TIGblogs - Dechen Wangmo

YES Bhutan Country Network

Workshop on Youth- HIV/AIDS
June 2, 2006
Youth Service Centre, Phuentsholing

Objective:
“To Educate our youth about the Disease and Its Economic Threat to the Nation, as they are leaders of Tomorrow”

8:30Hrs : Arrival of participants
8:45Hrs : Registration of Participants
9:00Hrs : Arrival of Chief Guest
9:05Hrs : Welcome Speech
9:05Hrs : Address by Chief Guest
9:20Hrs : Introduction
9:45Hrs : HIV/AIDS, STI
9:20Hrs :Disease Progression
10:00Hrs : Youth-Drugs-HIV (5Minutes Skits- school wise competition)
10:30Hrs : YES Bhutan networks Youth-Drugs-HIV award
Tea Break
10:45Hrs : Session ( Self Grading, Doors & Fluids, Can and Cannot, Prevention, Transmission, Q&A)
12:00Hrs : Common STI, Relation Between HIV & STI (Q& A)
13:00Hrs :Lunch
14:00Hrs :Condoms-Advantages and Disadvantages, Demonstration
14:35Hrs :VCT
15:00Hrs :Behavior Change
15:30Hrs :Set Objectives for Priority Population
16:00Hrs : Stigma and Discrimination
16:20Hrs : World Current Scenario
16:45Hrs : Bhutan Scenario-Current
17:00Hrs : Closing

Tashi Delek

I am not a Problem, I am the Solution-HIV
I am not useless, I am used less-Condom
I am Not Careless, I am Cared Less-Virus

YES Bhutan HIV/STI Award: Youth-Drug & HIV/STI
(Award received by the youth for skit Competition on Youth-Drug & HIV/STI)

HIV/STI: Youth -Drug & HIV

Introductions: What I Bring and What I Want to Take Away

HIV
STI
AIDS

What makes youth vulnerable to HIV/AIDS in our district, community or ministry?

What resources and networking already exist among vulnerable communities in our sector that could facilitate implementation of prevention strategies?

What misconceptions do youth in our area have about HIV transmission, disease progression, prevention, testing or treatment?

What have we already done to educate youth in our area about HIV and what is the most successful outcome we have had so far?

What are the biggest challenges we have faced in implementing your strategies?

What policies, if any, exist in our workplace or community that protect youth living with HIV from discrimination?

What skills would you most like to take away from the This training?

The Self- Assessment Questionnaire Tabulation
1. I am a skilled peer youth .
Strongly Agree Strongly Disagree
1 (0) 2 (7) 3 (11) 4 (3) 5 (3) A= 3. 08

2. I am comfortable discussing sex and sexuality in front of a group.
Strongly Agree Strongly Disagree
1 ( 12) 2 (11) 3 (1) 4 (0) 5 (0)
A= 1.54

3. I can explain HIV transmission in a way that others can easily understand it.
Strongly Agree Strongly Disagree
1 (12) 2 (9) 3 (2) 4 (0) 5 (1)
A=1.70

4. I am familiar with many participatory techniques for AIDS training.
Strongly Agree Strongly Disagree
1 (2) 2 (7) 3 (6) 4 (5) 5 (4)
A= 3.08

5. I can explain the difference between the widow period, the honeymoon period, and an AIDS diagnosis.
Strongly Agree Strongly Disagree
1 (4) 2 (11) 3 (4) 4 (2) 5 (3)
A= 2.58

6. I think it would be valuable to listen to someone from Bhutan who is living with HIV.
Strongly Agree Strongly Disagree
1 (17) 2 (3) 3 (4) 4 (0) 5 (0)
A= 1.46

7. I am familiar with behavioral change theory and communication.
Strongly Agree Strongly Disagree
1 (2) 2 (9) 3 (6) 4 (2) 5 (3)
A = 2.70

8. If I tested positive for HIV, I would not feel hopeless.
Strongly Agree Strongly Disagree
1 (7) 2 (9) 3 (4) 4 (4) 5 (0)
A = 2.20

9. I would feel comfortable sharing a restroom with a person living with HIV.
Strongly Agree Strongly Disagree
1 (19) 2 (3) 3 (0) 4 (0) 5 (0)
Two responses to this question were cut off in fax transmission.
A = 1.13

10. Working to prevent the spread of HIV in Bhutan is one of my highest priorities.
Strongly Agree Strongly Disagree
1 (19) 2 (4) 3 (1) 4 (0) 5 (0)

HIV Transmission and Prevention

Objectives: By the end of this session, participants will be able to:
1. Identify activities that can transmit HIV and activities that cannot transmit HIV
2. Define “portal of entry” and “universal precautions”
3. List three ways that HIV can be prevented
Materials: Clear glasses (7): coffee or dark soda: water
Prepared flipchart: What’s the fluid? Where’s the door?
Prepared signs: Can Transmit HIV, Cannot Transmit HIV
Index Activity Cards (already taped under chairs)
Handout: Basic Facts on HIV: from Peer Education Tool Kit for Uniformed Services
Preparation: Fill 5 glasses with water only half full: Fill 2 glasses with coffee also half full; The day before, prepare 7 people (training staff + extroverted others) to play in the skit. Roles attached. Tape activity cards under participants’ seats night before. Place What’s the fluid?and Where’s the door? signs on easel at front of room.

1. Introductory Skit
• Indicate that although most of us here are clear how HIV is and is not transmitted, it is important that we are able to answer questions about transmission in a clear and convincing way, since fears about casual transmission cause confusion, panic, or discrimination to occur in the community. These exercises can provide some helpful ideas for how to preset information to priority groups in a lively interactive way that reveals audience comprehension in the process.
• Direct participants’ attention to the front of the room and step aside to let the group silently perform the skit. After the performers move off stage, process the skit with some of the following questions:
1. What happened in the skit? What struck you?
2. What did the clinking represent? The exchange of water or coffee?
3. What was going on with her? (refer to the sex worker who always wore condoms) What was she doing? Why did she not get infected?
4. What was the basic behavior of the wife? How did she get HIV?
5. Describe her behavior (refer to the HIV+ woman) Did she pass HIV on? Etc
• Summarize the discussion describing the situations of vulnerability raised by the skit. Ask participants to describe what makes people vulnerable to HIV in their
dzongkhag. De-role the actors and emphasize that not all sex workers are negative and not all partying men are positive etc.

