14

India: Niranjan Saggurti, Population Council ..................................................................................................... 16

Session 4: Presentations from Thailand, Sri Lanka and Philippines followed by discussion.................................... 18

Thailand: Dr Pimpawun Boonmongkon, Mahidol University ............................................................................ 18

Sri Lanka: David Bridger, UNAIDS Sri Lanka ....................................................................................................... 21

Philippines: Malou Quintos, UNAIDS Philippines ............................................................................................... 22

Session 5: Presentations from Indonesia, Laos PDR, Malaysia and Pacific .............................................................. 24

Indonesia: Ira Atmosukarto, National AIDS Commission .................................................................................. 24

Laos PDR: Phokin Mouangchanh, Laos Women’s Union ................................................................................... 25

Malaysia: Azrul Khalib, UN Malaysia .................................................................................................................. 28

Pacific: Stuart Watson, UNAIDS Pacific .............................................................................................................. 29

Session 6: Positive women’s perspectives and the greater involvement of men ................................................... 30

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Culture of sexuality and gender in Thailand and women access to ANC clinics, Supeecha Baothip, Thai

Positive Women’s Organization .......................................................................................................................... 30

Priorities, strategies and questions for regional networks: Anandi Yuvaraj (ICW), Frika Chia (WAPN+), Vince

Crisostomo (Seven Sisters) .................................................................................................................................. 33

Session 7: Research needs, programmatic entry points and advocacy messages .................................................. 37

Researchers Group .............................................................................................................................................. 37

Programme Group ............................................................................................................................................... 39

Advocacy Group................................................................................................................................................... 40

Session 8: Stakeholder perspectives on the process and outcomes including action steps in country .................. 41

India, Pakistan, Bangladesh, Sri Lanka ................................................................................................................ 41

Malaysia, Cambodia, Philippines, Vietnam ........................................................................................................ 42

Thailand, Myanmar, Cambodia, Lao PDR, Indonesia ......................................................................................... 44

The Pacific and Papua New Guinea .................................................................................................................... 45

Session 9: Summary Comments UNAIDS/ UNIFEM ................................................................................................. 47

Jane Wilson, UNAIDS Regional Advisor Gender, GIPA and Human Rights ........................................................ 47

Caitlin Wiesen-Antin, UNDP Practice Leader ..................................................................................................... 47

Karabi Baruah, Focal point- Gender and HIV Programme UNIFEM-ESEARO .................................................... 47

Vince Crisostomo, Coordinator Seven Sisters .................................................................................................... 48

Agenda ..................................................................................................................................................................... 49

List of participants .................................................................................................................................................... 51

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About this report

This report summaries the presentations and discussions that took place during the joint UNIFEM and UNAIDS

Regional Technical Meeting on Responding to the Feminization of AIDS in Asia. Pertinent slides representative

of the issues described are reproduced within the text and full presentations (in PowerPoint format) are

available separately.

Background

The ‘Feminization of AIDS’ and spousal/partner transmission of HIV are critical problems unfolding in the Asia

Pacific Region. Despite evidence that prevention programs are beginning to have an impact in some countries

(e.g. in Thailand and Cambodia), HIV infections among women, especially young women, continue to outpace

those among men; a stark reminder that gender inequity and violence against women fuel the epidemic.

Epidemiological evidence from most countries in the region indicates that the largest number of new infections

is within stable or long-term relationships – with married women accounting for most of the new HIV infections

in the region – and notes the rise of discordant couples1.

In Thailand, for instance, approximately one third of new infections in 2005 were among married women who

are believed to have acquired HIV from their husbands or partners2. Similarly in Cambodia, where a rapid

feminization of the epidemic is also being observed, 43% of all new HIV infections are occurring in married

women, most of whom are believed to have acquired the virus from their husbands.3 In Viet Nam as the

epidemic evolves, increasing numbers of women are acquiring HIV from males who were infected during unsafe

paid sex and injecting drug use: in 2006, an estimated one third of people living with HIV in Vietnam were

women4. The HIV epidemic in Indonesia is among the fastest growing in Asia, and is currently seeing a gradual

shift away from a concentrated epidemic among key populations at higher risk to a more generalized one. HIV is

triggered mainly through heterosexual transmission and one of the main determinants of transmission in the

region is the tendency towards multiple sex partners and the portent vulnerability of wives or regular partners.

Feminization of the HIV epidemic does not refer solely to the increasing prevalence rate among women.

Feminization of the epidemic is tacitly acknowledged to be the result of insufficient responses to the various

interlinked, multi-layered, and deeply embedded gender issues, including: unequal power dynamics between

men and women in society at large and within marriages; violence against women; feminized poverty; violence

in the course of migration; gender disparity in education; and gender disparity in employment opportunities.

Feminization of the epidemic requires prevention efforts that target specific gender related risk factors.

Information provided by sound research and sex-disaggregated data pinpointing gender inequalities and gaps in

prevention, treatment, care and support for women is urgently needed to develop gender and HIV programmes

as an integral part of National AIDS Programmes.

1 Discordant couple, where one partner is HIV positive and one who is HIV negative 2 WHO (2007). HIV/AIDS in the South-East Asia region. March. New Delhi, WHO Regional Office for South-East Asia. http://www.searo.who.int/hiv-aids 3 UNAIDS, Scaling up Towards Universal Access to HIV Prevention, Treatment, Care and Support: Cambodia Country Report. Geneva. 2006 4 Viet Nam Commission for Population et al. (2006). HIV/AIDS in Viet Nam. Hanoi, Ministry of Health, Population Reference Bureau.

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Context

UNIFEM has a core role in gender analysis in the context of HIV and AIDS. In line with UNIFEM’s interest in the

feminization of AIDS and the Redefining AIDS in Asia report5, which highlighted the lack of focus on HIV

transmission to spouses of men at high risk, UNFFEM commissioned a two phased study in 2008. The first study

consisted of a “Rapid Assessment in Indonesia, Lao PDR and Thailand” to carry out a review and secondary

analysis of existing data/resources, programs and policies, laws and legislation addressing (a) ‘Feminization of

AIDS’ with specific focus on spousal/partner transmission of HIV and sero-discordant relationships (b) current

HIV post-test counseling program and prevention activities in response to national policies on HIV. The review

provided an overview of the situation facing young women and girls in the context of spousal/partner

transmission of HIV. The review resulted in a framework to ascertain: (i) the efforts undertaken so far by

Government as well as NGOs and other stakeholders involved in HIV and AIDS activities in the region, to

increase understanding of sexual and behavior patterns, practices and risks that expose women married or in

long term relationship to the risk of contracting HIV through spousal/partner transmission and of sero-

discordant couples; (ii) identify gaps/opportunities in areas that may require further information and data to

streamline, strengthen policy formulation and guidelines on prevention of HIV among women and girls; and (iii)

identify appropriate approaches/methodologies to carry out field research aimed at developing an evidence

informed knowledge base on ‘Feminization of AIDS’ and prevention strategies for spousal/partner transmission

of HIV.

Objectives of the workshop

The regional technical workshop was designed to foster discussions and sharing of experiences among

government agencies and concerned organizations in member countries in handling the issue of Feminization of

AIDS with focus on spousal/partner transmission of HIV; while at the same time, using the information derived

from the rapid assessments to identify appropriate approaches/ methodologies (country specific as well as a

common regional framework) with a view to guiding the second phase of the study, an in-depth qualitative

research with the following objectives:

To develop an enhanced evidence-informed knowledge base on gender-power dynamics in

marriage/relationships and sero-discordant couples;

To contribute to evidence-informed strategic information and increased use of that evidence in

programming and policies on primary prevention of HIV among and young men and women (of

childbearing age) and on appropriate treatment, care and support to women living with and affected by

HIV;

To improve information on the post-test counseling programmes in the areas of: sexual practice; risks

and implications of being HIV-positive; required treatment negotiated or ensured by clinicians; and

health education and its effectiveness;

To increase participation of women affected by and at risk of HIV through their active roles in the

research and subsequent related advocacy. The participation of groups or networks of women, whose

inputs and perspectives can keep the discussions grounded, were invited to make this technical

workshop more meaningful.

5 Redefining AIDS in Asia: Crafting an Effective Response, Report of the Commission on AIDS in Asia, 2008

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For countries like Cambodia, where sufficient information was generated through a rapid assessment in 2008,

the focus will be on the operationalization of the research findings: that is, the required actions to implement

the recommendations from the assessment reports.

UNIFEM’s Regional Meeting comprises a second technical meeting on spousal transmission on HIV as part of a

strong focus by the United Nations and its partners in 2008-9. The first Regional Technical Meeting took place

on 6-8 November 2008. The regional technical partners were UNAIDS, UNDP, UNIFEM, UNFPA, the Asia Pacific

Network of People Living with HIV (APN+) and the International Community of Women living with HIV (ICW).

Financial support was provided by UNAIDS, GTZ, GCWA and UNIFEM. Participating countries in South East Asia

were: Cambodia, China, Lao PDR, Indonesia, Malaysia, Myanmar, Philippines, Thailand, and Viet Nam, and in

South Asia: Bangladesh, India, Pakistan, Sri Lanka and Nepal. The first meeting aimed to assist countries in the

Asia Region to develop evidence-informed HIV prevention strategies for married women, to form and maintain

a network of national women’s organizations and other civil society organizations to address prevention of

spousal transmission of HIV and to facilitate provision of capacity building of organizations in the regional

network. A regional policy meeting will take place in May 2009.

Project strategy and objectives

Keeping the goal of the overall project in perspective, namely improved evidence base on women and HIV and

AIDS leading to increased use of that evidence in rights-based programming and in strengthened advocacy

initiatives, the objectives of this second regional workshop were as follows:

1. To identify the topical and geographical focus and appropriate country approaches/methodologies for

the follow up field survey to collect data as identified in the initial rapid assessment;

2. To prioritize recommendations (both short-term and long-term) and actions required for their

implementation for countries, such as Cambodia, that may not need further operational research;

3. To initiate identification of entry points for regional cooperation through bilateral and multilateral

relations that can contribute to improving gender responsiveness of policies and programmes for HIV

transmission in marriage/among partners and sero-discordant couples, such as migration, to be

continued at the May 2009 policy meeting;

4. To identify measures to strengthen the partnership with the positive women‘s networks in the region

(APN+ & ICW) including increasing capacity for effective liaising and communication between the

networks, UNIFEM and UNAIDS.

5. To identify networks of women’s organizations focused human rights and CEDAW and networks of

people living with HIV in each country to take the lead advocacy efforts in country.

Participants

Representatives from the National AIDS Commissions, networks of people living with HIV, researchers,

UNIFEM staff and UNAIDS Gender Focal Points from Cambodia, Indonesia, Laos and Thailand;

Members of the UN Joint AIDS Team from Thailand;

Other researchers previously involved in the regional work on spousal transmission;

Regional gender and HIV staff from UNIFEM, UNFPA, UNAIDS, UNDP.

Representatives from the Asia Pacific Network of people living with HIV and the International

Community of Women Living with HIV;

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Expected outcomes

The following are the specific outputs of the Workshop:

The scope and methodology for data collection and prioritization of recommendations and actions

required for their implementation including formats for regional reports about the country studies;

Identified points of entries for advocacy on gender and HIV in country;

Strategies for strengthening communication between the networks of people living with HIV and UN

agencies at regional and country levels;

The workshop report.

