MAINSTREAMING HIV
into Tearfund’s operational relief programmes
M A I N ST R E A M I N G H I V I N TO TE ARFUN D ’ S OP E RATION AL RE L IE F P ROGRAM M E S
Contents
Introduction
1
Context
2
Programme
3
Key Learning
9
Recommendations
15
Resources
17
Author: Fiona Perry
Photos: Fiona Perry, Tearfund
Edited by: Maggie Sandilands
Designed by: Wingfinger
© Tearfund 2008
Tearfund contact: Fiona Perry
Email: fiona.perry@tearfund.org
Website: www.tearfund.org/hiv/response
GLOSSARY
Tearfund is a Christian relief and development
agency, working for truly sustainable change for
people in poverty, responding to disasters and
challenging injustice. We are working to help
eradicate poverty for all, regardless of race or religion.
HIV mainstreaming is a process of reshaping and redesigning the core sectors of a programme to reduce
people’s vulnerabilities towards HIV and help people living with HIV to be better able to cope.
Risk is determined by individual behaviour and situations, such as having multiple partners, having
unprotected sex, sharing needles when injecting drugs, or having an untreated sexually transmitted disease.
Vulnerability stands for an individual’s or community’s inability to control their risk of infection due to factors
that are beyond the individual’s control. Such factors could be poverty, illiteracy, gender and living in a rural
area or being a refugee.
Impact refers to the long-term changes that HIV causes at an individual, a community or a society level.
Internal mainstreaming is inward-looking, focusing on the organisation, staff, policies and strategies. Internal
activities should ensure all staff are well educated about HIV and that those who are living with or affected by
HIV are supported.
External mainstreaming is outward-looking, focusing on project beneficiaries and project design. It is about
refocusing work to ensure those living with or affected by HIV are able to benefit from the programme, by
ensuring the programme does not increase vulnerability or undermine coping strategies.
HIV prevalence is the percentage of any given population that is estimated to be living with HIV.
HIV incidence rate refers to the annual diagnosis rate or the number of new cases of HIV diagnosed each year.
It is the percentage of people who are uninfected at the beginning, who will become infected over 12 months.
Comprehensive approach is how HIV can be addressed by ensuring all types of activities are implemented,
including HIV- and gender-specific mainstreaming, and ensuring that all sectors are involved.
Multi-sectoral incorporates all sectors in a DMT programme i.e. food security, human resources, finance,
nutrition, etc.
HIV-specific means those activities which are only concerned with HIV, such as implementing voluntary
counselling and testing services or giving out antiretroviral drugs.
Gender-specific means those activities that relate to just women or just men.
Cross-cutting refers to issues that need to be incorporated into the whole of the programme, across all sectors
(such as Water and Sanitation, Food Security, Health Education, etc), including internal and external activities.
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Introduction
Tearfund is committed to bringing about a reduction in the level of death and suffering due to natural and
man-made disasters. Tearfund’s strategic approach has been to encourage the building of a ‘preventative
culture’ in some of the world’s most disaster-prone countries, through the integration of a disaster risk
reduction approach. In most areas affected by natural disasters and conflict, Tearfund is working with
local partner organisations, and will respond through these partners when a disaster occurs. However,
for situations where partner capacity is absent, or cannot respond adequately to the scale of need, then
Tearfund responds operationally through its own Disaster Management Team (DMT).
Responding to HIV is a strategic priority for Tearfund. In October 2005, DMT began an 18-month pilot
project to mainstream HIV and gender into its operational relief work. At this time DMT was operational in
six countries; North and South Sudan, Burundi, Congo, Liberia and Afghanistan.
This case study documents the pilot project. It describes the process of mainstreaming and the challenges
faced, in order to share learning and recommendations with other agencies working in this field.
Mainstreaming HIV
Mainstreaming HIV is a process that enables relief workers to strengthen the way in which they address the
causes and consequences of HIV through adapting and improving both their existing work and their workplace
practices. It requires an understanding of the impact of HIV in communities, and adapting development and
humanitarian programmes to respond effectively.
Primary Health
Education (PHE)
worker giving a
child-focused health
education session in
Spin Boldak camp for
internally displaced
people (IDP),
Afghanistan.
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Context
The AIDS pandemic is today considered one of the most pressing development and security problems in the
world. Over 33 million people are currently living with HIV and there are 6,800 new infections daily.1
While sub-Saharan Africa remains by far the region most affected by HIV, other regions, such as South and
South East Asia, Eastern Europe, Central Asia and the Caribbean have increasingly worrying trends.
The dramatic spread of the virus cannot be explained solely by risky behaviour. Individual risk is influenced
by socio-cultural, political and economic factors, including economic underdevelopment and poverty,
political instability and population mobility, gender inequalities and unfavourable policies and legislation.
