HIV and AIDS

Risky Business Made Safer

Risky Business Made Safer
HIV Prevention in Zambia's Border Towns

Saranga Jain, Margaret Greene, Zayid Douglas, Myra Betron, Katherine Fritz
2011

In Zambia's border towns and commercial corridors, the HIV prevalence rate has been spiked due to an increasingly transient population. In response, the Corridors of Hope program works in border towns and corridor communities to promote HIV prevention and testing efforts to the general population and among at-risk groups.

This case study was prepared by the AIDSTAR-One project. As an AIDSTAR-One partner organization, ICRW provided technical oversight on this publication. The full case studies series and findings are available at AIDSTAR-One.

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Strategic Framework and Implementation Guidelines for Reducing HIV-related Stigma in India

Globally, stigma and discrimination impede HIV prevention, testing and treatment efforts. Yet research by ICRW and others shows that stigma and discrimination can be reduced in different contexts, such as the community and health facilities, thus contributing to the success of HIV programs and services.

India’s National AIDS Control Organisation (NACO) recognizes HIV-related stigma as a key challenge to controlling the epidemic. With support from the United Nations Development Program (UNDP) and in collaboration with NACO, ICRW designed and tested a strategic framework and implementation guidelines for stigma reduction in multiple settings in India. The framework built on one previously developed by a global working group made up of stigma experts and led by ICRW. The framework for India identifies key entry points for stigma-focused programming and measurement.  

ICRW also provided technical support to select organizations in applying the framework and guidelines for stigma reduction.  ICRW then collected data on the organizations’ experiences in applying the tools and used the information to finalize the strategic framework and implementation guidelines. The final tools as well as study outcome was widely disseminated to guide policymakers and practitioners in addressing HIV-related stigma and discrimination at the local and national levels.

Overall, ICRW found that the global framework was relevant to the Indian context and feasible for use by organizations and institutions in guiding stigma-reduction program development, implementation and measurement. Learning from the pilot interventions offers guidelines for broader implementation.

Duration: 
November 2011 to March 2013
Location(s): 
India

Girls Take HIV Risk into Their Own Hands

ICRW project offers promising model for adolescent girl programs
Wed, 11/30/2011

A pilot program designed by ICRW in Tanzania begins to shift social norms that make adolescent girls more at risk of HIV infection and unwanted pregnancies. It offers a promising – and needed – model that can be applied in a variety of settings.

In Tanzania's remote Newala District, adolescent girls are met with unwanted sexual advances on their way to the neighbor's house, to the water well, to the store. They feel forced to give in. Sometimes, they're raped. Girls are even scared to go to school because, they say, some teachers "just want to have sex with you."

Girls Preparing

The girls of Newala are not alone in their predicament. It reflects the experience of girls in many sub-Saharan African communities, where nearly 60 percent of all people living with HIV are women, according to UNAIDS. Sexual violence – along with early marriage, sex for pay with much older men and multiple, concurrent partnerships – are everyday realities for teenage girls. It's an environment experts say is fueled by numerous factors, including poverty, a breakdown in family and harmful norms that define girls' place in society.

All of this puts 12- to 17-year-old girls in Newala at greater risk of being infected with HIV. Unfortunately, HIV programming for vulnerable children gives little attention to teenage girls, whose needs tend to be eclipsed by those of very young children who lack basic food and care. And because of this, research evidence on adolescent girls' specific vulnerabilities and how to reduce their HIV risk remains insufficient.

Experts at the International Center for Research on Women (ICRW) are working to change that.

ICRW was tapped by U.K.-based ViiV Healthcare's Positive Action program to study the variety of ways in which girls are susceptible to HIV in four Newala communities, and then design a pilot project to address the most pressing risks. Working in partnership with local nongovernmental organization Taasisi ya Maendeleo Shirikishi Arusha (TAMASHA), ICRW found that long-held social norms can begin to shift when girls are encouraged to talk about their experiences and when others, including boys, reflect on their own behaviors.

Called "Vijana Tunaweza Newala" or "Vitu Newala," which means "Newala Youth Can," the project in Tanzania adds to ICRW's ongoing research about best practices to serve youth, particularly girls, and provides a model that can be applied in other settings. It also places ICRW among a small subset of organizations globally that focuses on girls – instead of institutions, such as schools – to drive community-based social change.