The results of the workshop, especially the presentations and discussions of the rapid assessments on

Feminization of AIDS will contribute to a planned publication for 9ICAAP6. UNIFEM funded the workshop and

participants from Cambodia, Lao PDR, Indonesia and Thailand as well as other researchers. UNAIDS RST funded

the participation of UNAIDS Gender Focal Points from other countries participating. UNIFEM/UNAIDS was

responsible for the monitoring proceedings and UNIFEM’s consultant/facilitator produced the workshop report.

6 9th International Congress on AIDS in Asia and the Pacific 9-13 August 2009, Bali

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Session 1: Opening address by Dr Jean D’Cunha, UNIFEM Regional Director, South East Asia

Date: February 18, 2009

Time: 17:00 hrs – 19:00 hrs

Moderator: Jane Wilson, UNAIDS Regional Advisor Gender, GIPA and Human Rights

Dr D’Cunha opened the meeting by discussing the emerging themes related to the feminization of AIDS and

spousal or partner transmission of HIV: Firstly that the feminization of AIDS is a significant issue; Secondly that

there is an increase of HIV among young women, more than young men, with gender inequality being a major

driver; Thirdly that the epidemiological data points to the fact that largest number of new infections are among

women (AIDS Commission Report) including in countries where overall new infections are declining such as

Thailand and Cambodia.

Root causes: The power dynamics between adults and children, same sex relationships, men and women, boys

and girls, are all affected by gender stereotypes. Gender stereotypes of men are constructed as breadwinners

and public figures, while those of women are constructed as unpaid caregivers, religious celibates or vamps.

Feminine qualities are promoted as passive, weak, docile and inert. Masculine qualities are promoted as potent,

active and aggressive. The result of these gender stereotypes on women include their lower access to resources,

lower access to information and little recognition of the link between HIV and gender. Women in the sex sector

cannot negotiate safer sex. In marriage they cannot talk about sex or condom use. Stereotyping women leads

to extreme stigmatization and doubles women’s burden. Men have multiple relationships as appropriate

outlets for their innate sexuality. Women are viewed as fitting options for release or seen as consenting adults,

while mythology pervades around the desirability for sex with young girls for pleasure, to increase potency and

to cure STIs, and condom use is seen to diminish pleasure.

What is needed: We want links between groups of men living with HIV and different women’s groups. The

distinction between different women’s groups perpetuates the madonna-whore divide and we must have more

discussion. We must engage men and women to understand their feelings about rejection, loss of love,

deception etc and convert the feelings of these groups into positive feelings to become guides and mentors. We

need to interrogate the institution of prostitution, based on sex as a male right, and that sex and feminine

bodies are to be sold to men. We must expand our partnerships to include not only the ministries of Health but

ministries of Women’s Affairs, Information, Education, Finance, Planning – we want the entire government

structure to address HIV. Among civil society, we must work with people living with HIV, migrant workers,

injecting drug users, same sex rights, youth, and the media so the issues are mainstreamed.

Actions

1. Systematic and rigorous research: we have the desk reviews and now we must identify gaps and

research sexuality in nuanced dimensions. How do men and women cope in the context of migration?

How do they cope in contexts facing alienation, fractured psyches and fractured sex, including children?

2. Use research to inform policy and programmes

3. Use research to develop advocacy messages to debunk the gender stereotypes. We must use the

recommendations to create new perspectives in counseling programmes.

4. Use the recommendations and data in development of informal and formal institutions, particularly the

desperate need for work with high school students

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Session 2: Setting the scene


ESEARO

Overview of “Gender dynamics in the epidemiology of HIV in the Asia Pacific Region” – Caitlin Wiesen-Antin,

UNDP Practice Leader


Time: 08:50 hrs – 09:30 hrs

Moderator: Vandana Mahajan, UNIFEM South Asia

Rapporteur: Dr Samia Hashim, UNAIDS Pakistan

The Session started with a welcome by Jane Wilson, UNAIDS, who thanked the participants for their

participation. She then introduced the day, meeting logistics and the program. She requested Karabi Baruah,

UNIFEM, to set the scene by briefing the participants on the progress to date.


ESEARO

Karabi once again thanked the participants and all the partners in working jointly on putting the meeting

together. This workshop is the follow-up of the technical meeting on spousal transmission on HIV held in

November 2008 and both meetings reflect a strong focus by the United Nations and its partners on the gender

dynamics and spousal/partner transmission of HIV. She shared the overall project goal, which was to improve

evidence-informed knowledge base on women, HIV and AIDS, which would facilitate the region and the

countries in increased use of this evidence in rights-based programming and in strengthened advocacy

initiatives in the region.

She updated the participants regarding rapid assessments in Indonesia, Lao PDR, Thailand and Cambodia were

commissioned by UNIFEM through which reviews and secondary analysis of existing data/resources, programs

and policies, laws and legislation addressing ‘Feminization of AIDS’ with specific focus on spousal/partner

transmission of HIV and sero-discordant relationships were conducted to provide an overview of the situation

facing young women and girls in the context of spousal/partner transmission of HIV. Karabi explained that the

objectives of the Workshop were to try to finalize the scope and methodology for data collection and

prioritization of recommendations and actions required for their implementation including formats for regional

reports about the country studies; also to identify strategies for strengthening communication between the

networks of people living with HIV, government and UN agencies at regional and country levels and points of

entries for advocacy on Gender and HIV. She emphasized that this exercise has tremendously supported

evolving partnerships. The technical partners in the first meeting in November 2008 Regional were: UNAIDS,

UNDP, UNIFEM, UNFPA, the Asia Pacific Network of People Living with HIV (APN+) and the International

Community of Women living with HIV (ICW). Financial support was provided by UNAIDS, GTZ, GCWA and

UNIFEM. This current technical workshop was being financed by UNIFEM; co-organized with UNAIDS, while

sharing experiences with UNDP and some national implementing partners.

This was followed by an introduction session, facilitated by David Bridger, UNAIDS, which also served as an ice

breaking session.

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Overview of “Gender dynamics in the epidemiology of HIV in the Asia Pacific Region” – Caitlin Wiesen-Antin,

UNDP Practice Leader

Caitlin outlined the HIV pandemic in Asia and the gender aspects of transmission and impact. Several slides

from the presentation are included below (the full presentation is available in the electronic annex).

Caitlin spoke of what drives the epidemic in Asia; what is the impact of the epidemic; and the mounting costed

national responses? An estimated 150 million people are living with HIV in Asia, 60 million of which are women.

There is a core group of people at high risk of HIV infection and sex work is the main driver of transmission. HIV

transmits from sex workers to male clients to their partners, and there is overlapping of sex work with injecting

drug use and sex between males. There is an increase in new infections among women: 19% in 2000 to 24% in

2007 but these averages mask dramatic increases in numbers, for example in Papua New Guinea where girls are

twice as susceptible to HIV infection as boys. Caitlin highlighted the 50 million married women whose spouses

visit sex workers, added to that the female partners of injecting drug users and males who have sex with males

and we have a very large number of women who are at high risk of HIV infection.

She shared the Commission’s projection of an epidemic in a typical Asian country with about 100million

population, based on an analysis of epidemic progression in a number of countries. It can be seen that majority

of new infections are occurring among adult men visiting sex workers, second largest among the sexual partners

and only a small percentage among low risk young men who engage in casual sex. So, contrary to popular belief,

casual sex in the general population is not the main cause of the epidemic in Asia. Instead, it is paid sex which is

the biggest risk factor in Asian epidemics. She shared the sobering data of the rise in the numbers of women

living with HIV in Asia. She shared the critical gender issues that fuel the epidemic, on how impacts of HIV and

AIDS on marriage and household is very direct and severe, transmission from men to women higher due to

higher non-disclosure rates by men as large number of people living with HIV choose not to disclose their status

to spouses immediately. She also shared the study from India where the evidence shows that HIV positive

widows are most likely to have contracted HIV from their husbands, majority of whom did not know their status

but those who did know their status had not disclosed it to their spouses.

In terms of the impacts of the epidemic, as it epidemic expands and matures, it strikes at the heart of

development. AIDS being the leading killer of Asians in their most productive years (15-44); it spreads and

deepens poverty and additional poverty 5-6 million households (25-30 million people) is expected by 2015; it

strains overstretched health system’s ability to reach most at risk populations and vulnerable populations;

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deepens gender inequalities; unravels social cohesion; the $2 billion annual economic loss is mainly borne by

poor households, though there is no perceptible impact on GDP growth there is severe impact at household

level. Women bear the major brunt of these since they bear the burden of care, blame and shame. 75%

caregivers in Vietnam are women; 90% positive women in South Asia infected by partners and 90% of HIV

widows are thrown out of marital homes after husband’s death in India.

There are a number of critical gender issues: constructs of masculinity and femininity make women’s

negotiation difficult. Education is low for women, and access to quality reproductive health is lacking. Women

have less economic opportunities which increase their dependency on others and increase their vulnerability to

exploitation. Mobility impacts on HIV transmission through men’s migration (internal and external) for work

and the increased likelihood they will buy sex the longer they have been migrating. Among trafficked women,

they younger the age of being trafficked, the higher the chance of being HIV infected. In addition to sex work,

violence also plays a key role in both intimate relationships and in conflict and war. Non-disclosure of HIV status

leads to increased transmission between partners. Most people don’t know their status or their partner’s before

(and during) marriage.

The AIDS Commission reported that “at present, there is no effective strategy to protect women within marriage

or steady relationship in Asia on a large scale”. There is a need for high quality research for designing prevention

programs for these populations. Caitlin emphasized the need for impact mitigation projects/programs in Asia as

they were lacking and were not part of national strategies in most Asian countries. These would cost only

US$300 million per annum for region. These programs must provide income support for foster-parents;

livelihood security for widows and affected families; secure property and inheritance rights for women and

health insurance to protect against catastrophic health expenditures. Caitlin shared excerpts from the recently

published Gender and HIV practitioners’ Guide developed by UNDP, ICRW, UNIFEM, UNAIDS, UNIFEM, UNODC

and UNICEF (see full presentation in electronic annex).

The Asian HIV and AIDS Resource Estimation and Costing Model developed by UNDP-UNAIDS-ADB is strongly

aligned with directions and recommendations of the Commission on AIDS in Asia Report, and has the Universal

Access targets for Asia and the Pacific embedded by default, with an addition of a new area of costing: “Enabling

Environment, addressing human rights, gender and governance dimensions of HIV responses”. To ensure that

women focused interventions are included and budgeted, the women-focused interventions were included in

the Asian HIV and AIDS Resource Needs Estimation and Costing Model. The suggested interventions are women-

friendly income support programs for HIV-affected households; support for families caring for children

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orphaned by AIDS; Review/develop/amend laws and policies to guarantee inheritance rights especially for

women; care for AIDS affected people incorporated into social security schemes and Prevention of Parent to

Child Transmission including the involvement of family and partners.

Costing the national response requires a re-focus on prevention. Impact mitigation is also included for the first

time, as is the creation of an enabling environment. It is a difficult question to answer in terms of how much

structural work the HIV response should take on, but we also must recognize that we cannot achieve our goals

without ensuring rights. 30% coverage rate of key populations is not enough to stem HIV transmission, but if we

reach 50% HIV transmission is modeled to level off. The Asia Commission pointed out there is no effective large

scale prevention strategy for women in marriage. Impact mitigation can include foster grants, health insurance

and property rights.