These factors increase people’s vulnerability towards the virus by limiting an individual’s ability to reduce
their exposure to risk.
Poverty and gender inequalities drive the epidemic, and are then made worse by the impact of HIV. HIV
particularly affects young people, children and women. Children who are orphaned because of AIDS not
only suffer the loss of their parents, but may also be marginalised and lack access to adequate nutrition or
education. Women are more vulnerable to contracting HIV due to physiological factors. In many places,
women’s lower social status, lack of power and economic dependence on men increase this vulnerability.
Gender-based violence and cultural practices such as female genital mutilation add to the risk.
HIV in emergencies
A recent study has shown that there is no data to suggest that HIV prevalence increases during an
emergency such as a conflict, particularly in countries of low prevalence.2 However, during the recovery
stage of an emergency, as communities cope with the physical and psychological trauma of the emergency,
and as transport and mobility increases and people migrate to urban areas in search of work, vulnerabilities
towards the virus may increase.3
The effects of a disaster encourage risky behaviour, as the breakdown of society increases power struggles and
gender violence as well as stress and boredom. Lack of resources can exacerbate the need to ‘buy’ or obtain
food through sex. Therefore people’s vulnerability to contracting HIV can increase in disaster contexts. People
who are already living with or affected by HIV will also find it harder to cope. During and after an emergency,
gender inequalities may increase, infrastructure is destroyed, family and community structures often break
down, access to safe water and sanitation facilities can be denied and food security may be affected.
The challenge for Tearfund was how to integrate the response to HIV, which is traditionally seen as a
development problem, within disaster relief responses that are often short term in nature. In addition, some
of the countries where Tearfund is operational have low HIV prevalence and consider other issues, such as
water and sanitation, food security and shelter to be higher priority.
Addressing HIV in an emergency setting requires a multi-sectoral approach as it is a cross-cutting issue.
An effective response needs to integrate prevention, treatment and care and impact mitigation.
2
1
UNAIDS 2007.
2
Spiegel PB et al (2007) ‘Prevalence of HIV Infection in Conflict-affected and Displaced People in Seven Sub-Saharan African Countries;
a systematic review’ Lancet (369) 2187–2195.
3
www.unaids.org/en/Issues/Impact_HIV/HIV_and_conflict.asp
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Programme
Tearfund considered how to scale up the response to HIV in its operational relief programmes. Most
programmes were already raising awareness of HIV, but a response was required that tackled the underlying
causes that drive the HIV epidemic and worsen its consequences. The response needed to address the
particular vulnerabilities that worsen during and after an emergency and can fuel the epidemic. It became
clear that it was essential to mainstream both HIV and gender4 into all emergency responses. Tearfund
realised the need to mainstream HIV both within its organisational policies, procedures and practices
(internal mainstreaming) and within its programmatic work with beneficiaries (external mainstreaming).
In October 2005, Tearfund began an 18-month pilot project implementing an HIV mainstreaming
programme into its operational relief work. An HIV Coordinator was employed to facilitate the programme.
The purpose of the pilot was:
‘to consider the vulnerability of the staff and the programme to the impact of HIV and develop appropriate
strategies to mitigate against it, and to consider appropriate approaches for including gender awareness and
gender sensitivity within the programmes.’
Participants in HIV
mainstreaming
workshop in Uvira,
South Kivu, DRC.
4
The pilot programme originally stipulated mainstreaming both gender and HIV, but in practice it was found that these issues were so
intrinsically linked that it was not necessary to treat them separately. In mainstreaming HIV, gender issues were inevitably raised and
could be responded to.
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Internal mainstreaming: workplace policy
In 2005, Tearfund’s International Human Resources team drafted an HIV workplace policy for overseas-based
staff, which aimed to reduce the vulnerability of staff to HIV by raising awareness, providing education and
ensuring a supportive and caring environment.
The principles behind the policy are:
■
to provide a standard of employment practice in relation to HIV
■
to create an environment that is free from stigma and discrimination associated with HIV
■
to provide an environment where people living with HIV can be open about their needs, concerns and
experiences
■
to empower staff in such a way that they retain their dignity.
The HIV workplace policy covers six main areas:
■
confidentiality
■
non-discrimination and reasonable accommodation
■
prevention (including raising awareness)
■
treatment and support
■
roles and responsibilities
■
monitoring and evaluation.
The initial plan was to pilot the policy in one DMT programme, training the teams on the content and
raising awareness amongst the staff about how to protect themselves from the virus. The policy was piloted
in Darfur, and staff ‘champions’ were chosen from each field site and trained about the basic facts of HIV.
The role of these champions was to ensure that all staff in their programme had a good understanding of
HIV. The champions would know about locally available resources and would provide confidential support
to other staff. Each champion was given a training manual to help them to share information, and a CD
containing background information.