2. What’s the fluid? Where’s the Door? (30 minutes)

• Segue to a discussion of HIV transmission. Despite the myths and fear surrounding HIV, one of the sources of hope is that we are clear about HIV is transmitted, so we can be clear about how to prevent it.
• Ask participants to brainstorm which fluids in the body are capable of transmitting HIV. Record the correct answers at the top of the What’s the Fluid? Flipchart.
Correct answers include: blood, semen, vaginal secretions, and breast milk. (Other secretions include amniotic fluid, synovial fluid, cerebral spinal fluid etc, but these will most likely not be issues for anyone but health workers) Fluids that do not transmit HIV include: saliva , tears, sweat, and urine. Vomit, diarrhea, urine etc. may contain white blood cells with HIV, but not in sufficient quantity to transmit the virus. But since these fluids may transmit other diseases, one should use precautions when handling them.
• Indicate that in addition to a fluid infected with HIV, the virus also needs an entry point to get into the body. This “door” is called a “portal of entry.” It is a place on the body that allows the virus to enter. Ask participants to think of possible “doors.” Write their answers under Where’s the Door. Some suggested answers include, cuts, sores, needle punctures, mucus membrane (soft tissues of the of the vagina, tip of the penis, anus, mouth, eyes, or nose).
• State that we can always tell whether or not it is possible to transmit HIV by asking ourselves these two questions: What is the fluid? Where is the door? Ask participants to brainstorm some activities that are the most common way for HIV to be transmitted and point out the fluid and door in those activities.
• Indicate that we are going to do an activity to practice what we have reviewed.
• Ask them to reach under their chairs and pull out the cards placed there. Read the card and come to the front and place the card under the appropriate heading: Can transmit HIV or Cannot transmit HIV.
• When they return to their seats review placement of cards, and make corrections with the group by asking them about fluids and doors.
• Ask participants what questions come up in the community. In the survey there were concerns about insects. Explain that we know mosquitoes do not transmit HIV both from epidemiologic studies, and from laboratory studies. Mosquitoes inject saliva, not blood, and they do not metabolize HIV. Ask them why girls and women are more vulnerable biologically to HIV. (larger mucus membrane surface, recipient of fluid, tearing of vagina during sex, especially dry sex, untreated STIs, sore often not visible ) Later we will discuss why women are more vulnerable to HIV on a social level. Ask about ways that HIV can be passed from mother to child (in-utero, during delivery, through breastmilk). If father is HIV+, but mother is HIV-, can the infant be infected? Where is the fluid? Ask doctors to clarify issues around breastmilk transmission, and what increases and decreases risk of maternal transmission. Relate these issues back to exposure to fluids and doors.

3. HIV Prevention (15 minutes)
• Suggest that clarity around transmission makes it clear how to prevent HIV. Return to chart with activities that can transmit HIV and ask participants to share methods of prevention for each activity. When discussing sexual transmission review the ABCs of prevention, but caution that we should not delude ourselves that preventing HIV is as simple as 1-2-3. The majority of women infected with HIV in the world state that they practice “ be faithful” but still become infected. When discussing blood-borne HIV transmission, review “universal precautions.”

Introductory Skit
_____________________________________________________________________

Actors

Husband and Wife The wife remains faithful to the husband, and for themost
part, her husband remains faithful to her. In a moment of
weakness near the end of the skit, the husband “clinks
glasses” with the coy woman, after which he becomes
infected with HIV. Later, he passes the infection on to his
wife. Both begin with water in their glasses, and end the
skit with coffee mixed into the water.

“Partying Man” This man actively seeks sex with all the women in the skit.
He begins the skit with coffee in his glass.

HIV+ woman This woman begins the skit with coffee in her glass, but
refuses to clink glasses with anyone in the skit. She is
approached often by the “partying man” and is given
some attention by the abstinent man, but refuses to engage
with either of them.

Abstinent Man This man seems interested in the ladies, smiling and chatting
with them, but he never clinks glasses.

Female Sex Worker Although she clinks glasses often with the partying man she
always uses a condom. She is seen to clink glasses and
exchange money, but she never exchanges fluid.

“Coy” woman This woman appears to be very shy, and rejects the advances
partying man repeatedly. Finally she shares fluid with the
partying man and then goes back to her shy behavior, until
she finally shares fluid again with the husband.

This skit is performed silently, with all actors gathered in the front of the room. Every few moments, one of the actors engages with another, before going back to his or her position. The actors may sometimes clink glasses (which represents having sex) and may sometimes clink glasses and exchange fluids (which represents having unprotected sex). Having coffee in one’s glass represents having HIV in the bloodstream. During rehearsal we will determine the natural order of the movements, but by the end, everyone but the sex worker and the abstinent man will have some coffee in their glasses.