The Asian HIV and AIDS resource estimation and costing model prompts us to ask questions about what should

be included, especially in relation to women’s rights based approaches. If these strategies are conducted at

country level in a collaborative way, they are more likely to have meaning for the costers and therefore more

likely to be implemented. We must avoid paralysis by analysis. It is important to move the response and define

our advocacy messages.

Discussion summary

Cost efficacy for prevention programmes: what’s the how? And how cost effective is it? There are little

examples of costed models for Asian countries (i.e. in comparison to African countries) which tell us and policy

makes the cost-effectiveness of various approaches at national level, and importantly the opportunity costs of

not implementing certain strategies. The challenge here is that this is currently unknown. Do we launch an

extremely large general campaign with high cost but potentially long term impact? The question is how do we

be strategic?

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Session 3: Presentations from India and Cambodia followed by discussion

Cambodia: Jenne Roberts, Consultant

India: Niranjan Saggurti, Population Council


Time: 09:30 hrs – 10:30 hrs

Moderator: Alankar Malviya, UNAIDS

Rapporteur: Jane Batte, UNAIDS Cambodia

Cambodia: Jenne Roberts, Consultant

Cambodia is an example of a country whose HIV epidemic has turned around over the last decade; currently

national prevalence is 0.9%. The gender analysis shows that the percentage of women living with HIV has

increased from 38% to 52% between 1997 and 2006, although this is more likely to reflect the fact that many

men have died rather than an increase in new infections among women. Fifty per cent of Cambodia’s

population is under 20 years of age which has implications for transmission and the response. There is a higher

prevalence in urban over rural areas. Evidence also shows that there is increased prevalence among the most

wealthy (although in percentage terms rather than in numbers). Much of Cambodia’s reduced prevalence is due

to the introduction of the Continuum of Care and a strong commitment to universal access. Antiretroviral

therapy coverage is 91%. 52% of both antiretroviral therapy and opportunistic infection patients are women.

Yet still 20,000 people don’t know their status and are without positive prevention messages.

In the 20-24 age range, women are three times more likely to be HIV positive than men. Projections show that

there will be slightly more women than men living with HIV, and more women than men will need antiretroviral

therapy. New infections are declining due to 100% condom promotion among sex workers, and the availability

of treatment. In 2008, just over ⅓ of infections were in children, just under ⅓ were in women, and ⅓ were in

men. The sex industry is changing in Cambodia and men are using brothels much less but there is an increase is

casual relationships and number of girlfriends. There is a small but growing number of injecting drug users,

among whom prevalence is 25%, with the next highest groups are transgender and female sex workers.

Vulnerability factors include: desensitization to violence, gender roles, migration, and women’s low decision

making power especially in relation to whether their husbands have relationships outside marriage. Outside of

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brothels condom use is very low. The situation within brothels is ambiguous: sex workers report high usage but

the level of sexually transmitted infections has not changed since 2000.

There are barriers to disclosure and 20-30% of people living with HIV at one clinic reported not knowing their

partner’s status. In fact there is little known beyond anecdotal evidence what these barriers are. There are

limited positive prevention approaches. 25% of HIV positive women have negative partners. There are few

family planning, sexually transmitted infection and reproductive health services and in those that are operating,

the staff often has discriminatory attitudes.

The national HIV response includes a strategy for women and girls but there is limited capacity. Funds are

directed mainly towards the Department of Health not the Ministry of Women’s Affairs. A draft strategy for

entertainment workers has been developed but no resources attached to it. Mandatory testing is not

encouraged. Only 2 out of 50 services are providing integrated family planning and HIV services.

Unmet information needs:

Information is collected but not analyzed, interpreted and disseminated

Incidence data for monitoring

Anecdotal understanding of gender, violence, property rights but no evidence

How discordance is managed

Barriers to disclosure and testing (including lack of testing equipment, and denial of difficult issues such

as child abuse)

Pregnancy among people living with HIV on treatment

Sexual behaviors of widows, divorced and separated women and men

Recommendations for action

Focus on prevention efforts for married most at risk populations and their sexual partners

Enable people living with HIV with positive prevention

Enabling environment and human rights approaches

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India: Niranjan Saggurti, Population Council

There are a high proportion of HIV discordant couples. Among couples affected by HIV, women are HIV positive

in 39%. Many people who are at high risk have spouses and may be sero-discordant but we have no data.

Vulnerability to HIV infection is increased due to the low status of women, different castes and violence. There

are societal and cultural norms that affect disclosure. What are the best practice models for secondary and

positive prevention?

The contextual framework shows that the context affects variable (gender, behavior) which results in non-

disclosure of status and low sexual health, both of which ultimately lead to HIV transmission.

Next steps: feedback will be given to the National AIDS Control Programme. There are currently no

guidelines/toolkits to support the targeting of spouses so the development of an advocacy toolkit is proposed.

This will seek the participation of civil society to build their capacity, especially among positive networks. In the

long term, programmes should be developed to facilitate disclosure among discordant couples among those

who know their status, and encourage those who don’t know to go for testing. The approaches will use

structural level coordination and not rely on vertical parallel programmes. All sectors must come together to

work on how to maintain sero-discordance among couples.

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Summary of discussion

Migration is also an issue for India, but evidence is lacking on testing of migrant workers (especially

internal).

There are other ways to support people in discordant couples, other than disclosure. For example, one

Cambodian clinics support women to reduce their viral load to an undetectable rate to protect their

husband.

An epidemiological model could be developed with a gender analysis of prevention among women.

91% coverage of antiretroviral therapy but adherence is less known, but this is one way of analyzing

discordance issues.

Positive prevention: what does this mean in reality and does responsibility always lie on positive people,

adding to their burden?

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Session 4: Presentations from Thailand, Sri Lanka and Philippines followed by discussion

Thailand: Dr Pimpawun Boonmongkon, Mahidol University

Sri Lanka: David Bridger, UNAIDS Sri Lanka

Philippines: Malou Quintos, UNAIDS Philippines


Time: 11:00 hrs – 13:00 hrs

Moderator: Alankar Malviya, UNAIDS

Rapporteur: Laura Tracy, UNIFEM Cambodia

Thailand: Dr Pimpawun Boonmongkon, Mahidol University

Dr Boonmonkon explained that the research undertaken by Mahidol University builds on the earlier rapid

assessment by the UNIFEM consultant, Jo Kaybryn, and aimed to elicit the voices and experiences of women.

Objectives: Examining the current policies, legislation and program implementation by government

organizations and non-governmental organizations working with people living with HIV. The research examined

the laws and legislation in regards to CEDAW7, abortion, sex workers, prostitution, prevention, and suppression

of the domestic violence law and any other laws that involve HIV issues. The above examination provided an

understanding of the sexual risk/behavior patterns and practices which expose women to HIV in Thailand. The

methodology consisted of a rapid assessment over a three month period, including, a document review from

research and other studies; and in depth interviews with three women living with HIV.

An analysis of the legal framework in Thailand reveals many issues related to gender and rights from CEDAW to

national harm reduction laws. However, it seems that most legislation is conceived from the paradigm of

maternity which emphasizes women’s roles as ‘good’ wives and mothers. This detrimentally affects women

perceived to be outside these categories i.e. those who want abortions, female sex workers and women living

with HIV. The Thai government realizes there is a need to shift from health/medical approach to understanding

the social dimensions.

The findings included: the most at risk women were 20-40 years old; and the laws have encouraged young

women to use marriage as a way to achieve conflict resolution in terms of male-female relationships, putting

them at risk as opposed to being used as an empowering tool for them. In extreme cases marriage is used

against women, for example in the case of sexual violence: a man is not prosecuted for rape if he marries the

female complainant.

Government policies on women living with HIV began in 1992. Various campaigns have focused on

strengthening families, non-promiscuity and safer sex negotiation. Campaigns promoting non-promiscuity

include: “say no to sex”; “respect and acceptance of women’s rights and roles”; and “love and warmth in the

family”. The aim has been to target married couples but the emphasis has been directed at women not men.

The result was to encourage women to put aside their own sexuality, desires and encourage ignorance of their

husband’s/boyfriend’s infidelity. The campaigns were not really focused on men taking responsibility to be

faithful and/or use condoms etc. Other examples of women-focused responses include prevention of mother to

7 Convention on the elimination of all forms of discrimination against women

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child transmission which is solely focused on drug delivery to women and is available at 800 hospitals, and the

100% condom use campaign which is targeted at women in brothels not their male clients.

In general, the analysis of policy on women shows that policy is based on an epidemiological approach, and

excludes women of varied backgrounds. The gender bias includes the focus on women but policy does not

empower women or address their rights. In fact violation of women’s reproductive rights is the norm, such as

sterilization imposed in exchange for abortion requested by women living with HIV. There are various leverages

used for testing women but not men. There are also fewer entry points for targeting men. Most engagement

with women takes place at mother and child health centers which largely exclude men’s participation.

Traditional values of women’s sexuality prevail and women are polarized as “good or bad”, monogamous and

non-monogamous. In addition to policy deficiencies, research is also lacking: only five studies discuss gender

power dynamics and HIV in the last 10 years. Mahidol University’s research looked at the reasons women have

sex, female sexuality in discordant relationships, sexual relationships, sexual practices including verbal and non-

verbal negotiation.

For women who have regular sexual relations the meaning of sex include love, duty, own pleasure and desire,

and male pleasure and desire. Most are monogamous and their sexual practice is characterized by no sexual

communication and a lack of access to information and health care services. Condom use is viewed as a male

responsibility and is also identified as a symbol of distrust (stigmatized due to the association of condoms with

commercial sex and extra marital sexual activity).

Women within HIV sero-discordant and HIV concordant relationships expressed their understanding of sex as

love, to fulfill their own sexual desire, to fulfill their partner’s desire, reproduction, pregnancy and responsibility.

Women also reported having extra marital sex for money transaction and in revenge for their partner’s

masculine pride, betrayal, abandonment, and his extra-marital sex. Women within sero-discordant and

concordant relationships are sexually active and have changed partners (total 2-7 partners). They find it difficult

to disclose their HIV status but when they do they are more likely to stay with someone who accepts their HIV

status. These men can be married or unmarried men, and HIV positive or negative. The women include both

heterosexual and homosexual.

Most women experience a lack of information with regards to positive prevention and avoiding re-infection.

They also experience a lack of sexual communication and negotiation power with their partners, and very little

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or no condom use. Women in relationships with men have varied approaches and ability to negotiate or refuse

sex. Non verbal tactics include going to bed later than their spouse and participating passively in sex act. Verbal

tactics include making excuses for health reasons or citing tiredness or the unavailability of condoms.

Sexual negotiation power depends on a range of factors. Women’s lack of ability to negotiate depends on the

time, the context and the type of partner. Other factors include their own inexperience, especially at the

beginning of marriage, their views of sex as shameful and a duty, and their partner’s sobriety and chauvinism.

