Purnima Mane

Coming to terms with complexity : a call to action for HIV prevention

A quarter of a century of AIDS responses has created a huge body of knowledge about HIV transmission and how to prevent it, yet every day, around the world, nearly 7000 people become infected with the virus. Although HIV prevention is complex, it ought not to be mystifying. Local and national achievements in curbing the epidemic have been myriad, and have created a body of evidence about what works, but these successful approaches have not yet been fully applied. Essential programmes and services have not had sufficient coverage; they have often lacked the funding to be applied with sufficient quality and intensity. Action and funding have not necessarily been directed to where the epidemic is or to what drives it. Few programmes address vulnerability to HIV and structural determinants of the epidemic. A prevention constituency has not been adequately mobilised to stimulate the demand for HIV prevention. Confident and unified leadership has not emerged to assert what is needed in HIV prevention and how to overcome the political, sociocultural, and logistic barriers in getting there. We discuss the combination of solutions which are needed to intensify HIV prevention, using the existing body of evidence and the lessons from our successes and failures in HIV prevention.

Gender and HIV/AIDS: What Do Men have to Do with it?

The world is facing an unprecedented crisis as a result of HIV/AIDS. The global epidemic is the most devastating in human history - shortening many lives and affecting the economic and social structure of many countries. Central among the factors influencing vulnerability to infection and its consequences are systems and structures of gender. Dominant ideologies of gender influence how women and men see themselves and the social relations into which they enter. While growing attention is being given to the position of women in the epidemic, less attention has been focused on men. This article explores the usefulness of concepts of masculinity for our understanding of HIV/AIDS-related risk and vulnerability. It examines the variable nature of masculinity, as well as its dominant, subordinate, alternative and oppositional forms, and how these impact on the vulnerabilities of men in this epidemic. It highlights the necessity for a more balanced understanding of gender as a set of structures created by, and affecting, both women and men. Some strategies and options for change are also discussed.

Combination HIV prevention

Michael Merson a, Nancy Padian b, Thomas J Coates c, Geeta Rao Gupta d, Stefano M Bertozzi e, Peter Piot f, Purnima Mane i, Michael Bartos f , for the Lancet HIV Prevention Series authors g h Although we applaud David Wilson and Daniel Halperins endorsement of the UNAIDS call to “know your epidemic and response” (Aug 9, p 423),1 they seem to imply an unfortunate narrowing of HIV prevention to just one or two stand-alone “interventions”. The real world of HIV programming is not so simple.

Gender relations, sexual communication and the female condom

Abstract An exploratory multi-site study supported by the World Health Organisation and UNAIDS was conducted in Costa Rica, Indonesia, Mexico and Senegal to examine the extent to which womens capacity to negotiate safer sex might be enhanced by the introduction of the female condom. Data were first collected on prevailing gender relations, sexual communication and negotiation. This was followed by the distribution of the female condom and a locally designed intervention devised to develop womens knowledge and confidence in relation to their bodies, health and sexuality. In each of the four research sites, two groups of women were involved: one consisted of women engaged in sex work, the other of women from a range of backgrounds which varied across the sites. The introduction of the female condom was particularly successful in enhancing sexual communication between sex workers and clients, in couples where the man was already supportive of family planning, in a context where men were reassured that acce...

Young people, sexuality and relationships

Put the words `youth’ and `sex’ together and you are sure to generate controversy. In the popular imagination, youth is supposedly a moment for sexual `experimentation’ and risk taking. And in the eyes of many professionals, `adolescence’ is still characterized by the storm, stress and uncertainty first written about at the turn of the century. At the same time, however, there are forces that encourage us to see young people quite differentlyÐ as somehow ìnnocent’ and in need of protectionÐ individual s who need support and guidance if they are successfully to make the transition to adulthood. The existence of these con ̄ icting images of youthÐ the negative and sometimes condemning, and the positive and more seemingly romanticÐ poses major challenges for an adequate understanding of young people and their needs. Nowhere is this challenge greater than in relation to young people, sexuality and relationships.