"Too often, programs targeting vulnerable girls are created without actually talking to the girls," said Jennifer McCleary-Sills, an ICRW social and behavioral scientist who led the project. "What makes the approach ICRW designed for Vitu Newala unique is that it didn't treat adolescent girls as passive beneficiaries of a pre-packaged HIV prevention program. Instead, it empowered girls to define their own needs, lead and interpret research on the issues that affect them and educate their peers with activities they developed."

Meet them where they are

Girl Power in TanzaniaLocated in southern Tanzania, Newala District is comprised of 28 rural, predominantly Muslim communities where families make a living farming cashews. It has one paved road. Mobile phone networks just developed more of a presence this year.

Women and girls here are expected to stay at home, and if they veer from that space, they risk harassment or sexual violence. The chances that girls will be sexually abused are so great that parents don't want to send their daughters to secondary school. Even taking part in Newala's traditional dance to mark girls' transition to womanhood has become risky. These days, young men attend. It's not uncommon for groups of them to fondle or sexually assault girls on the way home from the celebration.

"It all comes down to how gender is socially constructed – women are meant to live their lives primarily in the private, domestic sphere, whereas men control the public sphere," said Katherine Fritz, director of ICRW's global health research and programs. "When girls circulate in the public sphere, it can be seen as something that's outside of the norm and potentially provocative. If a girl is assaulted while moving around by herself, many people draw the conclusion that 'she asked for it.'"

Further fueling the situation, very few girls and boys grow up with two parents at home, in part because they have died from AIDS. When one or both parents die or separate, children often are left with grandparents or on their own. Researchers found that a number of teenage girls in Newala are heading households and providing for their siblings, a trend that has plagued girls across sub-Saharan Africa for years in countries where HIV-rates are high.

Such fractured families and the lack of adult presence in girls' lives contribute to their vulnerable state: Many are wooed by much older men who pay the girls for sex and help provide for their basic needs as well as those of their siblings. Sometimes, girls will have a series of such partners over time.

To better understand and address teenage girls' risks in Newala, ICRW designed an approach that allowed girls and the community to turn a mirror on themselves, analyze what they saw and determine the changes they wanted to make. Here's how it worked:

Risk mapGirls ages 18 to 24 were trained by TAMASHA to be youth researchers who aimed to better understand younger girls' lives in Newala. Researchers talked to 12 to 17 year olds about their aspirations and roadblocks to achieving them. They asked them to draw maps identifying spots in their communities where they felt unsafe. Girls were then encouraged to come up with ways to reduce the risks they faced.

Meanwhile, project researchers spoke with parents, community leaders and service providers in Newala to hear their perspectives. ICRW found that many adults put the onus on girls, accusing them of not making "better choices." Girls were expected to wait until they were adults – or ideally, married – to have sex. At the same time, researchers found that men and boys were not being held accountable for their actions.

Girls also told researchers they didn't feel as if anyone in the communities took responsibility for keeping them safe. Many were frustrated that they were blamed for not avoiding risks from which no one helped protect them. With that, TAMASHA asked the girls to suggest community members who should be responsible for making dangerous areas in their communities safer.

"The protective factors that used to be there in all African cultures have broken down," which is in part why men's behavior goes unchecked and girls' risks increasingly rise, said Richard Mabala, executive director of TAMASHA. "And there's nothing that has really taken its place."

"This is why we believe by young people coming together they can start creating what takes its place."

Youth lead social change

Indeed, young people were the driving force behind Vitu Newala, which essentially sought to empower youth to advocate for themselves and reduce their vulnerability to HIV. The program included activities created by adolescent girls and boys, such as dramatic plays, to learn about and discuss everything from reproductive health to goal setting. Together with adults, they figured out how to better protect the community's young people, especially girls.

Related News and Commentary

Such communal reflection by boys and girls had never happened before in Newala. For most girls, it was the first time they'd been asked their opinion or share their experiences. McCleary-Sills said this required a delicate balance – after all, men and boys perpetuate the forms of violence that increase girls' vulnerability to HIV. But she said they had to be involved if the environment for Newala's girls was to change.

"It was a matter of bringing boys and girls together on equal footing – not as good and evil, or victim and aggressor – and empowering them all to be agents of social change in their communities," McCleary-Sills said.