A staff survey was conducted to gain an understanding of people’s initial level of awareness about HIV.
This helped the champions to tailor their training to respond to what was needed. At the same time there
was consideration of how best to ensure the policy could be outworked in each field site, so that the support
Tearfund could provide was accessible and appropriate for each location. The contextual research that each
country programme needed to conduct, in order for the policy to be rolled out, was outlined in a template.
The responsibility for rolling out the policy went to the Human Resources (HR) Manager in each programme,
who would use the template to write contextual guidelines to help outwork the policy in their specific location.
PROGRESS TO DATE
4
●
Greater understanding of HIV and raised awareness amongst staff.
●
HIV fact sheet given to all staff at induction briefing.
●
Support network set up and available for all staff including knowledge of locally available resources and
confidential peer support.
●
Updated and piloted HIV workplace policy ready to roll out.
●
Methodology designed to assist HR Manager to develop and implement a culturally appropriate and context
specific policy to complement the principles in the work place policy.
●
Trained champions disseminating messages and available to support staff in all field sites.
●
Resource pack including CD and training manual given to all champions.
●
Procedures set up to manage accidental exposure to HIV amongst staff.
●
Policies in place to deal with HIV stigma and discrimination in the workplace.
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FLOW CHART
To help the HR
manager to ensure
the workplace
policy is properly
implemented
POLICY AND PRACTICE
EDUCATION AND
AWARENESS
HR manager to ensure
supporting policy is in
place where possible
International HR and
HR managers to train
champions and line
managers on education
and awareness
Supporting Policies
1 National Staff Policy:
• Salary and benefits
(medical schemes,
sickness policies)
• Recruitment and selection
(data protection for
confidentiality, equal
opportunities, treating
staff fairly)
Champions develop
Action Plans on
awareness for staff
(How/when/
methodology)
2 Personal conduct
3 Discipline and grievance
4 Violent attack
HR manager with champions and line managers
develop action plan for implementation of local HIV
Workplace Policy using questions and template
Main areas for implementation in Action Plan
• Clear roles and responsibilities
• Universal precautions
• HIV awareness for all staff and their
families
• First aid and medical kits
• Confidentiality, non-discrimination,
reasonable accommodation
• General good health
• Health and safety procedures
• Vaccinations
• Post-exposure prophylaxis, condoms
• Medical schemes
• Voluntary counselling and testing,
antiretroviral therapy
• Accidents
• Monitoring and evaluation
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External mainstreaming: programmatic
In October 2005, Tearfund employed a consultant with expertise in HIV mainstreaming to help facilitate two
initial workshops for key DMT staff from Burundi, Congo and South Sudan. The aim of the workshops was
to provide training on external (programmatic) mainstreaming of HIV, to enable participants to explore the
possibilities for mainstreaming HIV into their projects. The HIV Coordinator then further developed these
workshops and conducted them for the other DMT programmes.
These workshops represent the first steps towards mainstreaming. Participants discussed people’s risks and
vulnerabilities towards HIV, as well the needs of those affected by HIV, in each country context. Man-made
and natural disasters were considered in the analysis as factors which could fuel the epidemic. Project design
was analysed in terms of how the project could increase or decrease beneficiaries’ vulnerability towards HIV,
and help or hinder people’s ability to cope with the effects of HIV.
Participants were encouraged to take what they had learned and train others in their team about
mainstreaming concepts. It was also anticipated that action plans written during the workshops would be
further developed so that planned activities could be outworked in the current projects. Monitoring formed
an important part of the pilot programme and the HIV Coordinator planned monitoring visits to each
country to assess the team’s knowledge of HIV and follow up the action plans written at the workshop.
Countries and
programmes
involved in the pilot
PROGRESS TO DATE
6
Country
Programme activities and tentative exit date
HIV prevalence
Burundi
Food Security, Health Education March 2007
3.3%
Democratic Republic
of Congo (DRC)
Shelter, Water and sanitation (Watsan), Health Education
December 2010
3.2%
South Sudan
Primary Health, Food Security, Nutrition, Community
Mobilisation, Health Education December 2010
2.6%
North Sudan
Health Education, Watsan, Nutrition July 2009
1.6%
Liberia
Food Security, Community Mobilisation, Health Education,
Watsan December 2008
2.0%–5.0%
Afghanistan
Disaster Risk Reduction through radio and schools, Health
Promotion, Watsan September 2010
0.1%
Northern Kenya
Nutrition, Health Education, Conflict Resolution, Livelihoods,
Watsan September 2007
6.1% (Kenya)
●
Good Practice training module on HIV in relief settings designed for Tearfund’s Disaster Management
training course.