Women who can negotiate are economically more independent, have more life experience, influenced by their

residence (e.g. a couple living with the wife’s parents) and their own physical capital. Women’s attitudes

towards masturbation correlate with ability to negotiate. Those that do masturbate have been able to cross the

perceived lines of morality and sexual perversion. They have more sexual agency and they have experience in

touching and feeling themselves. Women who do not masturbate displace their interest to other activities

because they feel it is shameful. As a result they have no experience of touching and feeling themselves.

Another issue that affects women’s ability to negotiate is their self-perception. Women with greater agency

have increased self-perception of their physical power and beauty, which links closely to their confidence. This

is reflected in condom use within commercial sex: subjective perceptions of physical beauty and desirability by

providers and clients of sex workers play a significant part in setting the price for services and also dictate the

conditions, i.e. condom use.

Future research should look at gender, power and sexuality within couples, and especially within discordant

couples, for women growing up with HIV, for injecting drug users (positive and negative). We need to

understand the health providers’ perspectives of gender, women and rights and how these impact on the HIV

and the quality of care. The methodology should include both qualitative (focus group discussions, in-depth

interviews) and quantitative (survey questionnaires) research. Population samples should focus on:

- Young people living with HIV (14-18 years old), Female injecting drug users (18-25 years old)

- Women living within sero-discordant/concordant relationship (20-55 years old)

- Men living within regular relation and concordant relationship (20-55 years old)

Suggested study sites include Bangkok, North, South, Northeast, East, and hospitals which have PM prevention

of mother to child transmission programs (836), villages, and communities. Data analysis should include both

social science software (e.g. SPSS) and content analysis.

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Sri Lanka: David Bridger, UNAIDS Sri Lanka

Sri Lanka has a low overall HIV prevalence and there are 100-120 new infections each year. It is a truncated

epidemic: HIV is entering the country but does not appear to be spreading. 108 women are on treatment, 36%

reporting infection via spousal transmission, 94% of which reported their partner acquired HIV while working

overseas. The vulnerabilities of HIV transmission are predominantly due to separation (i.e. partner is a

migratory worker); gender-based violence; low knowledge and low condom use (women use hormone

treatments for birth control, which offers no protection against sexually transmitted infections or HIV); and

consensual and non-consensual sex. Vulnerability also stems from risk-taking behavior from the bridging

populations (sex workers, males who have sex with males, prison population and uniformed services).

Migrant workers were found to be over-represented in HIV research and results as they are subject to

mandatory testing. The Bureau of Foreign Employment pre-departure program for female migrant workers

responded by providing some information/education before departure. However, this response captures about

60% of women who work abroad. 30% of women and most young men do not get any support or input. Overall

the quality of both data and reporting is very weak.

The next step for UNAIDS Sri Lanka includes using the UNDP report on HIV vulnerabilities to develop advocacy

messages and strategies. Programming must include women and men and strategies to reach partners of the

most at risk populations. “Organizing our Messaging”- sexual and gender-based violence are huge issues in all

conflict zones Sri Lanka is no exception, although, there is no data from the North. There is a strong possibility

that when they receive the data from the conflicted North that the HIV statistics will rise.

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Philippines: Malou Quintos, UNAIDS Philippines

Objective: Undertake an assessment on spousal transmission of HIV in the Philippines as inputs to country and

regional strategic plan to address this issue.

Methodologies: Desk reviews - epidemiology of spousal transmission in the Philippines, mapping of policies that

facilitate or impede prevention of spousal transmission. Key informant interviews of AIDS programmers –

programmes that address directly or indirectly spousal transmission, resource mapping (budget for addressing

spousal transmission), organizations/sectors and their capacities to do work on spousal transmission,

opportunities for addressing spousal transmission in the Philippines. Focus group discussions with: discordant

and concordant couples. The discussions centred on; the psycho-social, emotional and economic impact of

spousal transmission on families. A Validation workshop was utilized.

Key findings: Passive data collection shows that: 6% of HIV infections are among people registered as

housewives; 10% are among people who claim to be married; 20% of transmission is through bisexual

transmission. The research on spousal transmission reviewed the available data and policies and determined

the key influential players through a desk review and interviews with key informants including men and women

who are in relationships where one or both are HIV positive.

“Spouse” in the Philippine context, not only means the legal husband/wife, but also live-in/common law

partners, mistresses and other forms of relationships considered long-term and stable. The 4th AIDS Medium

Term Plan is gender blind. For instance, ongoing prevention strategies and activities target most at risk

populations (sex workers, males who have sex with males and injecting drug users) and vulnerable populations

(e.g. migrant workers). But it is only among the migrant workers where there are ongoing efforts to target their

partners. There is a dearth of information on the issue of spousal transmission in the country. We are not even

sure who these positive women/spouses are who are reported in the AIDS registry. Some of them are wives of

migrant workers, but we are not sure of the others. We do not know whether they are wives of bisexual men

or wives of clients of sex workers, or from a different scenario.

Some good practices on work with migrant workers: (1) UNDP’s pilot impact mitigation project – livelihood

support for migrant workers living with HIV. (2) Integration of AIDS education in both the Pre-Employment

Orientation Seminars and Pre-Departure Orientation Seminars. Although on a small scale, efforts focused on

preventing HIV transmission to women including in relationships has targeted overseas workers. This usually

occurs in pre-departure orientation sessions but in terms of an intervention this is probably a bit late. Pre-

employment seminars prior to appointment would give people more time to think about their risks. It is also

important to look at the large segment of domestic workers (women) rather than only the male dominated

industries such as maritime and sea faring. The wives of maritime workers have begun demanding that HIV

information is included for both their husbands and themselves on exit and return of workers as part of

reintegration. One large company (30,000-40,000) has expanded its orientation and re-integration sessions to

include wives and families of the workers.

The study has generated some useful insights as inputs to ongoing strategy development and implementation of

intervention programmes. At the same time, the study raised the need for further related researches given the

dearth of information on the issue. The analysis of the Spousal Transmission Study will be enhanced and

understanding deepened by the Integrated HIV Behavioural and Serological Surveillance to be conducted

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starting June 2009 and the planned Country Assessment on Gender and HIV. Findings and analysis, including

issues around spousal transmission, will inform the development of the 5th AIDS Medium Term Plan (2011-

2015), the next Common Country Assessment and UN Development Assistance Framework (CCA/UNDAF) for

2011-2016 and future GFATM proposals.

Next Steps:

Findings to be presented to the Philippine National AIDS Council (PNAC)

Recommendations around data collection and reporting to be integrated in the revised manual of

operations for the AIDS Registry (Dept. of Health)

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Session 5: Presentations from Indonesia, Laos PDR, Malaysia and Pacific

Indonesia: Ira Atmosukarto, National AIDS Commission

Laos PDR: Phokin Mouangchanh, Laos Women’s Union

Malaysia: Azrul Khalib, UN Malaysia

Pacific: Stuart Watson, UNAIDS Pacific


Time: 14:00 hrs – 15:30 hrs

Moderator: Dr Khamlay, UNAIDS Laos PDR

Rapporteur: Ashley Heslop, UNAIDS Indonesia

Indonesia: Ira Atmosukarto, National AIDS Commission

Indonesia consists of 17,500 islands. The patriarchal culture is still very strong and affecting the AIDS epidemic. Cultural attitudes are also affecting the AIDS epidemic. Discriminating laws particularly affect women and transgender. The HIV epidemic was largely concentrated among injecting drug users, but a second wave impacts on women’s vulnerability through both their own sexual patterns with multiple partners (e.g. there are more women living with HIV than men in Papua), and impacts men’s vulnerability, especially those that are married and have high mobility and/or multiple partners. Key areas of progress include the formation of a positive women’s network (IPPI) and groups of female injecting drug users. Two national research workshops saw the creation of a national HIV strategy for women. The national AIDS commission has undertaken a gender audit (November 2008) and created a working group on Gender and Human Rights to review gender and rights mainstreaming. Gaps in response continue, especially in reaching migrant workers, women prisoners, sex workers (women, transgender and males who have sex with males). The national AIDS commission recognizes the need to connect with the region to cement the fragmented responses. Challenges to achieving holistic coverage include low gender awareness among government, divided civil society, clinical vs. non clinical approach, no integrated efforts from all players, problematic geography, and a virtually non-existent social security system vs. community based security system. The research on spousal transmission of HIV will take place in Jakarta, Bali and Papua. It is challenging to get women involved in the studies and there are also different views between the researchers.

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Laos PDR: Phokin Mouangchanh, Laos Women’s Union Overall Lao’s HIV prevalence is low 0.2%. Of those people living with HIV, 57% are male and 43 are %female. The highest affected age group is 20-29. 900 people are on antiretroviral therapy. The main vulnerability factors are economic and the migration needs of men and women. There are also social and cultural elements such as gender inequity within relationships, and men’s increased likelihood of having several partners. The response includes: voluntary counseling and testing, prevention of mother to child transmission, condom distribution, TV and radio campaigns, drop in centers, and programme to involve men (e.g. maternal health care). Background: By June 2008, the official cumulative total number of people living with HIV was 2,858. 1,837 AIDS cases were recorded and 873 had already died. 57% of people living with HIV are male and 43% female. More than 77% are between the age of 20 and 29 years. 85% reported as a result of heterosexual sex. 900 people are on antiretroviral therapy. Estimates: HIV prevalence among population 15 – 49 years (0.2%). HIV seroprevalence among female sex worker: 0.4%. HIV seroprevalence amongst males who have sex with males (in Vientiane capital) 5.6%. Total number of PLHIV: 8,000. Number of women over 15 years living with HIV: 1,500. Number of children with HIV: 65 Key findings Existing data, policies and programmes related spousal and partner transmission

Data limited to national HIV estimates and studies of populations most at risk which have implications for spousal transmission

Gaps:

Data on sex workers excludes information and services directed at clients of sex workers

Qualitative and quantitative data on female migrant workers and their male counterparts for policies and programmes

Vulnerabilities

Women’s seasonal external migration for work (illegally)

Sex work much more indirect than other countries

Lack of openness about sexual health

High HIV prevalence among men who have sex with men in Vientiane (males who have sex with males are often married to women)

Sexual patterns of men (concurrent partners)

Sexual patterns of women (serial monogamous relationships) Unmet information needs

Gender and decision making at household level

Sexual patterns and decision making

Internal and external migration decisions of and impacts on women Vulnerability factors for HIV infection

Discordant couples (men and women)

Low condom use

Migration for work – internal and external (men and women)

Selling and buying sex

Men who have sex with men – their male and female partners

Gender power imbalance: women’s negotiation in sexual relationships/barriers to access information and treatment

Men’s reluctance to attend clinics or seek treatment

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Low service provision in rural areas

Men’s concurrent multiple partners Vulnerability factors

Understanding economic and sexual power dynamics between women and men

Addressing barriers to women’s access to information and services

Understanding the sexual health needs of women who migrate (internally and externally) for work

Strategies to reach men who have multiple partners (male and female) with sexually transmitted infection and HIV information

Current responses Population priorities

Female migrant workers (internal and external) Geographical priorities

Northern and Southern provinces that border Thailand, Vietnam and China Social and cultural factors related to HIV/AIDS

Increased trade routes and construction projects

Increased commercial sex workers

Varying levels of knowledge

Increased sexual activity amongst youth

Low condom use

Stigma and discrimination

Traditional practices

Negotiation skills (particularly for women)

Alcohol and drug abuse

Men who have sex with men

Gender inequality (including violence against women) Responses

voluntary testing and counseling screening: antenatal care, pregnant women, gynecology patients, post-abortion, ectopic pregnancy, migrant returnees, men

Counseling

Prevention of mother to child transmission (nevirapine, formula meal, caesarean)

Free condoms

Drop in centre for women who sell sex

Information campaigns on radio and TV

Workplace approaches with trade unions

Involvement of men in sexual and reproductive health

Sexual and reproductive health education in schools National Response to the HIV epidemic

Voluntary counseling and testing networks cover 17 provinces and 20 districts

Expansion of antiretroviral therapy services in 3 provinces

National strategy and action plan on HIV/AIDS/STI 2006-2010

Strategy and action plan for women 2007-2010

100% Condom use programmes

STI treatment services

Training activities for people living with HIV

The Ministry of Education is promoting HIV/AIDS and sex education

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Sites for Voluntary Counseling and Testing

40 sites for provincial level

50 for districts level and

1 health center level Results of focus group discussions Stigma and discrimination

Some participants identified feelings of isolation arising from the social stigma and talked about this as a factor in their mental health.

