Making people less vulnerable to HIV infection

Cross-cutting themes

Public education campaigns

Mobilising domestic funds (public and private)

Mobilising international resources

Training and use of local managerial/technical talent

An individual or a community’s vulnerability to HIV is a measure of their ability to control the risk of infection. Personal factors, factors affecting access to relevant information and services, and societal factors including social, economic, political and cultural situations may either mitigate or exacerbate vulnerability. For example, a person who is discriminated against with respect to education or employment on the basis of race, gender, sexual orientation or other characteristics is also more vulnerable to HIV infection. Similarly, a young person who can not access condoms is more vulnerable to HIV than other young people.

In many settings, women – and in particular young women – are especially vulnerable to HIV infection. They may be less able than men to avoid non-consensual or coercive sexual relations.

Rural communities may be vulnerable because of lower levels of literacy and less access to information and services.

Many factors and forces exist that restrict people’s autonomy and leave them particularly exposed to HIV infection, or vulnerable to needless suffering once they are infected. Intolerance of racial, religious or sexual minorities; discrimination against people with known or suspected HIV infection; lower status of women; abuse of power by older or wealthier individuals; scarcity of HIV counselling and testing facilities and of condoms; lack of care and support for those infected or affected; poverty or trafficking that leads to prostitution; domestic violence and rape; military conflict and labour migration which split up families – the list is a long one and varies from place to place.

Recognition of the factors that fuel the HIV epidemic is key to the development of programmes for reducing vulnerability in the civil, political, economic, social and cultural arenas. Properly designed, these can reinforce the more traditional prevention approaches aimed at persuading individuals to change their risk-taking behaviour.

Social policy is essential

To be effective, therefore, personal risk-reduction programmes must be designed and implemented in synergy with other programmes, which, in the short and long term, increase the capacity and autonomy of those people particularly vulnerable to HIV infection. Social policy, with a clear statement of vision and values, is essential to provide a conceptual framework for vulnerability reduction. For example, the chronic and acute poverty of urban households that leads to their eventual breakdown and the move of children out of school and to the street (where they become highly vulnerable to HIV infection) is not an issue that can be easily addressed at a household or community level alone. Similarly, problems such as gender imbalance and the inability of women to negotiate when, how and with whom they have sex is the type of broad social policy issue that must be tackled if such programmes are to be successful.

Addressing the societal forces that determine vulnerability to HIV requires engagement at the policy level and political will and resources. Effective social policy reform is a long-term agenda, but even small-scale and incremental steps can send important messages about political commitment to reducing the vulnerability of individuals and communities to HIV. (For an example of broad social policy creation, see Malawi’s policy on orphan care in the accompanying paper.)

Fortifying young people

As programme planners turn their attention to different parts of the population, they must remember not only those who are currently exposed to risk but those who will face exposure in the future. Individual risk and vulnerability change over people’s life cycle, and this change is especially marked as children mature into adolescence and adulthood. Many young people can go in and out of commercial sex during their youth period.

Among the various measures tried to date, the teaching of life skills has proved one of the most important for young people. The skills enable them to manage situations of risk for HIV/AIDS infection and prevention of many other health problems. Such skills include: how to respond to demands for sexual intercourse and offers of alcohol and drugs, how to take responsible decisions about difficult options, how to negotiate and apply risk reduction techniques, how to refuse unprotected sex when sexually active, and how to seek peer support and seek care including health services and counselling.

An important priority in the African context, given the large numbers of children who are not in school, is to find ways to teach these skills in the settings where out-of-school young people spend their time. (See next chapter for a discussion of the special vulnerability of girls and young women in the general population.)

The vulnerability of women and girls

Women of all ages are more likely than men to become infected with HIV during unprotected vaginal intercourse. Compounding their biological vulnerability, women often have a lower status in society at large and in sexual relationships in particular.

In the sub-Sahara African context, a number of culturally specific, gender-based practices (varying widely from country to country and within different cultural groups) can increase HIV transmission. These include widow inheritance and certain circumstances related to polygamy. (While absolute fidelity will protect a polygamous household from AIDS, infidelity in just one spouse can lead to all members becoming infected). Lower emphasis on educating girls and women’s pervasive financial dependence on a husband or partner mean that they may endanger their primary relationship if they voice suspicions about male infidelity or ask for condom use. In addition, women entrepreneurs such as market vendors with little capital, unable to count on protection from the legal system, are especially vulnerable to sexual coercion in return for services or even the right to operate their business.