What’s the Fluid? Where’s the Door? - Sample Cards

Can Transmit HIV
• Anal sex
• Blood transfusion of untested blood
• Sharing injection needles
• Blood entering mucus membrane
• Breastfeeding
• Mother to child during delivery
• Mother to child during pregnancy
• Semen to mucus membrane
• Vaginal secretions to mucus membrane
• Blood splattering the eye of a laboratory worker
• Cleaning up blood without using gloves
• Amniotic fluid entering an open sore of midwife
• Vaginal sex
• Oral sex
• Only having sex with your husband
• Only having sex with your wife
• Having unprotected sex only one time
• Having sex with a virgin

Cannot Transmit HIV
• Sitting on a seat where an HIV+ person has sat
• Riding on a bus with an HIV+ person
• Eating from the same dish as an HIV+ person
• Hugging a person living with AIDS
• Shaking hands with a person living with AIDS
• Sharing a drinking cup with an HIV+ person
• Letting someone cry on your shoulder
• Stepping on a nail outside
• Cleaning up vomit or diarrhea with gloves on
• Using the same restroom as an HIV+ person
• Being sneezed on by an HIV+ person
• Sharing a towel with an HIV positive person
• Being bitten by a mosquito that has bitten an HIV+ person
• Breathing the same air as an HIV+ person
• Being coughed on by someone who is HIV+
• Sharing a cigarette with someone who is HIV+
• Using the same soap as an HIV+ person
• Having sex with a goat

Injecting Drug Use

Objectives: By the end of the session, participants will be able to:
1. List the most common drugs used in Bhutan and explain how they increase the risk for HIV transmission.
2. Describe the services available

Session Name: HIV Prevention through Condom Use

Objectives: By the end of this session, participants will be able to:
• Demonstrate comfort in handling male and female condoms
• List the steps for proper use of male and female condoms
• Demonstrate effective application of male and female condoms on a model

Time: one hour

Materials: Prepared condom “balloons” (5)
Small tape player with music
Male and female condoms for every participant
Wooden dildos (20) Small juice glasses (20)
Markers, flipcharts, masking tape
Reality condom handout
Instructions for putting on male condom

Handouts: Condom Use
Reality Vaginal Condom

Preparation: Prepare condom balloons by cutting the condom questions into small slips of
paper, folding it up, placing it inside a condom, and blowing the condom up.
Place one female and one male condom at each participant’s seat. Place one
dildo and one juice glass at every other seat.
Activities:

Condom Carousel (20 minutes)
• Invite participants to stand up and join you in a circle. Suggest that it may be difficult to talk about condoms, or touch them. The next two activities are designed to help us become more comfortable handling condoms, answering questions, and encouraging others to use them.
• Show participants the condom balloons and indicate that you will circulate one while the music is playing. Participants should pass it around the circle until the music stops. Whoever is holding the condom balloon when the music stops should break it, take out the slip of paper inside and answer the question.
• Clarify any misconception raised by the questions. If a participant finds it hard to break the condom, point out how strong they are. Remark on how large they are, for those who say condoms are too small.
• Invite participants to return to their seats, and ask them to share their feelings about handling the condoms. Allow time to express negative feelings.

Condom Demonstration (40 minutes )

• Invite one participant to come to the front of the room and guide us through the proper steps for using a male condom on one of the models. Suggest that fellow participants provide feedback or advice if needed. Correct any misinformation.
(Steps include checking expiration date, making sure that condom was not stored
in hot place, opening carefully, checking which way the condom rolls, pinching
the tip to avoid air bubbles, sliding gently all the way to the base of the penis.
If water lubricant available, two drops inside to increase sensation, and application
outside after condom applied. Remove carefully. Tie off to avoid spillage. Dispose
of in garbage.) Check for comfort level of group. Would men in Bhutan agree to using a condom with their wives if they asked? Would wife in Bhutan be able to participate in putting on condom?

• Ask participants to get together in pairs. (Same sex pairs may be more comfortable.)
Invite participants to take the condom in front of them and practice putting it on the dildo with their partner following the steps. Each partner will have a chance.

• When pairs finish, introduce the female condom. There is shared responsibility for condom use, whether for family planning or disease prevention. When women do not have decision-making power in a relationship, a female condom may give women more control over condom use.
• Encourage each participant to remove the female condom from the wrapper. (These are often hard to open. Have scissors handy.) State that female condoms are not made of latex like male condoms, but of polyethylene, which is stronger and less likely to break. Show that it is also covered with lubricant and comes with additional lubricant.
• Advantages of the female condom are: female controlled, may be inserted up to 8 hours before intercourse, more durable, covers wider surface, offers greater protection against STIs.
• Disadvantages of the female condom are: higher cost, lack of availability, awkwardness of application, noise it makes during intercourse.
• Ask if there is a volunteer who would like to demonstrate the application of the female condom in the juice glass. If not, do demonstration following steps in the handout. Have participants practice the application.
• Guide a discussion about condom promotion in their dzongkhag: Where are condoms available? How does MSTF or Ministry promote them? What did surveyed populations say about use of condoms? Availability? Acceptance by partners?
What about female condoms? What would they imagine its acceptance to be if it were available? How does condom use compare with fidelity and abstinence as a behavior one would consider adopting in Bhutanese society?

Condom Carousel – Sample Questions

• True or false. Petroleum jelly and suntan lotion are good lubricants to use with a condom.

• Does wearing two condoms provide added protection? Why?

• True or false. Female condoms do not protect well against HIV.

• True or false. Since condoms have holes bigger than the virus, they don’t protect against HIV.

• True or false. A married woman who only has sex with her husband doesn’t need to use condoms.

• True or false. A couple of drops of water-based lubricant inside the condom is safe and increases sensation for the man.
REALITY VAGINAL CONDOM

Description: The Reality vaginal condom consists of a soft, loose-fitting polyurethane sheath and two flexible polyurethane rings. One of the rings lies inside at the closed end of the sheath and serves as an insertion mechanism and internal anchor. The other ring forms the external edge of the sheath and remains outside the vagina after insertion, protecting the labia and the base of the penis during intercourse. The condom lines the inner contours of the vagina. It is pre-lubricated and is intended for one-time use only. Like the male condom, the vaginal condom does not require fitting by a health care professional nor does it require precise placement over the cervix by the user.