Anecdotal evidence from Vitu Newala shows that the pilot program made a difference in a short time: With the exception of school, girls reported that they felt safer at some of the most risky locations identified in the formative research. Communities are now supporting Vitu Newala to create youth centers and some are rewriting bylaws to limit boys' participation in girls' initiation ceremony. And young people said they now think and act differently about sex, relationships and their future.

Even if limited in reach and scope, Vitu Newala offers a promising model that can be applied to other efforts targeting vulnerable girls in sub-Saharan African communities and elsewhere.

"Although what we know so far is a small amount, it does appear to be moving social norms in the direction we want," ICRW's Fritz said. "But we need continued support to document and measure the impact at the individual and community level over a longer period of time."

Read more about ICRW's work with adolescents: Boys and Girls Becoming Equals, Changing for the Better

Gillian Gaynair is ICRW's senior writer and editor.

Tanzanian Youth Speak Up

Vitu Newala participants share their experience, observations
Wed, 11/30/2011

Anecdotal evidence shows that ICRW's Vitu Newala pilot program in Tanzania made a difference. The program's participants and youth researchers tell us about the the risks they face and how the project helped them.

ICRW applied its expertise in research, program design and evaluation to examine the variety of ways in which adolescent girls in four rural Tanzanian communities are vulnerable to HIV. In partnership with the local nongovernmental organization, Taasisi ya Maendeleo Shirikishi Arusha (TAMASHA), we then designed a pilot project to address girls’ most pressing risks. The project was called “Vijana Tunaweza Newala” or “Vitu Newala,” which means “Newala Youth Can.” It was implemented in Newala District, Tanzania. 

The effort was unique because it was entirely driven by youth: Newala’s girls defined their own needs. They led and interpreted research on the issues that affected them. Then, together with other community members – including young men and adults – they came up with ways to reduce the risky environment that contributed to their vulnerability to HIV and unwanted pregnancies. 

Anecdotal evidence shows that in a short time, Vitu Newala made a difference. Here’s what some of the youth researchers and program participants* told us about the risks they face and how the project helped them: 

On perceptions of girls: 

“People see me differently now because I’ve been called to do trainings ... Even adults see me as different from the other girls,” said Amina, a 21-year-old youth researcher. “I got different ideas and views from the other girls and I learned about the problems we face, even some I didn’t know about before. I was so happy to do the research and to talk to girls in my community.” 

A 19-year-old young man who helped lead peer-to-peer activities said he thinks of girls in his community differently now. “These changes are very important to me, my friends and my family as now they know the consequence of men’s behavior towards girls,” he said. “Some of them are our sisters, because when we are doing this to the girls outside, there are some boys out there who are doing the same to our sisters.” 

“People treat me differently now. I feel like a president! I feel different now because I’m able to talk to my peers and get them to listen to me. They take my advice and allow me to explain things to them,” said Hawa, 23. 

“I have a daughter, and I have decided that I won’t initiate her too young. I might have done it before coming to do the research. Before, I didn’t know the problems that early initiation can cause.” Hawa said that when she does allow her daughter to participate in the initiation, “I want to be sure she has self-awareness and that she knows sex can lead to pregnancy, HIV, gonorrhea, syphilis and other problems.  I’ll teach her to avoid temptations from boys and men in the world. I’ll teach her how to say ‘no’ firmly.”  

On sexual and reproductive health education:

“Teenage pregnancy is rampant in my village. Now, as an advisor, I can call the girls together and I can help,” said Hadija, 20. “I’m a girl like them; I can explain the dangers of boys in the community and help find ways to avoid these problems. I’d like to learn more about family planning to help them prevent pregnancy in the first place.”

Some girls said they don’t get any practical information at school about how to protect themselves from unwanted pregnancies. “They talk to us about our body and the different parts, but they don’t’ tell us anything useful,” said a participant from the 12- to 14-year-old group. “What we really need to know is how do girls get pregnant and how can we avoid that?” 

“I was so happy at the first sessions because we talked about these things,” a 17-year-old girl said about discussions on sexuality and reproductive health. “Nobody else talks to us about these things.” 

On girls’ risk and fractured families:

 “I feel different about myself now because I’ve learned about things that put me at risk as a girl. Now I can avoid these dangers and can help other girls avoid them, too,” said 21-year-old Leila. “There are so many ways I’ve benefitted from this experience. We’re just happy that you thought about Newala and came here to help us deal with the problems we face. Now we hope you can do more things to help us make changes in Newala.” 