This gender vulnerability, again, is particularly acute for young girls, where the interplay of biological, cultural and economic factors makes young girls particularly exposed to the sexual transmission of HIV. While both girls and boys engage in consensual sex, girls are more likely than boys to be uninformed about HIV, including their own biological vulnerability to infection if they start having sex at a young age. Girls are also far more likely than boys to be coerced or raped, or to be enticed into sex by someone older, stronger or richer.

While there are many cultural and economic reasons for cross-generational sex, the fear of HIV seems to be prompting some men to seek out partners they believe are less likely to be infected – young girls. There is a double deadly irony here. Men who are fearful of acquiring HIV may be infected themselves without knowing it. Moreover, given the very high infection rates now being seen in girls, it is unwise to expect young partners to be free of HIV.

Whether sexual initiation is consensual or coerced, it may occur at a very early age in particularly marginalised communities. In a survey of 1600 children and adolescents in four poor areas of the Zambian capital, Lusaka, over a quarter of children aged 10 said they had already had sex, and the figure rose to 60% among 14-year-olds. In South Africa, 10% of respondents in a study in six provinces said they had started having sex at age 11 or younger.

Men: also vulnerable, but in different ways

While women’s vulnerability to HIV is increasingly well known, it is less often recognised that cultural beliefs and expectations also heighten men’s vulnerability. Except in a handful of countries, men have a lower life expectancy at birth and higher death rates during adulthood than women. Many of the health problems that men face could be prevented or even cured with early medical intervention or a change in lifestyle. Yet men are less likely to seek health care than women, and are much more likely to engage in behaviours - such as drinking, using illegal substances or driving recklessly - that put their health at risk.

Some circumstances place men at particularly high risk of contracting HIV. Men who migrate for work and live away from their wives and families may pay for sex and use substances, including alcohol, as a way to cope with the stress and loneliness of living away from home. Men living or working in all-male settings, such as the military, may be strongly influenced by a culture that reinforces risk-taking behaviour. In addition to these specific risk settings, poverty and unemployment may increase men’s sexual risk-taking as a way of compensating for their perceived loss of manhood. Research in some rural areas of Kenya and Tanzania finds that when men become unemployed and hence lose their status as providers, they are more likely to have sex with sex workers or other partners to feel "more like men".

In addition to men’s prevention needs, far greater attention must be given to the needs of the millions of men now living with HIV, including helping them to avoid infecting others. On a continent where AIDS is causing illness and death on a vast scale, men must also be encouraged and helped to play a much greater part in caring for orphans and sick family members. Finally, even though the results may take years to materialise, it is important to challenge harmful concepts of masculinity, including the way adult men look on risk and sexuality and how boys are socialized to become men.

All this does not mean an end to prevention programmes for women and girls. Rather, the aim is to complement these by measures that more directly involve men.

In the year 2000, the theme of the World AIDS Campaign is "Men Make a Difference". By focusing on the male role in the epidemic, the Campaign aims to involve boys and men more fully in the effort against AIDS and to bring about a much-needed focus on them in national responses to the epidemic. In 2000, the Campaign has three broad goals. The first is to raise awareness of the relationship between men’s behaviour and HIV. The second is to encourage men and adolescent boys to make a strong commitment to preventing the spread of HIV and caring for those affected. And the third goal is to promote programmes that respond to the needs of both men and women.

Migration and AIDS

In East and Southern Africa, various studies have shown a much higher HIV prevalence in people with a record of international mobility or migration (this is probably also true for internal migrants, but so far there is little data on this question). In West Africa, studies carried out in health care centres confirm the correlation between international mobility and vulnerability to HIV. For instance, research in the main health care facility for HIV-infected patients in Senegal shows that 70% of them have a migration background in Central and West Africa.

As used by UNAIDS, the term "migrants" includes people who move from one place to another permanently or temporarily, voluntarily or involuntarily. Some may be refugees or displaced persons. Other people cross borders for a wide variety of professional reasons. Whatever the circumstances, it must be remembered that being a migrant, in and of itself, is not a risk factor for HIV and sexually transmitted infections; it is the activities undertaken and the situations encountered during the migration process that are the risk factors.

Migration issues are particularly important in the African context owing to the continent’s large numbers of migrant labourers (particularly for the agricultural and mining industries) and those who are displaced by violent conflict (see below). Both male and female migrants frequently occupy vulnerable positions in the receiving society, with few rights in the place where they are living, and little access to social and health care services. Many may see their families only once a year, and are highly likely to form local relationships, visit sex workers or seek casual sex in places where alcohol is consumed. In such circumstances, the risk of HIV and other sexually transmitted infections is very high – a risk which then travels back to the spouses and sex partners of migrant workers when they return home.