Potential Advantages:
1. It is the first product which gives women the opportunity to help protect themselves from STDs and pregnancy
2. It provides broad coverage, covering the labia and the base of the penis, and providing greater protection against some STIs
3. Its polyurethane membrane is stronger than the latex membrane used in male condoms. It is soft and thin and resistant to oils, so that oil-based lubricants may be used with it.
4. It is less disruptive to the sex act because the woman may insert it several hours before use, and a male erection is not needed to remove the female condom.
5. The vaginal condom remains stable for up to five years in accelerated temperatures.
6. When compared to male condom, the probability of women being exposed to seminal fluid using the Reality condom was 3% and 11.6% when the male condom was used.
7. In direct examination of vagina following 74 episodes of intercourse by 15 women using the Reality condom, 0% sperm were observed.

Potential Disadvantages:
1. Cost: the female condom is at least 3 times as expensive as the male condom.
2. The outer ring hanging outside the vagina can be cumbersome.
3. The vaginal condom can make an odd noise during intercourse.
4. Women who are not used to inserting tampons or diaphragms, may have initial difficulty getting used to the insertion.

Session Name: Sexually Transmitted Infections

Objectives: By the end of the session, participants will be able to:
1. Describe the relationship between STIs and HIV/AIDS
2. Identify symptoms of common STIs
3. Identify terms used in local languages to describe STIs
4. Increase their comfort level in talking to clients about STIs

Common Sexually Transmitted Infections and Their Symptoms

Gonorrhea Syphilis Chancroid Herpes Simplex

*Yellow-green or *Painless sore on *Painful sore on *Small painful
white discharge penis or in vagina penis or vagina blisters on mouth
from penis or or genitals
vagina

*Burning sensation *Sore appears 10 *Sore appears 3 to *Symptoms may
on urination to 90 days after 5 days after exposure recur when under
exposure stress

*Symptoms usually *Non-itchy rash *Inflammation of *Viral infection
appear 2 to 14 days on body (palms lymph gland on
after exposure and soles) one side

*Possibly no *Hair loss, fever *Greatest risk for *No cure, but Rx
symptoms and chills HIV transmission with acyclovir

*Possible sterility *Possible death * Severe
if treatment delayed and neurological neurological
damage to untreated damage or death
adult to newborn if
exposed in birth
canal
*Possible blindness *Possible bone
in newborn if not deformation in
treated with drops newborn if mom
in eyes not treated early in pregnancy

Session Name: Disease Progression

Objectives: By the end of the session participants will be able to:
1. Define window period, honeymoon period, and diagnosis of AIDS.
2. List at least 3 symptoms of early HIV infection and four infections that are common in people diagnosed with AIDS.
3. Explain the meaning of the term “co-factor” and give at least 3 examples of co-factors.
Honeymoon Period: The time between the end of the window period and the point at which a person is diagnosed with AIDS. This term was first used to explain risks of maternal/child transmission, and although it is not widely used today, it is helpful to think of this period as a honeymoon, because it emphasizes that this is the time a person is living in relative harmony with their virus. S/he may have a few minor symptoms, but usually not look or feel very sick. During the honeymoon period the antibody level is high and the viral load is low. Although the person can still pass the virus to others, they are less infectious. During this time, pregnant women have less chance of passing HIV to their babies. Anything that can help maintain this low viral load (use of ART, not putting stress on the immune system through exposure to alcohol and drugs or other infections, or avoiding further infection of the virus through unprotected sex with an infected partner) can help reduce the risk of transmission to an infant during pregnancy, delivery, or breastfeeding.

Diagnosis of AIDS: A diagnosis of AIDS occurs when an HIV+ person has an opportunistic infection, cancer, or specific combination of major symptoms that is considered diagnostic of AIDS. In Bhutan, TB is the opportunistic infection most associated with an AIDS diagnosis.

Convene the participants in a large semi-circle around the front wall. Distribute the cards out to individuals. Run masking tape horizontally along a baseline and explain that where the tape starts represents the point in time at which a person became infected. Put a small amount of tape vertically on the line to represent the 3 month mark. Ask the group to help create a diagram of what we have been discussing. Facilitator takes the red tape that represents the viral load. A volunteer takes the blue tape, which represents the antibody response. At the point of infection, where is the viral load on the timeline? Does it ascend slowly or fast? Why? Following their instructions, have the red tape make a steep incline. At the beginning of infection what is the antibody level? Does it rise fast or slowly? Have blue tape rise very slowly through window period. If the person were tested for antibodies during this time, would their test be positive? Why not? What do you call this period? Have the person who has the window period card place it in the appropriate spot below the baseline. By what time does the antibody response kick in? How will that affect the viral load? Make red tape descend and blue tape rise sharply. Due to the viral infection, the person might be feeling some symptoms. What would those be? Ask whoever has those symptom cards to place the cards along the beginning of the timeline. Now that the viral load has come down the person begins what phase? Ask the person who has the honeymoon period card to place it in the appropriate place. This will continue for a while, maybe years. Run the red tape horizontally just above the masking tape and run the blue tape horizontally at a high level. But if our HIV+ person does not know they are infected, they will not be taking medication so eventually their virus will multiply and attack their immune system. When their immune system is unable to fight back, other infections will make them sick. What will happen to their viral load? And their ability to marshal an antibody response? Following participants’ instructions have the red tape make an incline and the blue line descend. At this time they will get a diagnosis of AIDS. Ask the person with the AIDS diagnosis card to place it on the timeline, and those with names of opportunistic infections and cancers to place their cards along the line. Answer questions about these symptoms of these diseases, and mention any other ones that seem relevant.

Brainstorm with the group some co-factors that could make an HIV+ person get sick faster. Elicit and write down suggestions on flipchart such as:
• Not eating healthy foods
• Not getting enough rest
• Smoking, drinking, drug use
• Getting re-infected with more HIV
• Getting infected with other STIs or diseases
• Getting stressed
Answering Difficult Questions About HIV/AIDS

Objectives: By the end of this session, participants will be able to;
1. Identify 8 categories of difficult questions
Use public speaking strategies to answer difficult questions about HIV/AIDS

Categories of Difficult Questions

1. Hostile Why do you spend so much time on AIDS, when innocent
people are dying of so many other diseases?

2. Run-On How many people are infected with HIV in Bhutan today,
and what is being done to be sure that they don’t spread it
to others, and when will there be a cure for this disease
anyway?