●
Greater understanding of the risks and vulnerabilities that can increase the spread of HIV, particularly in low
HIV prevalence humanitarian settings.
●
Training of trainers manual developed, to help staff train people on external mainstreaming concepts.
●
Mainstreaming tools designed and used by DMT.
●
Key personnel trained about external mainstreaming concepts.
●
Action plans written for each DMT field site to reshape and redesign relief activities, in order to reduce
people’s vulnerabilities towards HIV.
●
Monitoring and reporting tools developed to assist staff to conduct ongoing evaluation of programme.
●
Checklist tool designed to assist managers to assess proposals for evidence of mainstreaming HIV.
●
Methodology developed to adapt Participatory Assessment of Disaster Risk (PADR) tools to include HIV
particularly in countries with low HIV prevalence.
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Tools for external mainstreaming
After a number of workshops it became evident that the tools used to train staff about external
mainstreaming needed to be simplified. Tearfund DMT programmes involve people with many differing levels
of education and language and it was important to ensure tools were clear and simple so that everyone
could understand the mainstreaming concepts.
There are three main tools that were used in training
for external mainstreaming:
■
HIV ‘problem tree’ for humanitarian settings
(see right) – this helps people to understand the
underlying root causes, vulnerabilities or risks and
effects that can fuel the HIV epidemic in postconflict and humanitarian situations.
■
HIV ‘spider graph’ for analysing project design
for vulnerabilities towards HIV (see below, with
examples from a nutrition programme) – this can be
used to check if the current and proposed project
activities and project design actually address any
of the vulnerabilities or risks highlighted in the
problem tree.
■
Action Plan (see next page, with example from
Northern Kenya programme) – this shows what
activities could be implemented to meet the gaps
or needs identified.
SPIDER GRAPH
For analysing
project design
for vulnerabilities
towards HIV
How do our project activities and project design help reduce vulnerability
towards HIV and help people better cope with the effects of HIV?
Education on balanced
diet is given to mothers at
feeding mothers centres
HIV messages are given to
mothers at feeding centres
POSITIVE
NEGATIVE
Local project staff stay together
in mixed accommodation for long
periods of time
Project:
NUTRITION
Stabilisation centres do not involve
household recovery of child in the
community which may mean when
they return home they will become
malnourished again
How do our project activities and project design not help reduce vulnerability
towards HIV and make it more difficult for people to cope with HIV?
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ACTION PLAN
For planning
activities to meet
the needs identified
(with example from
Northern Kenya
Programme)
Sector
Gap
Activity
By
when
Who will be
responsible
Measurable
indicator
Nutrition
Targeted feeding
criteria based
on malnutrition
not heads of
households with
chronic disease
Discuss with the
churches/clinics to
include the chronically ill
in their food distribution
programmes as an exit
strategy for Tearfund and
for future sustainability
of the programme
End of
April
2007
Nutritionist
Number of
churches/
clinics agreeing
to include the
chronically sick
in their food
distribution
programme
Community
Health
Education
(CHE)
Men are not
included in
the Village
Transformation
Programme
(VTP)
Conduct meetings within
chiefs’ committees to
inform them about VTP
and the need for men to
join them
April
2007
CHE Advisor
Minutes of
meetings
Conduct meetings in the
churches and mosques
to inform them about
VTP and the need for
men to join them
April
2007
Advocate to Tearfund UK
and partners to consider
a project that will
protect existing wells
and install hand pumps
June
2007
Area
Coordinator
Report on
advocacy
Train households/VTP
groups on the benefits of
harvesting rain water
June
2007
CHE Advisor
Number of
VTP groups
trained on
rain water
harvesting
CHE
Lack of access to
clean water
CHE
No encouragement in the use
of alternative/
natural medicine
Investigate the locally
available alternative
medicines and their uses
May
2007
CHE Extension
worker
Inventory
report
Nutrition
Increased
vulnerability
of women and
children due to
long distances to
feeding centres
Monitor the situation
with regard to the
long distance between
feeding sites and find
out if there are any
chronically sick members
of the community who
are unable to access the
programme
March
2007
Nurse
Regular
reports on
situation
Participant in an
HIV mainstreaming
workshop in Monrovia,
Liberia, during the
action plan stage.
8
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Key learning
Internal mainstreaming
LACK OF AWARENESS AMONGST STAFF
A staff survey was conducted in all seven countries where Tearfund is operational, which revealed a distinct
lack of awareness amongst staff about HIV. It was very difficult for the team to understand the HIV
workplace policy that was being presented to them when they did not understand the basic facts of HIV.
Levels of understanding varied between programmes, but there were consistent misunderstandings about
transmission and prevention of HIV. Some staff in all programmes mentioned kissing and insect bites as
ways of transmission and suggested female circumcision and avoiding sharing food and toilet seats as ways
to prevent the virus. It became apparent that there could be a lot of stigma and discrimination within the
team if someone was open with their HIV status.