People who are HIV positive are afraid

People living with HIV suffered stigma from their co-workers and employers

Some officer who has HIV positive said “I have to stop my work because I am afraid that they will know my HIV situation and I have to avoid to face in order to keep this secret”

Gender and HIV

Gender inequalities

Some women reported that they are totally dependent on men and have no decisions to make in matters of sex.

In the female group discussion, some women reported that they cannot refuse their husbands sex.

“My husband is a play boy. He goes away and commits adultery with other women and prostitutes. When he comes back, I have sex with him. Even when I am annoyed, I cannot deny him sex.”

Barrier to get HIV treatment

Limited number of health care professionals and places

Long wait times to see specialists.

In rural areas, there are fewer services for people living with HIV/AIDS.

Fewer health care providers who are knowledgeable about HIV/AIDS and want to treat people living with HIV/AIDS.

Travel a long distances to get services. Data Gaps

The Healthcare Experiences of Married Couples with HIV/AIDS

Factors contributing to spousal transmission

Barriers to receiving care

Interactions and relationships with the healthcare providers

Knowledge level about their illness

Information needs for their health care

HIV and Stigma

The root causes of stigma: knowledge and morality

Expressions and forms of stigma

Consequences and impact of stigma

The relationship between reducing HIV-stigma and uptake of HIV services, treatment and prevention

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Malaysia: Azrul Khalib, UN Malaysia

The epidemic has been concentrated in male injecting drug users. There are 5,640 new HIV cases each year but quality data is not available. A shift in the transmission patterns are occurring from injecting drug use to heterosexual, and therefore from men to women. Compulsory HIV testing is prevalent, and within pre-marital testing confidentiality is often violated. The testing is largely due to the influence of the religious department which is involved in all public health matters. However, a newly formed task force on HIV will include the participation of civil society. Incidentally, government public health settings provide all HIV treatment and testing.

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Pacific: Stuart Watson, UNAIDS Pacific

There are three major regions: Melanesia, Polynesia and Micronesia, and all three contain enormous diversity in terms of language, culture, political, social, history. Overall in the pacific HIV knowledge is low. There is an increasing rate of HIV and it is likely to be under reported. While the number of infections might be small, the impact can be significant among small island populations.

The impacts of gender interplay with high mobility of people. There is a high level of sexually transmitted infections. There are culturally based gender relationships, some of which are very fluid. At the same time there are ongoing changes in traditional male, female and other roles in society. Recommendations include:

Mainstream gender into national and regional policies and programmes

Gender equality in strengthen laws and enforcement

Address violence against women

Promote positive masculinity

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Session 6: Positive women’s perspectives and the greater involvement of men

“Culture of sexuality and gender in Thailand and women’s access to ANC clinics”, Supeecha Baothip, TPWN

Priorities, strategies and questions for regional networks: Anandi Yuvaraj, ICW - Frika Chia, WAPN+ - Vince

Crisostomo, Seven Sisters


Time: 15:30 hrs – 17:30 hrs

Moderator: Aleta Miller, UNAIDS Myanmar

Rapporteur: Malou Quintos, UNAIDS Philippines

This session bridges the country presentations with the later sessions in which the workshop will identify

strategies to address issues around the feminization of AIDS. This session focuses on the perspectives and

realities of people who are directly affected by HIV.

Culture of sexuality and gender in Thailand and women access to antenatal care clinics, Supeecha Baothip,

Thai Positive Women’s Organization

This presentation highlighted societal gender expectations which act as barriers to women’s and men’s access to information, prevention and treatment services. Gender expectations are also reflected in the formal healthcare response which: lacks gender sensitivity; does not uphold women’s rights; excludes men in reproductive health and HIV testing; remains unprepared for positive women’s pregnancies.

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Gaps in testing and counseling for women: staying negative, male involvement and disclosure

With 99% of pregnant women getting tested for HIV the procedure is unlikely to be voluntary. Group pre-test

counseling is followed by further group counseling if the results are negative, with little support or information

on how to stay negative. For those who test positive, one-to-one counseling does not support women to

involve their male partners or to disclose their status to them.

Unprepared pregnancy of positive women

Factors contributing to pregnancy

Cannot negotiate safer sex

The decision in having a baby is not women’s choice

Condoms are for positive persons and sex workers only

No choice of contraception or counseling about suitable options

UNPREPARED PREGNANCY

Health System is not ready

Unsafe abortion service

Positive women leaders cannot be good counselors as they are also expected to be good leaders who don’t have

a baby or sexual relationships

Rejection from healthcare worker

Conditioned services (abortion provided in exchange for sterilization)

RESULT

Positive women less likely to go to hospital when they are pregnant

Disclosure and male involvement

Positive men Positive women Healthcare system

Might use violence to solve problems.

Expectations of male behavior may blocks men from discussing problems, feeling guilty that they cannot earn enough to feed the family.

When learning about wife’s status, Husband started to feel less confidence.

Might not know that women are

Not ready to disclose their status

For the women who had sex before marriage, women tend to blame themselves that they might have given virus to men and babies

Afraid to be looked at as a bad women

Women who never had sex before marriage might be afraid that they will lose “family life”, afraid of violence, afraid that men will leave

Tend to pressure on Women to disclose their status, even by drafting the law for this.

Thought that disclosure will helps in prevention.

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positive at all (even when they are also positive)

Did not receive the needed information on aids.

Didn’t get to prepare about HIV status.

No involvement in HIV test

and they will have no family leaders.

Fail to assess risk in pre-test Counseling

Thought that men’s sexual relationship before marriage is normal men behavior

Recommendations 1) Reproductive Health care services for women should be to empower woman to help them make choices

and offer all available services For women

Pre-post test Counseling should be strictly on Voluntary and be effective in helping women to access their risk (even with their husband) properly

Informed choices of drugs in prevention of mother to child transmission

Choices for contraception and getting pregnant

Help women to understand the cultural factors of their attitude and that they have right in express their

opinions and needs which is the base where rejection of unsafe sex comes from.

For men

More program to encourage men to understand their attitude that blocks them from - performing participatory parenthood - Be able to express their feelings and needs - Be able to communicate in sexual relationship

Direct program to advertise for male involvement in - Birth control - Prevent unwanted pregnancy - Pregnancy preparation and testing

For health care workers

Be prepared for discussion on sexuality and gender

Be able to practice effective counseling especially - Deep listening - Watch out for one’s attitude in sexuality and gender - Respecting in women’s choices and rights than controlling and deciding for “the best choices”

for women

Provide choices of contraceptive and tools includes female condoms and lubrication

2) The participation of positive women as part of the counseling system and in planning process of the

program for prevention and care for women

3) VCT and prevention programmes need to be scaled up to include those who currently fall through the gaps

such as migrants and injecting drug users/drug using woman

Woman (injecting drug users)/(drug user)prevention programme need to include Needles and Syringe exchange programme /implementation of harm reduction Methadone-pregnancy woman

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Priorities, strategies and questions for regional networks: Anandi Yuvaraj (ICW), Frika Chia (WAPN+), Vince

Crisostomo (Seven Sisters)

Interactive group work The participants formed small groups to identify the following:

1 priority issue

1 strategy – who

1 burning question for regional networks

Priorities Strategies Burning Question for Regional Networks

Enabling environment to reach

women in marriage from prevention

to impact mitigation

Empowering women to access

prevention, treatment, care and

support services

How can regional networks help

communities on the ground in our

communities?

Paradigm shift in the way we do

business – moving the burden of

interventions/ response away from

the “victims” to what?

No business as usual with regards

prevention programmes

More gender friendly interventions

Can we do it?

Enabling environment which will lead

people to disclose, seek testing,

access services, reduce stigma

Involvement of men, government,

CSO, PLHIV network, local service

providers, media practitioners,

political champions

Do you feel there is real space and

involvement of communities in all levels

of the response, including decision-

making?

Advocate for safe sex in marriage How to advocate/negotiate safe

sex among married couples

How do you get different government

agencies to involve positive networks in

the response?

Changing power dynamics between

genders in society to prevent new

infections

Working with men and partners of

MARPs

Within the rights framework, what duties

do PLHIV networks have in promoting

safer sex and changing power dynamic

within in the community?

Working at the inclusion concept, why do

positive networks feel insecure about the

diversion of resources and focus away

from them to their partners with regards

the discourse on spousal transmission?

Raise awareness of sincerity in

relationships

Open discussion about sex and

sexuality within relationships

Start talking within the community

about sincerity in relationships

Stop dividing of “groups” (MARPS)

What is holding us back from expressing

how we feel?

Documenting and disseminating

information on good and promising

practices

Gather information but work with

positive networks in defining “good

practice”

What are your criteria for good and

promising practices in reducing spousal

transmission?

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Summary of discussion (responses of Frika, Anandi and Vince) Enabling environment

We need to look at “enabling environment” within the larger context of the country’s legal framework – criminalization, discriminatory policies, freedoms and liberties (e.g., right to speech)

Representation

The expectation on us is very high. The priorities are increasing and your expectations growing along with these priorities. The pace at which you want us to respond is not the same pace as we receive resources and support, including capacity building.

There is goodwill among partners to involve us. People assume we have all the tools and capacity in place. This is not true, but we have the potential. You need to invest in us to capacitate us to participate effectively and meaningfully.

What does “involvement” mean? Even some of our partners don’t understand. You invite us to meetings to provide our perspectives but we are not involved in the planning.

We are also challenged that everything has to be done fast. Deadlines here, new initiatives there. When do we have the time to do all these and still be able to consult with our partners on the ground, noting that the Asia Pacific region is huge? But we know that communicating with national networks is fundamental.

Every time we speak out is a risk. While we know our voices need to be heard, we also don’t want to embarrass our governments or our non-governmental organization partners. So we need to do some balancing act.

Regional network’s role is advocacy. We need to strengthen communication within our network as we do not have a common language. For example, the 7 Sisters to push APNSW to work with women’s networks.

We also have to be honest that we (7 Sisters) are not truly representing the MARPs. And even among ourselves we are fighting for inclusion.

Positive prevention

We have to admit that sex without a condom is nice. Yet we ask people to use condoms. We need time and space to do our own paradigm shift. Deep inside, no positive person wants to spread the virus because we know the pain of stigma.