“If your family sends you to the farm to work and you get raped in the bush, people ask you why you went to the farm alone. But why did they tell you to go there alone when they know it’s dangerous?” said a participant from the program’s 15- to 17-year-old group.

“Nowadays, families break up all the time and parents end up seeing children as a nuisance and nobody cares for them,” an adult community member said. “They end up begging in the streets. Nobody protects them or provides for them.” 

“We’re learning because of this education,” a 17-year-old boy said. “Even for older men in their 40s, they used to go with girls as young as 12 or 15 years old and have sex with them. That character is changing now because they’re seeing the risks they bring to girls.” 

*In accordance with ICRW’s research protocols, program participants are not identified.

MORE: Girls Take HIV Risk into Their Own Hands 

Commentary: Getting to Zero

Why Medical Science Alone Won’t Yield an AIDS-free Generation
Wed, 11/30/2011

On this World AIDS Day, ICRW challenges the global community to ensure solutions to the pandemic encompass both medical and social science. Only then will we achieve zero new infections, zero discrimination and zero AIDS-related deaths.

Imagine this: A pregnant woman is infected with HIV, but she doesn’t know it. She’s unaware she could transmit the virus to her baby. However, if she were to take a pill at the right time during her pregnancy she could drastically reduce the chances of transmission. Sadly she does not, and another generation is born into the world living with HIV.

Tragic, preventable scenarios like these continue to play out again and again across the developing world today. Despite advances in the development and roll-out of antiretroviral drug regimens, 400,000 children were born with HIV in 2010, according to the latest report from UNAIDS.

The reasons why are varied and complex. The short answer is that medical approaches, such as drugs to prevent mother to child transmission, will inevitably run up against the obstacles of people and societies – their behaviors, motivations, and cultural and social norms.  This can play out in a variety of ways: A woman decides against testing for fear of the stigma and discrimination that could come with a positive diagnosis. An HIV-positive mother cannot make it to the clinic for her treatment because it’s far from her home and the cost of transportation is too high or because she can’t afford to give up a day’s work in the fields.

Poverty, gender inequality, stigma and discrimination – these are invisible factors that increase an individual’s vulnerability to HIV infection, seriously undermining global prevention and treatment efforts. Thirty years into the epidemic, we still have more questions than answers when it comes to untangling how human behavior and social forces influence HIV vulnerability and developing interventions that work to mitigate them.  

There are those who believe the underlying causes of HIV vulnerability are too complicated to be addressed by donor-funded global health programs. It’s much easier to count the number of people on treatment than it is to understand why a pregnant woman would turn down a chance to give her child a healthy start in life.  Yet, complementary social science research is critical to fulfill the promise of medical breakthroughs like male circumcision, female microbicides and ultimately, perhaps, a vaccine. We must address social change in tandem with medical innovations to achieve zero new infections, zero discrimination and zero AIDS-related deaths.     

It’s a challenging approach. It will require more collaboration across many scientific disciplines. It will mean financial investments that encourage large, innovative studies. Take stigma and discrimination as an example. AIDS workers and researchers have long identified it as an entrenched barrier to prevention, treatment and care. Thanks to a decade of research and program work, we know what causes stigma. We know its consequences. And we have strategies that can effectively reduce it. Implementing a large-scale randomized study of a stigma-reduction intervention would yield much needed evidence on how such programs could be replicated. It has yet to be done.

To be fair, some trailblazing donors are focused on understanding the social drivers of HIV infection. The U.K.’s Department for International Development (DFID) is funding a multidisciplinary consortium of research institutions, led by the London School of Hygiene and Tropical Medicine and including ICRW, to investigate how to ameliorate the social factors that compromise HIV prevention and treatment.  ICRW recently completed a three-year project, funded by the Bill & Melinda Gates Foundation, to identify how gender issues that put women at risk of infection can be addressed in national HIV plans. But we need much more.

The world has made tremendous progress in the fight against AIDS, so much so that an end to the pandemic is in sight. In a recent speech, Secretary of State Hillary Clinton urged the global community toward achieving an AIDS-free generation and recommended that science guide our efforts.

“Success depends on deploying our tools based on the best available evidence,” she said. We could not agree more. But to get there, the evidence base must include all the scientific solutions – both medical and social.

Katherine Fritz is ICRW's director of global health.