3. Don’t know What is the relation between GP120 and CD4 and how
the answer does this affect the reproduction of HIV?

4. Not a question In Bhutan there is no need to keep people’s HIV test
results confidential.

5. Too personal Have you ever tried oral sex?

6. Off the subject Where did you get those shoes?

7. Inappropriate Are we going to have an AIDS victim talk to us?
Language

8. False Assumption Why would anyone go for an AIDS test in Bhutan,
when we know they marked the leg of an infected
woman at a BHU?

9. Pushes a moral If I only have sex with twelve year old virgins, I’m
button not going to get it, right?

Values Clarification

Values Statement Sheet

1. Since we know of less than 100 people infected with HIV in Bhutan, AIDS is not a serious issue in our country.

2. AIDS is like any other disease.

3. Now that people know how HIV is transmitted and prevented, it is irresponsible for someone to become infected.

4. Ideally, everyone in Bhutan should be tested for HIV.

5. It is important to maintain the confidentiality of people infected with HIV.

6. Men and women have equal sexual decision-making power in Bhutan.

7. A married woman is at less risk for contracting HIV than a sex worker.

8. I would feel comfortable sharing a glass of water with a person who had HIV.

9. If my steady partner asked me to use a condom, I would gladly do that.

10. If I were infected with HIV, I would have no problem sharing that information with this group.

Games for Testing HIV Knowledge
Questions for Game

Category #1: HIV Transmission
$100 True or false? There have been 3 cases in Africa where HIV was transmitted by
contaminated fluid left on toilet seats.
$200 Name 4 body fluids that can transmit HIV.
$300 Name 3 portals of entry for HIV.
$400 Explain to the group how you know that HIV is not transmitted by mosquitoes.
$500 Name 4 ways an infant could become infected with HIV.

Category #2: HIV Prevention
$100 List 3 ways that an injecting drug user can reduce his or her risk for HIV.
$200 Define “universal precautions” and give 3 examples.
$300 List 3 advantages and 3 disadvantages of the female condom.
$400 State 3 ways a pregnant woman can reduce the chance of passing HIV to her
baby.
$500 Do a role play showing how a parent explains to a teen son how to prevent HIV.

Category #3: Sexually Transmitted Infections
$100 Explain 2 ways that STIs increase the risk for HIV transmission.
$200 Explain 2 things you will do to make STI services more accessible.
$300 Explain why women are more likely to suffer complications from STIs.
$400 List 5 symptoms of STIs.
$500 Say words in local languages for these terms: discharge, vaginal intercourse,
anal intercourse, lice, and ulcer.

Category #4: HIV Disease Progression
$100 What is the opportunistic infection that is most common in Bhutan?
$200 List 3 symptoms that are common in the earlier stages of HIV infection.
$300 List 3 co-factors that can accelerate HIV disease progression.
$400 Explain how ART can slow down disease progression.
$500 Name 5 things an HIV+ person can do to improve his or her health.

Category #5: Bhutan Epidemiology and Policies
$100
$200
$300
$400
$500

Assessing Vulnerability in Priority Populations

Objectives: By the end of this session, participants will be able to:
1. Use assessment data to analyze the needs of priority populations
2. Identify the roles, situations and issues that make populations in their Dzongkhag vulnerable to HIV/AIDS.
3. Create a skit that dramatizes the vulnerability of priority populations in Bhutan

Principles of Behavior Change

Some Basic Principles of Behavior Change:

• Providing information is an important starting point, but is rarely enough to change behavior.

• Fear messages have limited use in changing behavior.

• People are more likely to change behavior if offered choices among alternatives.

• Relapse is expected. Programs must seek to build in ways to maintain new behaviors and to bring people back when they have failed in their new behavior.

• People are more likely to try behaviors they feel capable of performing, so it may be important to build skills or have positive examples of others engaging in that behavior.

• It is important to create an enabling environment by encouraging changes in social norms that support the necessary changes.

• Change is more likely if influential people adopt or advocate for the change.

• Programs must address risk and vulnerability. Contextual factors such as government policy, socioeconomic status, gender, culture, and spirituality may influence a person’s ability to follow through on their decisions to practice healthier behavior.

Maslow’s Hierarchy of Needs
(Original Five Stage Model)

Self Actualization
(Personal Growth and Fulfillment)

Esteem
(Achievement, Status, Responsibility, Reputation)

Belonging and Love
(Family, Affection, Relationships)

Safety
(Protection, Security, Law, Stability)

Biological and Physiological
(Basic Life Needs: Water, Air, Food, Shelter, Sleep)

Abraham Maslow’s Hierarchy of Needs is a well-known theory that postulates that all human beings have ascending needs. Our basic needs are biological: food, water, air, sleep, shelter from the elements. Safety means protection from violence and security in a stable environment. Belonging relates to our need to be part of a family, group or culture. Teenagers looking for acceptance from peers often have strong belonging needs. Esteem needs fall into two categories: 1) our desire for achievement, to feel confident that we are capable of performing and supporting ourselves, and 2) our needs for status and recognition from others. Self Actualization has to do with maximizing our potential as an individual, being true to our own nature so that we can be at peace with ourselves.

If needs on a lower level are not at least partially met, then we cannot expect an individual to be able to focus on other needs. And if needs of a lower level are fulfilled, the person will become restless to fulfill the needs of the next level. This theory has important implications for our efforts at behavior change that reduces risks of contracting HIV. If a child in school is hungry, s/he will not likely be able to concentrate on a lecture about AIDS. If a sex-worker has no money to feed herself and her child, she is not likely to refuse a customer who offers more money for sex without a condom. If a wife is afraid of being beaten by her husband for discussing the possibility of getting an HIV test, then this subject is not likely to be discussed. So how have successful HIV/AIDS projects incorporated these concepts into the design?