Many times, initiatives are handed down from Geneva or New York without taking into consideration the reality on the ground (example PITC translates into mandatory testing on the ground)

Terminology

“HIV in marriage” – what defines “marriage”?

“Spousal transmission” - use the term to help us increase coverage of services for sex workers

Criteria for good and promising practices

ICW is willing to assist in defining the criteria

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Frika presented the perspective of the networks (sex workers, lesbian gay bisexual transgender, injecting drug

users) on the issue of spousal transmission:

Discussion:

Networks recognize that more spouses are being infected but we are being undermined by the good/bad divide. Allocation of resources may later be a problem as government will prioritize the “good” over the “bad”.

We should not over-amplify the “good vs. bad” concept and create artificial fear such as allocation of resources.

We have to recognize that women get infected through no fault of their own, and we need to deal with this issue with more prominence.

The issue of spousal transmission is no longer academic, it’s already happening. Do we wait/remain passive for X million women to be infected before we take action? Is this a gap that can be addressed? Where do we start - sex work and their clients? Is that sufficient? , We need to empower women to act as their own agents of change.

This is not about shifting responses from one to another. The Commission is clear about focus on most at risk populations but also need to address the issue of spousal transmission as a gap.

Approach to women has been piecemeal. Some of these groups are not in water-tight compartments.

Spouse has no face; we are giving them a face.

Look at strategies and entry points – most at risk populations will definitely be an entry point, then spouses of most at risk populations.

We are making progress. No matter which angle each of us is coming from, we are beginning to talk.

THINK OF INCLUSION – ENOUGH OF CONSULTATION.

MARPs

IDUs

Sex workers

Migrant workers

MSMs

General

population

Spouses

“Bad”

Stigma:

o Criminals o Illegal o Immoral o Sinner o Not socially

accepted o Not valid work o Guilty

“Good”

“Innocent”

Bridge?

Prevention vs. treatment

Prevention and treatment

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What is needed?

Broad consultation with groups

Develop understanding, communication

Capacity on how to approach the issues

Empower sex workers and clients

Empower women as active agents

Multiple entry points

Multi-pronged strategy

37

Session 7: Research needs, programmatic entry points and advocacy messages

Researchers group

Programme group

Advocacy group


Time: 09:00 hrs – 12:30 hrs

Moderator: Jay Silverman, Harvard University

Rapporteur: Stuart Wilson, UNAIDS Pacific

Researchers Group

The researchers were asked to identify:

Standardized structure for country studies

Themes emerging from the studies

Framework for regional synthesis

Gaps needing further studies

Standardized structure for country studies

As the research and report writing are in various stages with some completed and others still in progress, it was

agreed that a common framework should be used for a summary of each study. All country profiles for

completed research should be submitted to UNIFEM/UNAIDS by 3rd March 2009

Country profiles: 2-4 pages max

1. State of the epidemic

2. Factors influencing spousal transmission (modes of transmission, disclosure, GBV, concordant/discordant

couples etc)

3. Key research findings

4. Gaps in research

5. Promising responses

Framework for regional synthesis

Needs to be a synthesis of reports which has clear country and regional recommendations for actions,

research and which identifies evidence for programmatic response

Need to review common themes, gaps, issues, epidemiology, risk contexts, etc which are common

across the region and which are country specific

Need to strategically focus on interventions – testing, prevention

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Prevention oriented research must identify vulnerabilities, areas which could put people at risk

Continues to be hard to reach most at risk populations in research context

Research needs to focus on: most at risk populations and their spouses, as well as sero-discordant

couples

Themes emerging from the studies

o testing and disclosure seem to be common issues in the region

o active case finding

o need to promote voluntary and confidential counseling and testing as opposed to mandatory

testing

o making use of research outcomes for policy development especially around testing

o positive prevention

o gender-based interpersonal dynamics

o sexual coercion,

o lack of sexual negotiation power

o condom use

o female dependence on males in marriage

o service provision denial for certain vulnerable groups

o enabling environments that lead to transmission in marriage including injecting drug users

research is inadequate at the moment to explain dynamic of commercial sex related to injecting drug

use and transmission risk inside marriage

males who have sex with males should not be excluded

Gaps needing further studies

Need regional as well as country applicability

Need to look at secondary transmission

Need to develop capacity to undertake research and to make use of research findings

Need to know the barriers to testing disclosure – men, women, spouses

Need to know norms and practices that increase risk of spousal transmission and within sero-discordant

couples

Need to look at the bio-medical determinants which can reduce transmission: sexually transmitted

infections, antiretroviral therapy (i.e. not only disclosure but lowering viral load etc)

Mechanisms of spousal transmission – has there been research?

Need to know what communication systems work when targeting what is essentially a private

relationship

Needs to know modes of transmission and what prevention modalities work

How do we work with men? – Men are often left out particularly when it is the spouse being talked

about.

Reactions to the report back from the research group:

Overwhelming – thought we would learn more out of the mapping and research exercises

Where are the connections to gender-based violence?

Are we going to only focus on transmission or also on the impact?

39

Programme Group

The programme group was asked to identify

Programmatic entry points

Key partners

Programmatic entry points

Have to acknowledge the perspective of good/bad divide but leaving it is a risk from a programmatic

perspective. We need to move forward with the discussion at country level.

Diagram does now acknowledge that populations are not boxed in but interact with each other, sexual

and other forms of networking, therefore need to see most at risk populations as part of general

population

Be careful of how to package messages – maybe we need advocacy now rather than modeling and

projections

Entry point through service delivery to most at risk populations– strategies to reach families

Mobility and Migration

Target migrant workers and spouses

Need to give a space to spouses/partners to become more comprehensive in our approach

Capture migrant workers when they come back. RISK: mandatory testing. Involve partners when

migrant workers return home

Multi-sectoral approach – targeted, integrated; HIV feeding into other programmes

Review testing guidelines, look at sero-discordancy

Work with migration/labor ministries/agencies

Include female migrants – analyze migration patterns for entry points; include men and women +

spouses

Develop comprehensive package for migrants

What about International Organization on Migration?

Above strategies are for documented migrants; what about internal migrants? Need to be inclusive and

analyze trends

Sustainable entry point: cross-border programmes. When we speak of systems, whose system? Include

border authorities.

Reproductive Health

Capacity development for basic health staff, traditional birth attendants

Analyze factors defining married women who are more vulnerable and at risk to HIV - who are they?

Where are they?

Making health staff aware of who these women are and what to include in their SRH counseling

Engaging with women’s organizations

Sexual and reproductive health is also entry point for gender-based violence, family health

Most at risk populations as entry points

Training for sex workers on negotiating condom use

Discussing relationships with partners with most at risk populations

Looking at who are the spouses

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Private health care providers (example Philippines medical associations), targeting those who are not

reached by the public health system

Look at size of most at risk populations in each country – who, where, are they married? We need these

size estimations to every country to begin to respond

Other partners

Private migration agencies

Ministry of welfare

Ministry of law/human rights

Ministry related to police border

Advocacy

To policy makers

Involve mass organizations/women’s unions – they know well who are these spouses

Need tools to support programming

Tenderize AEM to include analysis on spousal transmission

Actions How do we begin measuring impact? (Of prevention programmes for most at risk populations and spouses) Unanswered questions:

Define at country level who are the partners/spouses at risk

o Quantify extent of problem – build the evidence: who are they, how many are there, what are

the demographic markers vs. gen pop

o Extrapolate from size estimation the population of spouses/partners of most at risk populations

(incl. Most at risk populations)

How can we cost these programmes with some evidence

What are the advocacy gaps

Advocacy Group

The advocacy group was asked to identify

Possible messages

Key partners

Mechanisms needed

Feedback:

Must find ways to package messages around having pleasurable but safe sex

Have mechanisms in country which can be exploited

Increase involvement of men as well as working with women

Have existing champions in each country who can be made use of

Use the partners - parliaments, government, the media

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Session 8: Stakeholder perspectives on the process and outcomes including action steps in country

India, Pakistan, Bangladesh, Sri Lanka

Malaysia, Philippines, Cambodia, Myanmar, Vietnam

Laos PDR, Thailand, Indonesia

Pacific and PNG


Time: 13:30 hrs – 15:30 hrs

Moderator: Niranjan Saggurti, Population Council

Rapporteur: Azrul Khalib, UN Malaysia

India, Pakistan, Bangladesh, Sri Lanka

What kind of commitment is needed by different stakeholders in order to take initiative forward?

Commitments from governments, policy and decision makers to ensure that there is national priority for addressing spousal transmission and HIV is part of a national response (i.e. National Strategic Plan on HIV)

National AIDS Commission is on board The UN Joint Team is able to be mobilized according to the respective strengths of the UN agencies

UN agencies expertise and resources committed to programmes related to spousal transmission

Donors are on board and provide funding and prioritization for ST related interventions.

Building partnerships with community-based organizations, non-governmental organizations and people living with HIV.

What are the key challenges and how to address these challenges?

Strengthening national and sub-national capacity to mainstream gender and HIV utilizing a multi-sectoral approach response.

Limitations of pre-existing structures and institutional boundaries

The need to quickly demonstrate results, and impact of interventions

Bringing different stakeholders together with the help of National AIDS Commission

Mapping of potential partners beyond usual stakeholders and partners

Conducting a pilot intervention research (operations/ action research).

What can make an informed action on spousal transmission?

Development of advocacy tools.

Presentation of evidence gathered by countries as part of proving that most at risk populations and spousal transmission are joined and not treated separately.

What resources currently exist and what are needed?

Resources exist within other ministries and Ministry of Health. Accessing those resources is still a challenge and catalytic support needed to begin pilot programmes.

Sexual reproductive health services at community level – Identification and utilization of practical entry points for convergence and interventions

The need to identify mobilize additional funding to upscale the programmes of community based organizations/ non-governmental organizations

Capacity building of existing human resource to ensure sustainability and continuity of programmes.

Mobilization of Global Fund grants

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How to promote national programmes buy-in (government)?

Ensure that SAARC ministers commit to a Declaration to respond to spousal transmission of HIV in upcoming May meeting.