Few national AIDS plans deal with migration in ways that take into account its importance to the international epidemic. This could be because of an "us" versus "them" mentality by national authorities, legal requirements to spend national resources only on citizens, or the political temptation to ignore illegal or undocumented immigrants. In fact migrant and ethnic minority populations, and also those who are internally displaced, all too often become ‘invisible’, and are easily forgotten.

War and AIDS

Armed conflict also causes mass displacement on the continent, particularly in chronic "hot spots" such as the Great Lakes region, the Horn of Africa, and the southern Sahara. Besides "official refugees" (as defined in the relevant UN Convention) there are also millions of internally displaced persons. The vulnerability of the latter may be even greater than that of refugees since, lacking official status, they are frequently ignored in public health planning and therefore have little or no access to services. Many are concentrated in conflict zones where relief organisations (including those providing health services) are frequently refused access on the grounds that the relief workers’ safety cannot be guaranteed.

Such populations often fall between the cracks of international AIDS programmes as well. Since they move from place to place they become the responsibility of no one – yet the fact is that they interact with local populations, and can both affect and be affected by a wide cross-section of society.

Marginalized groups: forgotten or wilfully ignored

Groups who live on the margins of society exist in every country, although they differ from place to place. What marginalised groups have in common is an increased vulnerability to HIV, whether the individuals concerned are illegal immigrants, drug users, sex workers or men who have sex with men.

Those who engage in stigmatised behaviour are less likely to be cared about or even acknowledged by society’s decision-makers, who do not want to spend their political or financial capital on AIDS programmes for them. Even where AIDS prevention and care services for them exist, individuals whose practices are against the law – or whose presence in the country is illegal – may be reluctant to risk exposure by participating in them and taking self-protective action against HIV.

Examples of Best Practice

Kenya: Life skills to fortify young people against HIV

Leadership issues summary

Leadership level(s): young people, community leaders, private sector (both national and international)

Contribution to success: understanding that leadership can be exercised by young people if properly supported and organised

Opportunities: could be used as a model for other countries

In Kenya, Mathare Youth Sports Association (MYSA) brings life skills and awareness of the HIV risk to young people before they become sexually active.

Mathare is the largest slum area in the Kenyan capital, Nairobi. MYSA began in 1987, when a football league was formed with the dual purpose of carrying out environmental clean-ups and organising sporting activities. By 1998, it was Africa's largest football organisation (410 boys' teams and 170 girls' teams). The original aim was to promote social responsibility and leadership both on and off the field. Since then, it has taken on the mission of fighting the HIV epidemic by promoting healthy living, teamwork, and involvement in community-improvement activities.

MYSA has been training its footballers to be peer educators about HIV since 1994, and is estimated to have reached some 20,000 young people between 1994 and 1997. Members of the senior squad, who are well-known and respected, and therefore have influence with their peers, were the first to be trained. The adolescents stress abstinence from sex; but for those who are sexually active, they emphasize the importance of using condoms and staying faithful to one partner.

MYSA peer educators talk about the problems of boy-girl relations, particularly the problems that arise when boys base their self-esteem on sexual conquests, and girls base theirs on having boyfriends. Peer educators aim to provide information and improve communication skills, with the goal of changing values and attitudes and strengthen peer support, all of which help reduce vulnerability to HIV risk behaviour..

The leagues are run by local committees of team coaches and captains. There is strong support from the private sector. Funding comes from a number of private-sector sponsors, including Orbitsports (supplies sporting equipment), Norsk Hydro (sponsors MYSA's professional football team), Coopers & Lybrand (audits the club's annual accounts gratis), Norwegian Agency for Development (NORAD), the Ford Foundation, and the Population Council.

Ethiopia: Save Your Generation Association targets out-of-school young people

Leadership issues summary

Leadership level(s): young people, community in cooperation with international agency

Contribution to success: willingness of young organisers to reach out to traditional leaders; emphasis on understanding the perceptions of the target group

Gaps and insufficiencies: insufficient funding to extend coverage

In Ethiopia, the Save Your Generation Association (SYGA) was implemented by a group of young men who wanted to do something about the rising impact of AIDS on young Ethiopians. Its main objective is to change the health behaviours, including the sexual behaviour, of out-of-school young people in Ethiopia through peer education. The project's various activities include producing and distributing educational materials, training peer counsellors and educators, and promoting condoms.