It is important not to assume that staff already have a clear and accurate understanding of HIV. It is
necessary to provide training on the basic facts of HIV before beginning to outwork the workplace policy,
or conducting external mainstreaming training.
UNEQUAL REPRESENTATION OF WOMEN AMONGST STAFF IN DMT
One of the unexpected findings of the survey was the significantly high ratio of males to females amongst
the staff. This could impact any HIV or gender mainstreaming that DMT wants to do. In some of the cultures
where Tearfund is working there are some activities, such as facilitating a women’s group or training women
on HIV, which cannot be done by a man. Of the 473 staff who completed the questionnaire, 78% were men.
It is difficult to find women with appropriate skills and educational levels for DMT roles in many countries.
However it is important to help facilitate the process of recruiting more women by guaranteeing there
are equal opportunities for men and women applying for jobs. This includes ensuring the language and
placements of adverts is equally accessible for both men and women.
WORKPLACE POLICY
It became clear that the standard workplace policy was not in itself sufficient for all seven countries, but
required further clarification and contextualisation. For example, when the policy said ‘promote access to
services’, this needed further explanation as to which services were actually available and accessible on the
ground in each location. In addition, many of the terms used, such as ‘discrimination’, ‘accommodation’
and ‘accessibility’ needed further explanation to ensure that all staff members could fully understand how
Tearfund would support those living with or affected by HIV.
Other issues such as provision of condoms, Antiretroviral Therapy (ART), and Post-Exposure Prophylaxis
(PEP) required further discussion and consideration by Tearfund head office. This was mainly due to the
sensitivity of these issues, local availability of such resources and the long term commitments that Tearfund
needed to consider.
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It also became clear that all other standard HR practices and policies needed to be in place in order for the
HIV workplace policy to work effectively. These other policies are: National Staff Policy, Equal Opportunities
Policy, Health and Safety, Personal Conduct, Violent Attack and Discipline and Grievance.
An HIV workplace policy needs to be clear, comprehensive and contextualised. Other HR policies need to
be properly outworked in order for the HIV workplace policy to be effective.
External mainstreaming
PRIORITISING HIV
Many of the countries where DMT is working currently have low HIV prevalence. This has meant that HIV is
not seen as a priority. Most of these countries are in post-conflict situations, or are continually affected by
natural disasters. This has meant that the immediate needs on the ground are generally related to water and
sanitation, food security and health issues. Teams at first did not see the importance of addressing HIV, as
the impact was not immediately evident on the ground. However, research5 has shown how vulnerabilities
common during and after disasters can fuel the epidemic. Those countries that do have low HIV prevalence,
such as Afghanistan, often have other cultural vulnerabilities that could indirectly cause the spread of HIV,
such as extreme gender inequality.
The mainstreaming tools were redesigned to help teams understand the importance of responding to
HIV. They encouraged staff to analyse the context they were working in as well as their programmes, to
understand what other vulnerabilities could indirectly cause HIV to spread. Activities in the action plans
drawn up by staff therefore often address issues such as gender inequality, illiteracy, harmful cultural
practices, healthcare and water and sanitation. Participants in mainstreaming training often commented that
they had not previously realised that these activities were actually addressing vulnerabilities towards HIV.
‘I learnt about the
effects of vulnerability
in a close knit society
due to conflict, poverty,
culture and HIV’
‘I learnt that HIV
can develop into
AIDS in a short time
if people are poor’
Afghanistan
evaluation
Northern Kenya
evaluation
‘Mainstreaming is a
way to not disclose
people’s status’
Northern Kenya
evaluation
Afghan children
line up to attend
a child-focused
health education
lesson at a temporary
school in Mohammed
Kheil camp, Pakistan.
Staff working in countries in a post-emergency context and where there is low HIV prevalence, need to
have a good understanding of the vulnerabilities that can fuel the HIV epidemic in order to design their
programme to prevent the potential increase in HIV prevalence.
5
10
‘After the peace settlement in Mozambique in 1992, a sharp increase in HIV prevalence has been observed (9.9% in 1998, 13.2% in 2000
and 20% in 2004) among pregnant women in Maputo.’ Strand R T et al (2007) ‘Unexpected Low Prevalence of HIV Among Fertile
Women in Luanda, Angola. Does war prevent the spread of HIV?’ International Journal of STD & AIDS (18) 467–471.
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HIGH TURNOVER OF STAFF AND NEED FOR A FOCAL PERSON
One of the main problems for mainstreaming, which is characteristic of disaster response programmes, is the
short duration of the projects and the high turnover of staff. Many of the programmes had only one year or
less funding, which meant that teams were reluctant to invest in the HIV programme and spend time and
resources mainstreaming HIV when the project might be over in a few months. Programmes did not do well
in training new staff members, so often within six months of a workshop over half the participants who had
been trained had already left and the new staff were unaware of the mainstreaming concepts.