Organizing a forum to discuss spousal transmission at the upcoming 9ICAAP in Bali

A letter of commitment highlighting spousal transmission jointly signed by UNAIDS, UNDP, Global Fund, UNIFEM, Global Coalition of Women on AIDS

Malaysia, Cambodia, Philippines, Vietnam


Financial resources

Technical resources

Political will

Leadership – political leaders, civil society


Key challenges How to address

Absorptive capacity of health systems and health staff Staff focusing on what works, stop working on what’s not working

Staff capacity at community/government level Pooling funding, support/ capacity building of government staff

Government with top-down approaches

Hard to find most at risk populations, even harder to find their partners

Problem of engaging the right partners and giving people a voice in the right forum

“Housewives” not sexy to work with/on (yes and no)

Competing priorities with limited resources

Not clearly defined interventions for spousal transmission Simple, well-defined, regional best practices; Information sharing

Conversations about gender/social issues aren’t welcome in the HIV industry

Use their language, their framework; appeal to what matters to them; make them look good

Men in decision-making positions (doctors) not open to discussing gender and HIV

Challenge of discussing gender in UN JTA Internal advocacy

43


Regional

Forums for discussion/sharing o 9ICAAP – presentation of reports

Advocacy statement/factsheets

Use regional/global bodies to make statements/policy to mainstream action into core AIDS work

Regional advisor can advocate to UN Heads of Agencies to integrate gender aspect in their work plans

Include interventions in regional costing model (but first we need to know which interventions)

In-Country

Disseminate country reports

National workshop to share, develop action plan

Analyze data on modes of transmission to inform response and for advocacy

Explore data that exist (e.g., non-governmental organizations) and do analysis, interpretation and utilization

Review international commitments of country (e.g., CEDAW) and integrate spousal transmission in programming and advocacy around these commitments

Explore with partners expanding programmes already targeting most at risk populations to include their partners


Existing

International resources

Country studies

Technically competent consultants but not enough

Women’s machinery; sexual and reproductive health workers, mass organizations as entry points – need capacity

Needed

Personal risk assessment tools (e.g., in counseling and testing) appropriate for the region

Regional consultants – need development

Tool/checklist for defining “markers” of sub-population of women with elevated risk that can be applied in each country, migration, sexually transmitted infections (RISK: could lead to mandatory testing)


Buy-in comes with funding

Data management – improving data collection, reporting o Input at operational policy level (e.g., national AIDS registry)

Placing spousal transmission in national strategic plans (e.g., during mid-term review or roll-over)

Will be affected by community buy-in – getting communities on-board so they can input on what works and contribute to planning process (theory to reality)

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Identify our spheres of influence

Countries adapting spousal transmission response to Millennium Development Goal indicators or Universal Access targets (localize targets)

Influence how the data is analyzed

Thailand, Myanmar, Cambodia, Lao PDR, Indonesia


Non-governmental organizations, government partners, researchers

High level political commitment

Commitment of financial resource

Commitment from multisectoral stakeholders: government, researchers, human rights activists


How to get commitment and responses utilizing evidence based advocacy

Obtaining equal participation from all stakeholders due to different levels of involvement.

Development of a coherent policy framework of action Sustainable resource mobilization Lack of gender empowerment.

Improving common awareness and understanding of spousal transmission in the country contexts (e.g. development of common terminologies, and descriptions of the epidemic)

Indicators of involvement Organizing a consultative process/ forum where

issues can be included, agreed upon and responsibility taken.

Gender movement must include others such as human rights activists and lesbian bisexual gay and transgender groups


Knowing your rights training

Provision of training for service providers especially healthcare service providers such as doctors.

Testimony from community members to strengthen evidence based interventions, particularly in policy development.

Equal participation of non-governmental organizations in decision making and policy development relating to spousal transmission.


Financial (existing and continue to be needed)

Global Fund

International donors

Government

Business communities/ private donors

Community

Non-Financial (existing and continue to be needed)

Technical support

45

Capacity building

Human resources

Peer educators

Faith groups

Life experience/ skills

Community knowledge (local wisdom)

Academic/ research institutions

Media (mainstream/alternative)


Utilizing research to push for evidence based interventions

Sharing of testimonies from community representatives

Creating environment to ensure participation and engagement of high level officials related to the national AIDS programmes

Mutual ownership from all stakeholders

Recruitment of political leadership

Policy formulation utilizing a bottom up approach whereupon civil society is involved and actively participates in the process.

Taking a positive approach and thinking, emphasizing on the need for harmonious and complimentary relationship between government and non-government programmes.

The Pacific and Papua New Guinea

1. What kinds of commitments are needed in order to take forward initiatives to address spousal transmission in the Pacific? First, acceptance by all players that there is an issue around spousal transmission / HIV transmission

in intimate relationships in the Pacific Commitment to conduct research to better understand what information already exists, and around

identified evidence gaps Commitment from all stakeholders including the faith community and the private sector to

participate realistically in responses to spousal transmission / transmission in intimate relationships, and in issues around sexuality and sexual behavior in the Pacific

Commitment to ensure good school-based / out of school education around gender-based violence, gender and HIV, relationships

Commitment to incorporating gender-based violence and related issues in teacher education and health worker prep training

Commitment to ensuring that programmatic and research initiatives are culturally appropriate and sensitive (without sacrificing reality and an ambitious approach)

Commitment from governments and policy makers with commitment to fund interventions / prevention

Commitment from governments, policy makers, regional bodies to deal with migration and reintegration issues especially for those living with the virus noting the significant issues around the maritime, peacekeeping and resource industries

Commitment to better understand the potential nexus between HIV transmission, gender-based violence and conflict, disaster, and civil / political upheaval

2. What are the challenges that we would face?

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Difficulty in negotiating with various stakeholders (government, civil society, private sector) in developing consistent and realistic messages and response approaches

Prioritizing the resources both at national and at the Pacific regional levels Poor evidence base at country and regional levels in the Pacific around HIV, modes of transmission

and gender Not enough hours in the day – i.e. time The generally low capacity levels amongst all stakeholders Poor resourcing (human, financial) and high turnover levels with personnel Poor infrastructure to support responses throughout the Pacific region Geography, isolation, challenges of confidentiality in small island communities, poor transport

systems, political instability, diversity of language, culture and sexual identity / diversity, and government systems (American, French, New Zealand or Australia affiliated states, colonial governance, military regimes, failed states, monarchies, parliamentary democracy, etc)

Disproportionate epidemics and responses across the region The 4+ Pacific’s – Papua New Guinea, Melanesia, Micronesia, Polynesia, American territories, French

territories Burnout – migration of trained personnel

3. What can make an informed action or response? Better and stronger monitoring and evaluation systems - Tracking progress, better coordination,

communication and networking between various responders throughout the Asia-Pacific region Better evidence, more research, better involvement of all Improved consultation processes between stakeholders both at national and at regional levels

4. What resources currently exist for us and our stakeholders? Some very committed and vocal champions from a range of sectors and levels UN system, SPC and the other CROP agencies, good committed donors (Australia and NZ), GFATM

funding, Clinton Foundation / Gates generally good government commitment if not always good or realistic responses All countries have at least some sort of national strategic plan, NCM, though most do not have

monitoring and evaluation systems Good funding sources (e.g. the regional response fund, Global Fund, bilateral) Strong communities, cultures and acceptance (in some countries / contexts) of diversity

5. What resources are needed? Just need more and better More and better trained human resources

6. What do we need to do to increase / improve national government engagement? Better and more evidence for better advocacy Ensuring that the Pacific is on the international and Asia-Pacific regional agenda and not lost to Asia Even more money – the cost of doing business in the Pacific is considerably higher than other parts

of the Asia-Pacific region Improved coordination around training and capacity development which helps to value and

recognize the experience of training beyond the opportunity to come to Fiji on a shopping trip. Need to foster a culture of social involvement, of activism, of community research and involvement

– there is a very small and weak civil society sector across the Pacific And yes, we did talk about social capital……….

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Session 9: Summary Comments UNAIDS/ UNIFEM

Jane Wilson, UNAIDS Regional Advisor Gender, GIPA and Human Rights

Caitlin Wiesen-Antin, UNDP Practice Leader

Karabi Baruah, Focal point- Gender and HIV Programme UNIFEM-ESEARO

Vince Crisostomo, Coordinator Seven Sisters

Jane Wilson, UNAIDS Regional Advisor Gender, GIPA and Human Rights

So many things have happened in the past decade improving the HIV response (e.g. better healthcare services available, not just doctors anymore involved in HIV prevention, care and support, implementation of GIPA - greater involvement of people living with AIDS)

Challenges continue to exist, particularly on the need to sustain and upscale progress and achievements. Constantly need to retrain and build capacity, raising awareness with more and more stakeholders.

HIV in marriage – enormous and constructive opportunity to address issues relating to testing and disclosure

So much data available but not able to effectively assist National AIDS Commission colleagues to utilize data well for evidence based interventions.

Emerging economic challenges which will affect the HIV response. Food imports, food security, changes in the economy resulting in increased migration related issues. Mass repatriation of migrant workers back to their home countries may have impact on spousal transmission in the Asia Pacific region.

Next Steps - Regional

Continue to support civil society organizations in addressing this issue.

Commit to assisting ICW and APN+ in regional consultations

Dialogue with Asia Pacific Business Coalition on HIV – workplace efforts to reach spouses (utilizing UNGASS data)

Conducting regional analysis through country studies to understand, analyze implications for the region.

Production of synthesis by end of March 2009.

Regional Head of UNIFEM, Dr. Jean D'Cunha committed communications person to draft communications strategy on this issue.

Organizing of regional meeting on spousal transmission: 20 -22 May 2009

Regional support for in-country networking, capacity building

Caitlin Wiesen-Antin, UNDP Practice Leader

Need to identify key indicators to take action at country level – identification of best practices around the region to support much needed actions.

We need to strengthen advocacy utilizing civil society as the main driver – civil society knows how best to develop campaigns, develop effective core advocacy messages.

Need to recognize that we continue to not have an effective prevention programme to address spousal transmission– know how to engage with sex workers but no idea with 50 million women of spouses at risk (AIDS Commission)

Karabi Baruah, Focal point- Gender and HIV Programme UNIFEM-ESEARO

Strength in responding to spousal transmission is in partnership with UN family as well as different project partners in different countries.

48

Still need to identify and discern the responses needed but the workshop has brought about many issues often addressed on assumed understanding of the issues that need evidenced-informed responses.

Acknowledgement of communities concerned of shifting priorities and resources, namely addressing spousal transmission will deprive support for marginalized groups such as sex workers, males who have sex with males, etc.

Need to address 50 million women who may contract HIV from spouses/partners. Give a face to 50 million while addressing all women's issues in general

We should be careful to not give conflicting messages. Exchange ideas and information between stakeholders.

Expectations for the workshop have been met. Blueprint to all solutions not expected and was not intended to solve all problems. But there are actions we can start with now.

Vince Crisostomo, Coordinator Seven Sisters

Input from community not usually reflected into the outcome of such workshops. This workshop has involved community input from the very beginning and has been able to ensure that community views are taken into serious consideration in the development of programmes responding to spousal transmission. This is progress and acknowledgement of the partnership necessary to ensure the success of programmes, country or regional level.

49

Agenda

17 February

9:00 – 5:00 One day gender and HIV training for UNAIDS Gender Focal Points

18 February 9:00 – 13:00 Meeting of UNAIDS Gender Focal Points

Review recommendations from Gender Exchange Meeting in November 2009

Sharing of plans and strategies for 2009 Finalize regional support plan for 2009

18 February

17:00 – 19:00 Session 1: Registration and opening address at the Library by Dr Jean D’Cunha, UNIFEM Regional Director, South East Asia.

Day 2, 19 February 08:30 – 08:40 Introduction to the day, logistics and the programme – UNAIDS

08:50 – 09.30 Session 2

Setting the scene and progress to date – Karabi Baruah, UNIFEM Introduction of participants – David Bridget, UNAIDS Overview of “Gender dynamics in the epidemiology of HIV in the Asia Pacific

Region”, Caitlin Weisen-Antin, UNDP Practice Leader

09:30-10:30 Session 3: Presentations from India and Cambodia followed by discussion (researcher or nominee) and including planning with advocacy/ consultation with stakeholders.