Best Practices that incorporate needs:
Basic Needs: Some HIV prevention programs provide income-generating activities for reducing the HIV vulnerability of women and children. Poverty and hunger often drive women and children to exchange sex for food. In Thailand, young girls are under pressure to enter into prostitution in order to support their families. The Sema Pattana Chewitt and the Thai Women of Tomorrow Project are two HIV prevention programs that address these basic needs. The first provides very disadvantaged girls with scholarships to attend secondary school, and the latter works on changing the attitudes of families and girls towards prostitution while providing vocational education in agriculture, nursing, and work/study programs. Evaluation shows that only 1% of the girls in the program have dropped out of school by the 9th year.
Safety Needs: The Safe-House Project in Australia, inspired and led by an ex-sex-worker, is a good example of a project that met the safety needs of sex-workers and linked it to HIV prevention. A safe-house is a brothel where neither violence against the women or unsafe sex is permitted. The rule of the house is strictly enforced. The logo of the safe-house is printed and prominently posted. Any man who breaks the rules of the house, refuses to use a condom, harms a woman or leaves without paying, has his description printed in the Ugly Mugly, a newsletter, which is circulated to all the other brothels that joined the consortium. All offenders are refused service or reported to the police. This practice increased condom usage in the participating brothels to nearly 100%.
Belonging Needs: The Memory Book Project of Uganda, was created by Beatrice Were, leader of a pan-African support group of HIV+ women. It helps children of HIV+ parents to feel included in their family and community. So much secrecy around HIV sends the message to children that something so awful is going on that they can’t even be told about it. The memory book gives the parents a tool to discuss the disease with their children. The HIV+ parent builds a scrap book with her children that has pictures of the family that represent happy memories. While creating the book, the parent explains about her or his illness and indicates who in the community is part of the children’s extended family. The myriad of HIV+ support groups throughout the world also meet very important belonging needs for HIV+ people who are frequently isolated and stigmatized by the community. Youth groups and sports clubs that integrate HIV/AIDS into young people’s activities, like The Youth Development Fund here in Bhutan, are other examples of programs that address the belonging needs of adolescents.

Can you think of other examples? Can you think of ways that your HIV projects can incorporate some of Maslow’s concepts and address the unmet needs that put people in your community at risk for HIV?

SOCIAL MARKETING

PRODUCT PRICE
(Object, Idea, Attitude, Belief, Behavior) (Monetary or Social)
PLACE PROMOTION
(Channel for message or service) (Name, Packaging, Image)

“Social Marketing may be defined as the adaptation of commercial marketing and sales concepts and techniques to the attainment of social goals. It seeks to make health-related information, products and services easily available and affordable to low income populations and those at risk, while at the same time promoting the adoption of healthier behaviors. In fact, it may be said that the ultimate goals of social marketing is to effect healthy and sustainable behavior change.”
UNAIDS – Condom Social Marketing: Selected Case Studies - 2000

In HIV work, social marketing is most commonly associated with the promotion of condoms, but it may be applied to any HIV intervention. There are four Ps in social marketing: Product, Price, Place and Promotion. Social Marketing has also measured the effectiveness of segmenting the population, in order to tailor messages and interventions to particular groups, as you are doing by choosing priority populations
A product is the knowledge, attitudes, skills or behaviors you want your priority population to adopt. It can be a behavior like abstinence, or an attitude like compassion towards people living with AIDS, or a belief that AIDS is a serious problem in your country. What are the products you want to market in your project?

Price is what the audience members must give up to receive the program’s benefits. It can refer to the monetary cost of a product, like the high price of female condoms, but price can also be analyzed in terms of social costs. Treatment of STIs may be free in Bhutan, but the social stigma attached to being treated at a clinic may be more of a cost than paying for the medicine over the counter. The price to a sex worker for carrying a condom when police may use it as evidence of solicitation may be too high for a woman to risk. What are the costs of your program and how can you reduce them?

Place is the channel where the message, service, or product is disseminated. Since drug use is illegal, users are not likely to seek information or care at government-run
institutions. Finding discreet places to conduct outreach and offer condoms is important. Some programs dealing with migrant workers have distributed condoms along with blankets and food. The Bhutan HIV/AIDS program’s use of festivals for HIV outreach is a good example of a culturally appropriate channel. How is it working? How effective have the cell-phone messages on HIV been so far?

Promotion is the means for persuading the audience that the product is worth the price. The name and packaging of the product is important. In Kenya condoms are packaged in national colors and have a picture of a couple holding hands in order to give condoms a more romantic image. The brand name of the condom is Trust in order to help overcome fears that condoms don’t really protect one from the virus. A peer sex-worker
HIV outreach project in Mexico City had success with condom distribution when it wrapped the condoms in packaging resembling chocolate bars. What sorts of promotional ideas would you use for condoms in Bhutan? What name? What color packaging? What images?

On the supplemental CD you will find Best Practice selections of condom social marketing published by UNAIDS that gives details of how one project was designed, implemented, and evaluated.

Robert Westermeyer, Ph.D.

The harm reduction model upholds that abstinence is the ideal goal for those using illegal drugs. Abstinence from drugs reduces drug-related harm completely. It is hoped that all individuals who use illicit substances will eventually come to give them up entirely. Proponents of Harm Reduction recognize, however, that there will always be illicit drug use (unless we can successfully eliminate every psychoactive plant and synthetic relative from the face of the planet) and that many people are unwilling or unable to give up drugs entirely but nonetheless could benefit from intervention. It cannot be mandated that people give up drugs in order to receive help. The abstinence mandate keeps the majority of addicts away. What then occurs is that people with drug problems continue to use drugs – use drugs in a way that presents a high risk of health problems to the individual user and those associated with him or her.