It became clear that there needed to be a focal person in each country programme to be responsible
for monitoring the progress of the action plans and to train new staff. In North and South Sudan, after
discussions with the Programme Directors, the Community Health Education (CHE) Advisors were asked to
do this. However, although they tried to follow up the HIV activities, it was not always seen as a priority.
When both the CHE Advisors came to the end of their contracts, those replacing them were not trained or
informed about their added responsibility for monitoring HIV mainstreaming activities.
There is a need for a focal person to take responsibility for HIV mainstreaming in each country. They
should see the response to HIV as a priority, and HIV activities should form part of their job description.
This will also help to encourage ownership of the programme rather than it just being an additional
cross-cutting issue for busy staff to consider.
HIV AS A CROSS-CUTTING ISSUE
HIV is usually viewed as a cross-cutting issue, but because of this it may not be prioritised, as there are so
many other cross-cutting issues to consider. In most programmes there was confusion over priorities and
roles for mainstreaming. The objectives for the HIV mainstreaming programme were not specified for each
country and there was no one person responsible in each programme for the activities designed. Proposals
with sector-specific objectives often took priority over cross-cutting issues such as HIV.
If mainstreaming HIV is a strategic priority then it should be seen as more than a cross-cutting issue. It
is essential that all staff are involved and have a good understanding of the process. This is particularly
important at the management level to ensure the process is driven forward.
REPORTING
Initially there was no system set up for reporting against the action plans that had been written for each
programme. After each workshop, the HIV Coordinator sent the draft action plans to the Area Coordinators
(ACs) in each field location and to the Programme Director (PD). However, in many cases these were not
followed up by staff, and the requested progress reports were often not forthcoming. To address this, a small
section was included in the standard DMT programme quarterly report, to summarise the progress made on
the HIV mainstreaming programme. However, there was not room for field locations to report against the
activities they had put in the action plans or whether they had re-evaluated and updated them. A monthly
report template was written by the HIV Coordinator but is not yet officially included as part of the monthly
reporting system.
It is important that reporting of HIV activities is incorporated into the standard monthly or quarterly
reporting systems to ensure that the process is continually monitored and evaluated.
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PROPOSALS
Each country programme writes a number of project proposals every year, but there is not yet a system
whereby during the development of the proposal design, the process is monitored for the inclusion of HIV
mainstreaming. The same analytical tools6 used in the mainstreaming workshops, which help assess projects
for how they impact people’s vulnerability to HIV, should be used at the proposal stage. This should ensure
that donors understand why certain decisions have been made in the design of the project activities. However,
during this pilot it was found that in practice, these tools were not used and the proposals were not passed
on to the HIV Coordinator, so often mainstreaming concepts had not been included at the proposal stage.
To address this, it was agreed that all new proposals should be reviewed by the HIV Coordinator.
The analytical tools for mainstreaming and assessing vulnerability should be used as standard practice
during any proposal design and development and should be incorporated within the internal project
approval system.
HIV AND GENDER MAINSTREAMING
In the beginning, the training emphasised mainstreaming both HIV and gender. However it became clear that
gender did not need to be considered in isolation as it was so connected to HIV that often the HIV activities
chosen already included gender-specific activities. In Afghanistan for example, nearly all the activities in the
action plan for mainstreaming HIV were related to gender issues. The table below provides some examples.
ACTION PLAN
Afghanistan
programme
Sector
Gap
Activity
By when
Who will be
responsible
Measurable
indicator
Community
Radio
Disaster
Management
Potential increase
in vulnerability
for women due to
design or location
of training
The women in
the community
are trained in safe
and culturally
appropriate places
September
2006
Project
manager
Appropriate
place selected
and women
are happy to
attend training
Community
Radio
Disaster
Management
No crossover
between single
gender groups
Representatives
of both gender
groups will meet
later in the project
at quarterly
meetings
August
2006
Project
manager
Attendance of
representatives
in quarterly
meetings
Staff also became confused when too many mainstreaming options were discussed. These included:
■
Gender-specific (such as income generation activities for women)
■
Gender and HIV (such as water points that are designed to be accessed safely by women)
■
HIV-specific (such as HIV awareness sessions).
It was therefore decided to just talk about ‘HIV mainstreaming’, but to ensure that gender issues are
considered as one of the vulnerabilities towards HIV.
As HIV mainstreaming was a priority, other vulnerabilities highlighted during the analytical stage – for
example lack of curative health care in Northern Kenya – were put to one side as they were not considered
to be part of DMT’s core sector skills and abilities. However, these needs could not just be forgotten about,
so these other activities were put into a second action plan, whereby the team could decide to lobby for
6
12
See ‘Tools for external mainstreaming’, page 7.
