Katherine Fritz

Engaging the community is core to an AIDSTAR-One pilot project – in which the International Center for Research on Women (ICRW) is a partner -- that strives to curb people’s heavy use of alcohol in order to reduce their chances of becoming infected with HIV. And so far, the community of Kabila, Namibia, has been on board.

Kabila is a relatively new, informal settlement on the outskirts of Namibia’s capital city, Windhoek, and a former township where black Namibians were forced to live during apartheid. Kabila is one of Windhoek’s fastest-growing urban neighborhoods, largely due to migration from northern Namibia. And it’s a place where brewing or selling alcohol is one of the few steady sources of income for resettled families. Needless to say, there are plenty of opportunities to drink: A newly-released ICRW research report found 265 bars in a 2½-mile area, most of which operate out of people’s homes.

In partnership with Society for Family Health (SFH) in Namibia and AIDSTAR-One, ICRW in 2011 helped to launch a pilot program in Kabila that aims to fire up the community – particularly bar owners – to change Kabila’s alcohol-rich environment in order to help reduce individuals’ HIV risk. ICRW designed the program and is leading its evaluation.

The work is part of the AIDSTAR-One initiative, which is funded by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), through USAID’s Office of HIV/AIDS. AIDSTAR-One provides rapid technical assistance to USAID and US government country teams to build effective, well-managed and sustainable HIV and AIDS programs as well as promote new leadership in the global campaign against HIV.

The effort in Namibia is one of a few taking place globally that seeks to develop community-level solutions to hazardous alcohol use.

“Research is increasingly making it clear that we won’t win this battle by intervening on individuals’ behavior alone,” said Katherine Fritz, who leads the project and directs ICRW’s global health research. “In fact, community dynamics may be the most powerful determinants of alcohol-related risk in any case.”

In Kabila, those dynamics include social norms that encourage heavy or binge drinking. Such behavior is fueled by the easy availability of cheap alcohol and prevalence of aggressive ad campaigns by alcohol manufacturers. Taken together, such an environment further drives the behavior and norms, including those that promote the idea that a man is more masculine if he drinks a lot or indulges in a certain brand of beer, Fritz said.

“Gender is very important in all of this because concepts of masculinity are tied up with alcohol consumption in most cultures,” she said, adding that women and children often suffer when men, who tend to control family resources, spend money on alcohol rather than investing in their families. Men who drink heavily are also more likely to engage in risky sex and to perpetrate violence against their intimate partners.

To investigate how to change the environment in Kabila, ICRW and its partners are focusing on helping residents to think critically about how the pervasive availability of alcohol as well as its unregulated sale contribute to many social and health problems, including HIV.

For instance, as part of the project, a community action forum is coordinating events around Kabila to raise awareness and provide education to residents about the correlation between heavy drinking and poor health. The forum also is reaching out to bar owners to help them learn how to sell alcohol responsibly.

Meanwhile, 35 bar owners are enrolled in an intensive training program to learn the international standards for serving alcohol safely and the requirements of the Namibian liquor law. These bar owners continue to receive mentoring and support from SFH and the community action forum members. Finally, the project also works closely with Namibia’s Coalition on Responsible Drinking —a governmental and civil society initiative to advocate for improved policies and programs on alcohol, including revisions to and enforcement of the laws governing how and where alcohol can be sold and advertised.

Once results from the pilot project are available later this year, Fritz said that ICRW would like to conduct a larger study to explore how programs like the one in Kabila can impact a range and health and social issues, such as helping to reduce violence against women.

Ultimately, one of the goals is for the Namibia project to become a model for organizations working on HIV prevention. Fritz said she would like to see all community-based HIV prevention programs address the role of hazardous alcohol use in communities where HIV is prevalent.

“We’d also like to encourage economic development programs to support alternatives to alcohol production and selling at the community level,” she added. “National governments also need to take a look at how multi-national brewing corporations are being encouraged to do business – and at what cost to society.”

Gillian Gaynair is ICRW’s senior writer and editor.

The evidence is clear: Women who experience social and economic inequities based on gender are at greater risk of contracting HIV. The same is true for men in societies where being a "real man" is equated with having numerous sexual partners. Or where people are marginalized because being gay, lesbian or transgender is viewed as falling outside of what's considered acceptable.

Challenging gender inequality and changing these types of inequitable norms is now recognized as a key strategy for bringing down the rate of HIV infection among women and men. The good news is that a growing number of international donor organizations such as The Global Fund to Fight AIDS, Tuberculosis and Malaria, are funding programs that use innovative – and at times courageous – strategies to tackle gender-related drivers of HIV. Although such efforts are critical, their sustainability and long-term impact are limited in the absence of supportive national laws, policies and strategic plans.

If the world wants to achieve lasting and continuous decreases in HIV infections, national governments need to step up and civil society advocates need to hold leaders accountable. We need policies and strategies that create an environment in which HIV prevention programs that reduce gender inequities can thrive and expand. Governments need to earmark HIV funding for specific activities, such as preventing violence against women, which is known to exacerbate women's HIV risk. And, to ensure that policies and strategies result in effective programs, it's critical that governments collaborate with a variety of civil society players – from local research and implementation organizations to people living with HIV.