Using Participatory Research and Action to Address the HIV-related Vulnerabilities of Adolescent Girls in Tanzania

Using Participatory Research and Action to Address the HIV-related Vulnerabilities of Adolescent Girls in Tanzania

Jennifer McCleary-Sills, Zayid Douglas, Richard Mabala
2011

Girls and young women are more likely to be HIV-positive than their male peers, due in large part to an array of gender inequalities that negatively impact their mental and physical well- being. Vijana Tunaweza Newala, or Newala Youth Can, is a participatory research and action project in the Newala District of Tanzania, aimed at both understanding and responding to girls’ HIV-related vulnerabilities. The project’s overarching purpose was to design and qualitatively assess a pilot intervention model to address their most pressing needs.This report highlights the project’s four phases of action: formative research, intervention design, peer education program, and assessment.

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We encourage the use and dissemination of our publications for non-commercial, educational purposes. Portions may be reproduced with acknowledgment to the International Center for Research on Women (ICRW). For questions, please contact publications@icrw.org; or (202) 797-0007.

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Vijana Tunaweza Newala

Vijana Tunaweza Newala
Findings from a Participatory Research and Action Project in Tanzania

Jennifer McCleary-Sills, Zayid Douglas, Annagrace Rwehumbiza, Aziza Hamisi, Richard Mabala
2011

Girls and young women are more likely to be HIV-positive than their male peers, due in large part to an array of gender inequalities that negatively impact their mental and physical well- being. Vijana Tunaweza Newala, or Newala Youth Can, is a participatory research and action project in the Newala District of Tanzania, aimed at both understanding and responding to girls’ HIV-related vulnerabilities. The project’s overarching purpose was to design and qualitatively assess a pilot intervention model to address their most pressing needs. This report provides details on the joint research and action process.

(2.52 MB)

We encourage the use and dissemination of our publications for non-commercial, educational purposes. Portions may be reproduced with acknowledgment to the International Center for Research on Women (ICRW). For questions, please contact publications@icrw.org; or (202) 797-0007.

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Meet Them Where They Are

Meet Them Where They Are
Participatory Action Research with Adolescent Girls

Jennifer McCleary-Sills, Zayid Douglas, Richard Mabala, Ellen Weiss
2011

To protect and empower girls, programs must start with the girls themselves. This approach – one that meets girls where they are in their lives – was the foundation for an innovative participatory action research pilot project, which aimed to both understand and respond to girls’ HIV-related vulnerabilities. Working with older girls ages 12-17 and their communities in Newala District, one of the least developed and poorly resourced districts of Tanzania, the project's ultimate goal was to design and qualitatively assess a pilot intervention model to address the most pressing vulnerabilities of adolescent girls. This brief report summarizes the process and findings of the participatory action research with lessons for researchers, development practitioners and policymakers working with adolescent girls.

(1.57 MB)

We encourage the use and dissemination of our publications for non-commercial, educational purposes. Portions may be reproduced with acknowledgment to the International Center for Research on Women (ICRW). For questions, please contact publications@icrw.org; or (202) 797-0007.

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An Action Guide for Gender Equality in National HIV Plans

An Action Guide for Gender Equality in National HIV Plans
Catalyzing Change through Evidence-based Advocacy

Reshma Trasi, Katherine Fritz, Katya Burns, Zayid Douglas
2011

National governments must design policies that support gender-responsive HIV programs. ICRW developed and tested a replicable process through which countries could build and sustain gender-responsive national plans for a more effective HIV response. This publication describes how the process unfolded in two countries, Cambodia and Uganda, and shares lessons that can inform similar efforts. It describes how to identify partners and collaborators, conduct a gender assessment of the current HIV policy and program environment, use the assessment findings to develop recommendations, create communications and advocacy plans to feed the recommendations into policy formation, and plan for sustained national gender and HIV efforts.

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We encourage the use and dissemination of our publications for non-commercial, educational purposes. Portions may be reproduced with acknowledgment to the International Center for Research on Women (ICRW). For questions, please contact publications@icrw.org; or (202) 797-0007.

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New Opportunities Give Sub-Saharan Women Room for Change

Wed, 07/27/2011
Voice of America

Voice of America quotes ICRW’s Mary Ellsberg in an article about how advancements in gender equality in Africa have given women more voice in the political sphere. The piece also explores challenges women and girls continue to face, such as vulnerability to HIV and AIDS.

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