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other key stakeholders to meet the needs identified. If the country and HIV strategy allowed, the teams
could also consider designing a proposal to apply for funding to address the HIV-specific activities that they
had identified. In Liberia, this included lobbying donors to provide funding to purchase food and drugs to
combat opportunistic infections for people living with HIV, as seen in the action plan below:
ACTION PLAN
Liberia Programme
Sector
Gap
Activity
By when
Who will be
responsible
Measurable
indicator
HIV
No funding
to purchase
opportunistic drugs
and food for people
living with HIV
Lobby donors
for funding to
provide support
for people living
with HIV
January
2007
HIV Advisor
Funding
available
It is important to ensure there is a good understanding of the term mainstreaming and that it includes
all activities that reduce people’s vulnerabilities towards the virus. Mainstreaming can also be referred
to as risk reduction, which may help people to understand the concept. When HIV is mainstreamed, the
activities designed should address the underlying root causes of the epidemic such as gender inequalities.
MEASURING RESULTS
Even though the concepts are simple, for mainstreaming to become an integral part of the project cycle,
considered at both the proposal stage and as part of the ongoing monitoring of a project, requires both time
and staff commitment.
It is difficult to know how best to measure a mainstreaming programme in order to see if it has been successful.
We may never know whether the design of the programme is the reason HIV prevalence has gone up or down,
or if it has lessened the impact of HIV in the community. Results from Darfur about six months after the initial
workshop (see below) showed which mainstreaming activities had been successfully implemented.
WORKSHOP RESULTS
Nutrition
programme
Limited distribution of mosquito nets so that beneficiaries are not being targeted for nets on
their way home (reducing vulnerability to rape or attack)
Activities to reduce
vulnerabilities –
El Geneina, Darfur
Programme
Hygiene
promotion
and activity
clubs
Activity centres and clubs spread throughout community to limit distance travelled (reducing
vulnerability to rape or attack)
Women conducting income generating projects, to empower them and stop them being vulnerable
to act for incentives (reducing the potential of women forced to engage in ‘sex for food’)
Literacy classes held in summer (empowering women, increasing education and knowledge)
Water and
sanitation
School latrines designed so they do not expose user to risk of attack (reducing vulnerability to
rape or attack)
Latrines and water points sited in appropriate locations (reducing vulnerability to rape or attack)
General
Distributions made to whole community so that certain groups are not singled out and made more
vulnerable to attack because of what they have received (reducing vulnerability to rape or attack)
Work with all sections of community, including nomads (reducing marginalisation and
vulnerability)
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However, whether these activities had actually reduced the vulnerability of individuals or communities
towards HIV was impossible to measure at such as early stage. It is presumed, based on research and reports,
that undertaking these activities designed to reduce vulnerabilities will indeed help reduce the impact of HIV.
To measure the success of a mainstreaming programme, the following principles can be used. These help
determine whether the mainstreaming activities have been implemented and are successfully helping to
reduce people’s vulnerability to HIV.
●
The activities in the proposal design do not have the potential to increase people’s vulnerability
towards HIV.
●
Consideration is taken of all the potential vulnerabilities that could be present in the design of the
programme.
●
The community are satisfied with the design of the activity and do not report any vulnerabilities
towards HIV.
●
The project design does not make it more difficult for people living with HIV to cope with the effects
of the virus.
Participants in an
HIV mainstreaming
workshop in Monrovia,
Liberia, analysing
project design
for vulnerabilities
toward HIV.
14
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Recommendations
Internal mainstreaming
■
It is important that any relief organisation working in any country has an HIV workplace policy to ensure
their staff are well supported and protected against HIV.
■
All staff should have a good understanding of the basic facts of HIV.
■
All staff need to have a good understanding of the workplace policy.
■
Training staff ‘champions’ is a good way to ensure peer support and to ensure all staff receive training on
the basic facts of HIV and are helped to know where to access locally available resources.
■
The workplace policy should be contextually adapted to each field location to ensure it can be
outworked effectively.
■
The draft workplace policy should be piloted before implementation.
■
All standard HR practices and policies need to be in place and rolled out in order for the HIV workplace
policy to work.
■
All new staff should receive a basic fact sheet about HIV and an orientation to the HIV programme as
part of their induction period.
■
Champions and line managers should be trained together.
■
Line managers should assist with the development and monitoring of an action plan to ensure the
implementation of the workplace policy in their location.
External mainstreaming
■
Staff need to understand the HIV epidemic and be able to analyse the vulnerabilities and risks within the
context and culture where they are working.