It's a challenging task, but not impossible. Here at ICRW, we developed and tested a process through which any country could build and sustain what we call a "gender-responsive" national HIV prevention strategy. By that I mean creating a plan that acts on evidence regarding how HIV affects women and men differently, promotes equal access to HIV-related information and services as well as strives to deliberately change social norms that create gender-based vulnerability. Gender-responsive HIV strategies also ensure that people who are traditionally discriminated against because of their gender identity receive legal protection and equal access to services.

Our research took place in Uganda and Cambodia because each had national HIV policies that we could study and build upon. Both countries have significantly reduced HIV prevalence. However, the political and socio-cultural environments in each are vastly different. While Uganda is experiencing a generalized HIV epidemic, Cambodia's is concentrated among high-risk populations, such as sex workers, migrants and injecting drug users.

Although both countries had taken steps to address gender within their national HIV prevention plans, neither had implemented a well-coordinated gender strategy, which was hampering their ability to sustain long term reductions in HIV. This is a typical situation. In too many countries around the world, the mandate to integrate gender into national HIV strategy is carried out as a perfunctory duty by short-term external consultants. The result, as we saw in both Uganda and Cambodia, is the inclusion of general language about gender inequality as a social driver of the epidemic, but few specific, funded strategies or activities to meet women's and men's unique HIV prevention and treatment needs. We found that for any country to create a truly gender-responsive national HIV plan, governments, civl society and funders must collaborate in a long-term process: They have to study the issues, review the evidence, carefully plan programs, ensure they are funded and collect data on their impact.

The world has made significant progress in the last 30 years beating back the HIV pandemic. But for many countries, such as Uganda, the rate of decline is stagnating. New and innovative strategies are needed now more than ever. After all, there were still about 34 million people worldwide living with HIV at the end of 2010, while some 2.7 million became infected that year, according to UNAIDS. Preventing new infections requires a committed, multi-faceted approach, one that adopts medical innovations such as male circumcision in tandem with programs that address the gender inequalities that have been at the root of so much HIV transmission for so long.

It's not too late to accomplish what could have been achieved decades ago — building smarter, more effective national HIV strategies by making gender equity a central goal with specific programmatic strategies, adequate funds and measurable targets.

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

Katherine Fritz is ICRW's director of global health research and programs.

In South Africa, the end of apartheid in 1994 affected many things, including gender relations. Many men support government efforts to achieve the vision of a gender-equitable society as articulated in South Africa’s Constitution and Bill of Rights. However, men still face widespread pressures to express their manhood in more traditional ways, such as authority figures in relationships with their wives and children. While such traditional male norms give men greater decision-making power, they also limit who they are and what they can do. Many men fear being mocked—by men and women—if they enter the kitchen, care for their children or make decisions jointly with their wives. Some fear being seen as weak if they go to a health clinic because they are sick. They may feel pressure to have many sexual partners. And a substantial number are encouraged—by the examples of men around them and by society’s failure to fully implement laws on domestic and sexual violence—to abuse women and children. Harmful male behavior is interlinked with HIV risk and sexual and gender-based violence. But more men are rejecting the stereotypes of manhood in South Africa and are stepping forward to challenge gender roles that compromise their own health and well-being and that of their partners and their families.

Sonke Gender Justice Network created the Fatherhood and Child Security project to mobilize men to play an active role in changing traditional norms that are harmful to men, women and children. Among various activities, the program has an innovative approach to changing norms and behaviors through digital storytelling, which uses the media to give adults, youth, and children an opportunity to share their experiences with violence and HIV. Read the full case study, “Allowing Men to Care: Fatherhood Project in South Africa,” to learn how the organization designed a program to reduce HIV transmission and address related problems, such as gender-based violence, women’s overwhelming burden of care and the preponderance of children in need of care and support.

Livingstone, Zambia, is a bustling border town, filled with truck drivers, immigration officials, money changers and many others who live there or pass through to take advantage of the town's economic opportunities. With eight neighboring countries, similar towns dot the country's borders and major transportation routes, which are the heart of the nation's agriculture, mining and trading activities. Yet economic opportunities are also what make these towns hotbeds for the HIV epidemic. Zambia's HIV prevalence was an estimated 14 percent: 16 percent among women and just over 12 percent among men. In areas along the borders, the rates are much higher.

Poor women from Zambia and neighboring countries come to these towns to sell sex, using what they earn to feed themselves and send their children to school. These women are vulnerable to HIV and violence because of their limited power with clients. The illegal nature of their work makes it harder for them to access services to protect themselves. Their clients—truck drivers, vendors and traders, as well as uniformed personnel such as police officers, immigration officials and military servicemen—return home to their wives and other partners, spreading HIV throughout towns and across borders.

Corridors of Hope worked closely with these groups to provide HIV prevention information as well as health services through clinics and mobile units. Key to its efforts was a behavior change and communication strategy that engaged directly with sex workers, their clients and the broader community to change risky sexual behavior. Read the full case study, “Risky Business Made Safer: HIV Prevention in Zambia's Border Towns,” to learn more about the program’s efforts to reduce HIV among most at-risk groups and the general population.