Working with addicts from a harm reduction perspective, involves accepting that some people are not going to give up drugs at this time. Offering them services opens the door to helping them reduce harm in some way – even an infinitesimal way – that wouldn’t otherwise occur. Small reductions of harm are better than no reduction. An open door policy can result in a harm reduction snowball effect: small improvement can pave the path for further reduction of drug use and an improved lifestyle in other ways. This snowball effect can continue eventually to the point of abstinence.

How, according the harm reduction model, do you help an addict who doesn’t wish to quit?
• Determine if the person’s use patterns could be altered to reduce harm
• Determine whether other aspects of their lives could be focused on to improve health and enhance the likelihood of abstinence (therapy for depression, anxiety etc.)
• Motivational interviewing to help the person tip the scale of ambivalence in favor of change
• Discussion of switching substances to one with less associated harm
• Discussion of gradual reduction toward abstinence as an alternative to cold turkey

When conducting outreach to drug users (either through street outreach, clinical settings, needle exchange programs, or drop-in centers) the harm reduction model focuses on reducing the vulnerability to HIV of the user. Find where the person is on the continuum and motivate them to move towards safer behaviors:

LOW RISK No substance use
Occasional non-injecting use
Frequent non-injecting use
Injecting drugs without sharing needles
Injecting drugs, cleaning needles before sharing
Injecting drugs, sharing needle with one partner
HIGH RISK Injecting drugs, sharing needle with multiple people

If harm reduction were used for sexual activities, what would this continuum look like?

Best Practices in Harm Reduction:

Needle Exchange Programs for Injecting Drug Users (IDUs) have been some of the most successful programs for slowing the spread of HIV among IDUs. Recognizing the physiological need that the drug creates in an addicted person, outreach workers offer clean needles in exchange for used ones. Instead of requiring that users immediately stop their use, the program uses a harm reduction strategy. In Santa Cruz, California, where a large IDU community has a very small number of infected users, community volunteers exchange clean needles with users at specified street corners or Laundromats, places that feel safe to users. At the exchange site, users are also given HIV information, condoms, bleach and alcohol preps, referrals to treatment programs, HIV testing at a neighborhood drop-in center when requested, as well as emotional support and insight from ex-users. Besides reducing the rate of HIV infection in the IDU community, the program decreased the amount of contaminated needles discarded in the neighborhood. Bangladesh has a very successful needle exchange program that led to decreased sharing of needles and reduction in STI symptoms among those who participated in the program. (See graphic.) The Ukraine has a successful needle exchange program which is described in the accompanying handout from UNAIDS Summary of Best Practices.

Best Practices of harm reduction in sexual activities: In San Francisco, the number of new HIV infections dropped dramatically in the late 1980s when the STOP AIDS Project held safer-sex educational events in homes and coffee shops with gay men. These models were based on harm reduction. Men assessed their own risk and were motivated to reduce their risk in one way that felt right for them. The program was peer-led and sex-positive. To evaluate program effectiveness, participants filled out surveys describing their risk behaviors before the events. Six months after the events they completed follow-up surveys. At the end of the series of group sessions, the men made public commitments to reduce at least one risk behavior and to do one thing to help educate their community prevent HIV. A large percentage of men at that time stopped anal sex and switched to oral sex, which was responsible for reducing HIV transmission more than condom use. This was reflected in both the drop of new syphilis cases in San Francisco as well as the dramatic drop in new HIV infection at that time.

Behavior Change and Best Practices: Teaching Session

Objectives: By the end of the session, participants will be able to:
1. Teach major concepts of one model of behavior change.
2. Describe one major concept of six models of behavior change.
3. List 3 best practices in HIV/AIDS prevention.

Activity:

As participants return from break, ask members of previous working groups to spread out at different tables. Confirm that each group has a representative from each model. Participants may go in any order to share their 15-minute lesson with the rest of the group. One person in the group should be assigned as timekeeper to keep the group on target. Facilitators spread out with the groups. Go until each person has had a turn.

The Best Response Game

Overview: In order to have the experience working with at least two of the models we have learned about, we will do two longer interactive exercises. The first is from Life Skills. (If a volunteer is willing to lead this exercise, have them take over. Thinking critically and communicating effectively are important components of dealing with peer pressure in risky situations. This game provides a fun forum to practice the skills young people will need to delay sex.

Objectives: By the end of this session, the participants will be able to:
1. Identify typical lines people use to pressure others for sex.
2. Strategize appropriate responses to those lines.
3. List effective responses to common pressure lines.

Materials: Small slips of paper
Watch with second hand
Flip chart and markers

List of pressure lines:

1. Everybody is doing it.
2. If you truly love me, you will have sex with me.
3. I know you want to – you’re just afraid.
4. But I have to have it!
5. If you don’t have sex with me, I won’t see you anymore.
6. If you don’t, someone else will.
7. You don’t think I have a disease, do you?
8. But I love you. Don’t you love me?
9. Girls need to have sex. If they don’t, they get rashes.
10. Nothing will go wrong. Don’t worry.

Activity: Divide group in teams and ask for three volunteers to come forward as judges.
Pretend that a night prowler has entered the house of a young girl and is pressuring her to have sex. Facilitator will read aloud the line of the prowler and your team is to come up with the best possible response for the girl in one minute and write it on the paper. The papers will be read aloud and then handed to the judges, who have one minute to decide on the best response. The team that gets the best response is awarded two points, which is tallied on the chart. At the end of 30 minutes, the team that has the most points wins.
Process the activity by mentioning that there were a wide variety of possible responses. It is helpful for people to think of these lines and rehearse them before an actual situation arises. Parents can also help their children think up these responses when they talk to their kids about peer pressure.

The Role of Culture and Spirituality in Behavior Change

Cultural Questions to Consider

• Who are the cultural gatekeepers? What is their role in the flow of information?