Early on, the project recognised that achieving behaviour change among young people would require support from the wider community. SYGA therefore pursues meetings with established community groups (Edir members) to discuss the vulnerable conditions and HIV risks facing young people and what can be done about them.

Both community leaders and young people themselves agree that one of the most pressing needs of out-of-school young people is a source of income. If this need is not met, the prospects for successfully changing behaviours are extremely poor, and so SYGA works hard to create income-generation opportunities for its clients.

Tanzania: Advanced planning for AIDS prevention among migrant and local labour at a hydroelectric project

Leadership issues summary

Leadership level(s): national electric authority; international private sector and international donors; national and local authorities

Contribution to success: emphasis on learning from previous experience and thinking hard about vulnerability; willingness to invest resources in prevention and care

Opportunities: extend this model to other major infrastructure projects in sub-Saharan Africa

Planning for a five-year hydroelectric project for the Kihansi Falls in south-central Tanzania established that preventing HIV and other sexually transmitted infections was a priority both for the estimated 2,000 workers (mostly young men) expected to migrate to the area and for the 40,000 people already living near the dam site.

The national power company, TANESCO, working with its Scandinavian partners and local government authorities, benefited from lessons learned from an earlier project in the early 1990s. A public health project called MUAJAKI (taken from the Swahili name meaning "Kinhansi Participatory Public Health Project") was created early in the project cycle. It placed HIV/AIDS among several negative health consequences expected from the project, including a rise in malaria, alcohol and substance abuse, and industrial and motor vehicle accidents.

Activities began in 1996. These included: collection of baseline health data; information, education and communication campaigns; social marketing of condoms; new sexually transmitted infection (STI) clinics; monitoring; and support to people living with HIV. All MUAJAKI activities were integrated with the health care system of the local district, bolstering it with 10 health professionals, more support staff, and additional funding from the hydro project funders. Condom sales to date are far above the Tanzanian average, and the number of infections diagnosed in the STI clinics has been dropping.

Though final evaluation is not complete, MUAJAKI already shows the benefits of two important approaches to preventing HIV transmission in the workforce at major construction projects: (a) anticipating their social and public health impacts; and (b) integrating local health authorities in the planning and implementation of activities to mitigate such impacts.

International: Advocacy for AIDS responses that benefit women

Leadership issues summary

Leadership level: civil society as represented by women’s groups

Contribution to success: determination to increase understanding of the gender component in HIV/AIDS epidemic

Gaps and insufficiencies: projects are all small-scale, with insufficient resources to scale up

The Society for Women and AIDS in Africa (SWAA) was formed in 1988 to provide a platform for women to address HIV/AIDS and the socio-economic conditions which make them vulnerable to the epidemic. The initial focus of SWAA was to bring to the fore the impact of AIDS on women in Africa, mobilise women at country level to carry out relevant activities, and develop a regional network of SWAA branches for inter-country exchange and collaboration.

After its first three years, SWAA recognised the need (i) to work with national programmes to promote action in respect of women and AIDS, (ii) to work with adolescents, especially girls, to develop risk-reduction skills and (iii) to broaden its network to include women living with HIV/AIDS as well as community-based women's groups not yet working on the epidemic to enable them to incorporate HIV/AIDS into their activities. Since then, SWAA’s regional mobilisation initiative has resulted in the formation of 28 country branches. In Senegal, for instance, SWAA has achieved a high profile, particularly in its work among women working in factories and in its promotion of the female condom. As yet, however, no projects have been scaled up to a national level.

The spontaneous response of women to the epidemic has been encouraging, as is the high level of their commitment. A broader perspective on women and AIDS issues and interventions has ensured that women (besides female sex workers, who have been the focus of many prevention programmes) received greater attention than was the case. The involvement of adolescents has been rewarding, resulting in the formation of SWAA youth wings in some countries.

Tanzania: Female guardians at schools

Leadership issues summary

Leadership level(s): local educational authorities, working with students

Contribution to success: realistic understanding and willingness to openly talk about vulnerability of young girls; willingness to encourage leadership among community members

In Mwanza, primary schools work on an AIDS-competent environment by training so-called guardians. The main goal of the guardian programme is to create a more protective environment for primary-school girls, to prevent sexual harassment and exploitation, and to assist the girls in dealing with social and reproductive health problems encountered during their schooling period. The school Board, based on specified criteria, selects a guardian who is offered special training.

The programme is successful: pupils have been empowered to report culprits. The District Education Officer indicated that cases of sexual abuse of schoolgirls by teachers and of pregnancy among schoolgirls have gone down considerably. The school programme has now been accepted by the national government for replication nation-wide.