10:30 – 11:00 Coffee break

11:00 – 13:00 Session 4: Presentations from Thailand, Sri Lanka and update from the Philippines followed by discussion

13:00 – 14:00 Lunch break

14:00 – 15:30 Session 5: Presentation by Indonesia (Ira and I Gusti Wahyunda), Lao PDR (Researcher), Malaysia (Azrul Khalib) and Pacific (Stuart Watson) on progress to date

15:30 – 17:30 Session 6: Positive women’s perspective and the greater involvement of men. This session will be led by Anandi Yuvaraj, Frika Chia Iskandar and members of the Thai Positive Women’s Network and will include group work. (The coffee break will be incorporated).

18:00 – 19:00 Dinner

50

Day 3, 20 February

09:00 – 11:00 Session 7: Group work session

1. Researchers Group to focus on Standardized structure for country studies Themes emerging from the studies Framework for regional synthesis Gaps needing further studies

2. Programme Group Programmatic entry points Key partners

3. Advocacy Group Possible messages Key partners Mechanisms needed?

10:30 – 11:15 Coffee break

11:15 – 12:30 Plenary session: Jay Silverman, Harvard University

12:30 – 13:30 Lunch

13:30 – 15:30 Session 8: Stakeholder perspectives on the process and outcomes including action steps in country (who/how/where/when)

Moderator: Niranjan Saggurti, Population Council 15:30 – 15:50 Coffee break

15:50 – 17:00 Session 9: Wrap up and way forward

Feedback from four groups Summary comments UNAIDS/UNIFEM Participants Review

Moderator: UNIFEM/ UNAIDS

List of participants

No. Country Name and Position and Organization E-mail address 1. Cambodia Ms Jane Batte

Social Mobilization Advisor UNAIDS Cambodia Tel: +855 23 219 340 / Fax: +855 23 721 153

[email protected]

2. Cambodia Ms Jennifer Clare Roberts

Researcher and Consultant on A Rapid Assessment on Spousal/Partner Transmission of AIDS and Sero-Discordant Couples in Cambodia Tel: +855 12 409 132

[email protected]

3. Cambodia

Ms Laura Tracy

Gender and HIV/AIDS UNIFEM Cambodia Tel: +855 23 216217

[email protected]

4. Fiji Mr. Stuart Watson

UNAIDS Coordinator (UCC) - Pacific region Tel: +679 331-0480 or 331-0481 Fax: +679 331-0425

[email protected]

5. India Mr. Alankar Malviya

National Programme Officer, Advisor - State Support UNAIDS India Tel: +91 11 4135 4545 Fax: +91 11 4135 4534

[email protected]

6. India Mr. Niranjan Saggurti Senior Program Officer Population Council, India Tel:+91 98 71211195

[email protected]

7. India Ms Vandana Mahajan

Programme Officer, Gender and HIV/AIDS UNIFEM - South Asia Office

[email protected]

8. Indonesia Mr. Ashley Heslop

Operations Officer UNAIDS Indonesia / UNIFEM Tel: +62 21 3141308 ext 213

[email protected]

9. Indonesia (Researcher)

Ms Geni Floribunda Achnas

Country Director Uplift International Tel: +62 21 7197476, 912 67729 Mobile: +62 816 1613 561

[email protected]

10. Indonesia Ms Ingrid Irawati Atmosukarto

Research coordinator and regional coordinator for eastern Indonesia Tel: + 62 21 390175 Mobile: + 62 8158957124

[email protected]

11. Indonesia Mr. I Gusti Ngurah Wahyunda

IKON Bali Tel: 62 0361-724699.

[email protected]

12. Lao PDR Mr. Khamlay Manivong

Partner and Social Mobilization Officer UNAIDS Lao Tel: : +856 21 267 795 Fax: +856 21 267 799, +856 21 264 939 Mobile: +856 21 267 796

[email protected]

13. Lao PDR

Mrs. Kaysamy Latvilayvong

Chief of Development Division Lao Women's Union Tel: +856 21 223543 Fax: +856 21 214300

[email protected]

14. Lao PDR

Mr. Phokin Mouangchanh

Member of research team Lao Women's Union Fax: +856 21 214300

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No. Country Name and Position and Organization E-mail address 15. Malaysia Mr. Azrul Mohd Khalib HIV/AIDS Coordinator [email protected] 16. Myanmar Ms Aleta Miller

Resource Mobilization and Technical Assistance Coordination Officer UNAIDS Myanmar Tel: +95 1 252361, +95 1 252362

[email protected]

17. Pakistan Dr Samia Hashim

Senior National Programme Officer UNAIDS Pakistan Tel: +92 51 825 5781 Fax: +92 51 265 5051

[email protected]

18. Papua New Guinea

Ms Maria Nepel

Social Mobilization Adviser UNAIDS Papua New Guinea Tel: +675 321 2877 Ext 242 Fax: +675 321 3968, 321 1224

[email protected]

19. Philippines Ms Teresita P. Bagasao

UNAIDS Country Coordinator Tel: +632 901-0411, 632-889-7414 (Direct) Fax: +632 901-0415

[email protected]

20. Philippines Ms Ma. Lourdes (Malou) Quintos

Programme Assistant UNAIDS Philippines Tel: (632) 901-0414

[email protected]

21. Sri Lanka Mr. David Bridger

UNAIDS Country Coordinator Tel: + 94 115 764 666 / Tel: +94 112 580 691 Ext: 361 Fax: +94 112 581 116

[email protected]

22. Thailand Ms Orawan S. Bettenhausen

Programme Assistant UNAIDS Thailand Tel: +662 288 1203 / Fax: +662 280 2701

[email protected]

23. Thailand

Ms Yupin Chinsa-nguankiet

Bureau of AIDS TB and STIs Department of Disease Control, Ministry of Public Health (MOPH) Tel: +66 2 2759903

[email protected]

24. Thailand

Ms Lisa Kuntamala

Bureau of AIDS TB and STIs Department of Disease Control, Ministry of Public Health (MOPH) Tel: +66 2 2759903

[email protected]

25. Thailand (Researcher)

Dr Pimpawun Boonmongkon

Deputy Dean of Academics and Research, Director of Center for Health Policy Studies, and Advisory Board Member of Southeast Asian Consortium on Gender, Health and Sexuality, Faculty of social Sciences and Humanities, Mahidol University Tel: 662-441-9184 ext 0 / Fax: 662-441-9184 ext 112

[email protected]

26. Thailand Ms Sulaiporn Chaowilai

Researcher Center for Health Policy Studies, Mahidol University Tel: 662-441-9184

[email protected]

27. Thailand Mr. Ronnapoom Samakekarom

Researcher Center for Health Policy Studies, Mahidol University Tel: 662-441-9184

[email protected]

28. Thailand Ms Supeecha Baothip

Raks Thai Foundation Thai Positive Women Network

29. Thailand Ms Prairat Kaewwansa

Ozone Home, assistant to Network coordinator Thai Positive Women Network Tel: +662 9136994 / Fax: +662 9136993 Mobile: +66 89 2147935

[email protected]

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No. Country Name and Position and Organization E-mail address 30. Thailand Mr Apichai Mai-Uggree Thai Positive Women Network [email protected] 31. USA Dr Jay G. Silverman

Associate Professor of Society, Human Development and Health Harvard School of Public Health ph 617-432-0081 fax 617-432-3123

[email protected]

32. USA Ms Michele Decker, ScD Instructor and Research Associate Harvard School of Public Health ph 617-432-0081 fax 617-432-3123

33. USA Ms Heather McCauley, MPH Research Coordinator Harvard School of Public Health ph 617-432-0081 fax 617-432-3123

34. Viet Nam Ms Phan Thi Thu Hien

Gender & Rights Based Approaches Officer UNAIDS Viet Nam Tel: +84 4 734 2824 ext. 117 Mobile: 0914127084 Fax: +84 4 734 2825

[email protected]

35. Viet Nam Mr Le Xuan Tho

Programme Officer United Nations Development Fund for Women UNIFEM VIETNAM Mobile: (844)- (0) 94-522-8072 Tel: 844- 3 942-1495 (extra 208) Fax: 844-3 8223579

[email protected]

36. Viet Nam Ms Nisha Prichard

UNIFEM Vietnam Campaigns Officer UNIFEM Vietnam Tel (84-4) 9421495 - Ext 138 Mobile: 0936115746 Fax (84-4) 8223579

[email protected]

37. ICW, Thailand

Ms Anandi Yuvaraj

Asia Pacific Regional Coordinator International Community of Women Living with HIV/AIDS (ICW) Tel: +662 255 7477-78 Mobile:+66 876818060 Fax:+662 255 7479

[email protected]

38. WAPN+, Thailand

Ms Frika Chia Iskandar WAPN+ Coordinator Women working group of APN+ (WAPN+) Tel: +662 255 7477-78 Fax: +662 255 7479

[email protected]

39. Thailand Mr Vincent Crisostomo

Coordinator The Coalition of Asia Pacific Regional Network on HIV/AIDS (7 Sisters) Tel: +662 255 7477-78 Fax: +662 255 7479 Mobile: +668 969 8 2432

[email protected]

40. UNIFEM Dr Jean D’Cunha

Regional Programme Director UNIFEM East and Southeast Asia Regional Office, Tel: +662 288 2225 / Fax: 662 280 6030

[email protected]

41. UNIFEM Dr Karabi Baruah

Focal point- Gender and HIV Programme UNIFEM-ESEARO UNIFEM East and Southeast Asia Regional Office Tel: +66-2-288-2453, Fax: +66-2-288-6030

[email protected]

42. UNIFEM Consultant / Coordinator

Ms Jo Kaybryn

Director of Policy Plurpol Consulting, New Zealand Tel : +44 794 222 734 Fax : +44 808 280 1257

[email protected]

43. UNDP Ms Caitlin Wiesen

HIV/AIDS Practice Team Leader and Regional Coordinator Asia & Pacific Asia & Pacific Regional Centre, UNDP Regional Centre in Colombo

[email protected]

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No. Country Name and Position and Organization E-mail address Tel: +94 (11) 4526400 ext. 150 / Fax: +94(11)4526410

44. UNAIDS RSTAP

Ms Jane Wilson

Regional Advisor Gender, GIPA and Human Rights UNAIDS RSTAP Tel: +662 288 2869 / Fax: 662 288 1092

[email protected]

45. WHO Ms Suwanna Sangsuwan

Programme Assistant (HIV/AIDS) WHO Country Office for Thailand Office of the WHO Representative, Permanent Secretary Building 3, Tel +662 590 1526 / Fax +662 591 8199, GPN Tel 24819

[email protected]

46. UNESCO Ms Xia Chen

Researcher, UNESCO Mom Luang Pin Malakul Centennial Building Tel +66 2 391 0577 Ext. 172

[email protected]

47. UNFPA Dr. Taweesap Siraprapasiri HIV/AIDS Programme Officer, United Nations Population Fund Tel: +662 687 0130 Fax: +662 280 1871

[email protected]

48. Bangladesh Mr Dan Odallo

Line Director, National AIDS/STI Progamme and UNAIDS Country Coordinator

[email protected]

49. UNIFEM Ms Sara Brinkberg Intern UNIFEM East and Southeast Asia Regional Office Fax: +66-2-288-6030

[email protected]

Gender Power Dynamics in Marriage and HIV Sero-discordant Relationships

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