• Who has the most influence in communities? (think of subtle and overt power)

• What are the relationships that tie priority populations to the community?

• What types of oral and visual media is used among the population?

• What cultural values do members of your community hold that could be harnessed in HIV prevention and care?

• How have cultural traditions already been utilized in HIV prevention work in Bhutan? What worked best and what did not work? Why?

Spiritual Questions To Consider

• What are the religious affiliations and spiritual beliefs of the communities you are trying to reach?
• What communication channels are used by religious and spiritual leaders?
• What types of influence is wielded by local religious and spiritual leaders?
• What spiritual beliefs and practices can be harnessed to prevent HIV and mobilize support for people living with HIV/AIDS?
• What spiritual beliefs and practices can be harnessed by people living with HIV in Bhutan to cope with their illness?

Voluntary Counseling and Testing: The Decision to Test

Invite all participants to stand and listen carefully to the instructions. Each participant has been given a bag of beans. At no time during the exercise should they look inside their bag or at their beans. When the facilitator gives the word, participants should walk around the room. When they hear the word “greet” they should introduce themselves to one other person and, keeping their eyes on their partner, remove a small amount of beans from their bag and place those beans in the bag of the person they are meeting. Demonstrate this and emphasize that neither person should look at the beans. Check that they understand the instructions and instruct them to begin walking. Call out “greet”, let participants exchange beans, and repeat pattern 3 times then ask the participants to take their seats.

Explain that they should still not look in their bags. They should pick a partner and exchange bags. Say that everyone began with a bag of white beans except for one person who had a bag of red beans. The bag of red beans represents HIV infection and anyone who has even one red bean in his or her bag has been infected with HIV.

Ask participants how they feel at this point. If they do not want to know their HIV status they should simply ask their partner to return their bag to the facilitator. For those who did not return their bags, decide among the pairs who will be the counselor and who will be the client first. When ready, the counselor should ask: (have these questions written on flipchart)
1. How are you feeling about coming for your test results?
2. What would a negative test mean to you?
3. What would a positive test mean to you?
4. Whom would you tell if your test were positive?
5. What do you think would be the reaction of whomever you tell?
6. Do you have any questions?
7. Are you ready to get your test results?

If the client says “yes” the counselor opens the bag and checks for red beans. If all beans are white, tell the client that his or her test is negative. If there is even one red bean, tell the client that his or her results are positive. The counselor should say nothing again until the client speaks. Respond to client’s reaction in any way that feels appropriate.

Facilitator gives a few minutes and asks participants to switch roles and repeat the process.

After everyone has finished, invite the group to face forward. De-role the participants and say that this was merely an exercise and in no way reflects one’s status or chances of becoming infected. Ask:
How are they feeling after this exercise? Was it just a bag of beans or did you relate to the experience of getting an HIV test result?
1. What did people respond to the question about what a negative test would mean to them?
2. What did people respond to the question of what a positive test would mean to them?
3. Were those responses accurate on a medical level?
4. Whom did people decide to tell? Why? What were the reactions they expected?
5. What other questions came up in the process?
6. Did anyone actually want to look into his or her own bag of beans?
7. What motivated those who decided to turn in their beans? How did they feel during the rest of the exercise?
8. How did those who tested negative feel?
9. How did those who tested positive feel?
10. Did anyone feel or fear stigmatization?
11. There was no mention of confidentiality in the exercise. Is confidentiality something that is important to them in a situation like this?
12. What tone did the counselor use to give the results? Would they have preferred a neutral tone? What words did they use?
13. Overall, how did you as a client respond to the counselor?
14. What additional information would you need in a counseling session?
15. What kind of follow up support do you think you would want?

Ask if anyone in the room has actually been tested for HIV. Would they like to share about that experience? What motivated them to get tested? Who did they feel waiting for their results? Whom did they tell about getting tested? If they had counseling, what was that like for them?

Invite anyone in the group who has done HIV counseling in Bhutan to share his or her experience with the group? Pass out lab slips and have them explain what it means? Difference between and ELISA and a confirmatory test? Length of time for results to come back? How important is confidentiality to the client? Why? Where do they give counseling sessions? What is the major content of pre-test counseling? Of post-test counseling? What kinds of questions do clients have? What kind of support do clients ask for? What is the process for partner referral?

Thank everyone for their participation, and mention that after break we will be watching a video with vignettes of people who have tested positive for HIV, and will learn about their experiences of living with HIV/AIDS.

Stigma and Discrimination

Stigma and Discrimination—Some definitions (10 minutes)

1. WRITE the following terms on the flipchart and guide a brief discussion about the definition of each, asking participants for specific examples of each type of stigma:
• Self-stigma: self-hatred, shame, blame, people feel judged by others so they isolate themselves
• Felt stigma: Perceptions of feelings towards people living with HIV
• Enacted Stigma: discrimination; denying HIV+ people rights to goods, services, legal rights
• Stigma by association: sometimes felt by those who teach about HIV/AIDS or work with HIV/AIDS—these HIV/AIDS educators, counselors, and so on may experience stigmatization from others based on their association with HIV/AIDS

Techniques for combating stigma: The Hot Seat (Remainder of session)

1. Examples of hot seat statements are:
• People who sleep around deserve to get AIDS.
• Don’t stand to close to him. I hear he has HIV.
• I feel sorry for children who get HIV.
• I thought some AIDS victims were going to talk to us today.
• I don’t know why people with HIV in Bhutan are so afraid to tell anyone about their disease. It’s not so different from leprosy or any other disease.
• If I got AIDS I would kill myself.
• I don’t want my children to go to school with a kid who has AIDS.
• That woman over there is really skinny. I bet she has AIDS.
Now the person in the hot seat role-plays someone who is HIV+ and has come out to the group.
• So, how did you get it?
• (Move chair a distance away and ask) So how do you like the training?
• You should have thought about your family before you had sex.

Resource: YES Bhutan yes/bht/2006-dwangmo/file