■
Staff need to understand how the effects of a humanitarian situation can fuel the HIV epidemic.
■
Staff need to analyse their projects to consider whether they are addressing the vulnerabilities and needs
highlighted, or whether their project design is making the situation worse.
■
Mainstreaming HIV into relief projects is important in any country, regardless of HIV prevalence.
■
In low prevalence countries, work should focus on addressing indirect vulnerabilities that can fuel the
epidemic such as illiteracy, gender inequality, access to health care, protection issues and water and
sanitation.
■
A comprehensive approach (see flow chart, page 16) is needed to address all the vulnerabilities and needs
identified in the community.
■
To address identified needs that fall outside the capacity or remit of a programme, consider engaging in
advocacy, to ensure other agencies will meet these needs.
■
Raising awareness about HIV should be part of all projects, regardless of the HIV prevalence in the
country or the type of project.
■
There is a need for a focal person in each country programme to monitor the programme’s response
to HIV, to follow up action plans and train new staff to use analytical tools for assessing vulnerability
towards HIV. It would be best if this person is an HIV specialist so they can concentrate on all aspects of
the response to HIV, not just mainstreaming.
■
A reporting system should be introduced to ensure the HIV programme is monitored and evaluated
■
It would be helpful if the HIV focal person could analyse all project proposals for evidence of HIV
mainstreaming. During the design stage of a proposal there should be evidence that the analytical tools
(see page 7) should be used to assess the project design for any vulnerabilities.
■
All management staff should be involved in HIV training and the development of action plans, to ensure
that HIV is considered a priority in any programme.
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PROCESS
FLOW CHART
A comprehensive
approach: practical
steps for analysing
and addressing
vulnerability towards
HIV and communities’
ability to cope with
HIV in relief settings
Understand
epidemic
Ongoing
monitoring and
evaluating
(Focal person)
Understand
target
community/
beneficiary
context
ACTIVITIES
Analyse
programme for
vulnerability/risk
versus community
need (every six
months)
Advocate and
lobby other
NGOs, UN
government
etc to
address gaps
Reshape and
redesign core
sector activities
Action plan
to address
critical gaps
(Mainstreaming)
(Proposal stage)
Implement
specific
HIV
activities
Assess extra
funding if
required
INTEGRATE HIV AWARENESS WITH STAFF AND BENEFICIARIES THROUGHOUT ACTIVITIES
16
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Resources
Useful documents from Tearfund DMT
These can be accessed from the website
www.tearfund.org/hiv/response, or by emailing
fiona.perry@tearfund.org
■
Tearfund’s HIV Workplace Policy for Overseasbased Staff
■
Training Manual for Champions Creating HIV
and AIDS Awareness with Tearfund Staff
■
Briefing Fact Sheet on HIV
■
Tearfund Disaster Management Team – Good
Practice Guidelines on HIV Mainstreaming
■
Training of Trainers Guideline Manual for HIV
and Gender External Mainstreaming
■
Monthly Reporting Format for Internal and
External HIV Activities
■
Mainstreaming HIV into Proposals
■
Participatory Assessment of Disaster Risk
(PADR) and HIV
Nomadic Rendille women during a needs
assessment in Kargi, Northern Kenya.
Other publications
■
Barnett T and Whiteside A (2002) AIDS in the Twenty-First Century
■
Baylies C (2002) ‘The impact of AIDS on Rural Households in Africa: A shock like any other’ Development
and Change 33 (4) 611–632
■
Holden S (2003) AIDS on the Agenda – Adapting development and humanitarian programmes to meet the
challenge of HIV Oxfam www.oxfam.org.uk/what_we_do/issues/hivaids/aidsagenda.htm
■
Inter-Agency Standing Committee ‘Guidelines for HIV/AIDS Interventions in Emergency Settings’
■
Mock NB et al (2004) ‘Conflict and HIV: A framework for risk assessment to prevent HIV in conflictaffected settings in Africa’ Emerging Themes in Epidemiology 1 (6) www.ete-online.com/content/1/1/6
■
Spiegel P (2004) ‘HIV/AIDS among Conflict-affected and Displaced Populations: Dispelling myths and
taking actions’ Disasters 28 (3) 322–339
■
Strand RT et al (2007) ‘Unexpected Low Prevalence of HIV Among Fertile Women in Luanda, Angola.
Does war prevent the spread of HIV?’ International Journal of STD & AIDS (18) 467–471
■
‘The Silent Emergency: HIV/AIDS in conflicts and disaster’ Report of the UK Consortium on AIDS and
International Development, London, June 1999
■
Walden V et al (2007) ‘Humanitarian Programmes and HIV and AIDS – A practical approach to
mainstreaming’ Oxfam
■
www.unaids.org/en/Issues/Impact_HIV/HIV_and_conflict.asp
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