Sex, Drugs and Young People : International Perspectives

Chapter 1: Introduction Peter Aggleton, Andrew Ball and Purnima Mane Section 1 The structuring of vulnerability Chapter 2: Young people, poverty and risk Kim Rivers, Peter Aggleton and Andrew Ball Chapter 3: Gender, vulnerability and young people Rita M. Melendez and Deborah L. Tolman Chapter 4: Ethnicity, culture, drugs and sex Carol Jenkins Section 2 Young people, sex and drugs Chapter 5: Young people, sexual practice and meanings Deborah Keys, Doreen Rosenthal and Marian Pitts Chapter 6: Young people and illicit drug use Neil Hunt Chapter 7: Drug use among same-sex attracted young people John Howard and Anthony Arcuri Chapter 8: Drinking behaviour, coming of age and risk Sandra Bullock and Robin Room Section 3 Special circumstances, special needs? Chapter 9: Sex, drugs and vulnerability - young people who sell sex and use drugs Cheryl Overs and Chris Castle Chapter 10: Young migrants, refugees and displaced people Mary Haour-Knipe, Linda Eriksson and Danielle Grondin Chapter 11: Young people, the military, sex and drugs Martin Foreman Chapter 12: Young people in detention Jan Copeland, John Howard and Anthony Arcuri Chapter 13: Sex, drugs and indigenous young people Sherry Saggers, Dennis Gray, & Philippa Strempel

HIV Prevention, Gender and Sexual Health

Abstract Drawing on a review of relevant literature as well as global experience, this paper focuses on aspects of the growing feminisation of the HIV epidemic, especially the combination of age and gender which makes young women particularly vulnerable to HIV. It also briefly touches upon the gender-constructed vulnerability of young men. The linkages between gender, sexual health and HIV-and what works to forge these linkages-have now been well established. Not acting on the basis of this knowledge in order to avert millions of infections and deaths due to HIV, is no longer an option.

Enabling positive change: Progress and setbacks in HIV and sexual and reproductive health and rights

ABSTRACT At a point in history when the future of sexual and reproductive health including HIV looks particularly uncertain, it is helpful to recognise that many of the challenges currently faced are neither new nor insurmountable. Reflecting on past achievements and lessons learned helps us to have confidence that positive change is feasible. This paper reflects on some of the changes observed in countries like India and Mozambique and identifies a range of factors which need to coalesce to enable these developments, along with specific contextual factors. It is the combination of these influences rather than any one of them alone that brought about the change in the three instances described – fostering a positive political response to HIV in its early years in India; bringing about policy reform on abortion in Mozambique; and increasing contraceptive prevalence and age at marriage in some districts in Bihar, India. Change is always fragile and susceptible to setbacks, but change-seekers can learn in the process and gain renewed hope that progress can and often does take place if they persevere.

Some thoughts on disrespect and abuse in childbirth in response to FIGO’s Mother–Baby Friendly Birthing Facilities Initiative

Women everywhere deserve respectful, affordable, quality maternal care. The guidelines for mother–baby friendly birthing facilities recently developed by the International Federation of Gynecology and Obstetrics (FIGO) Safe Motherhood and Newborn Health Committee [1], which propose certification of health facilities that meet 10 essential criteria, are an important contribution to that end. Like FIGO, Pathfinder International has observed that facility delivery/skilled birth attendance does not guarantee qualityofcareorareductioninmaternalmorbidityandmortality. Quality of care can still be absent in facilities, thus countering the usual health benefits of skilled birth attendance over home birth. Pathfinder salutes FIGO’ sM other–Baby Friendly Birthing Facilities Initiative as an important step toward eliminating disrespectful treatment within maternity care, as well as improving quality of care during pregnancy, birth, and the postpartum period more generally, which is so sorely needed given the greater-than-expected and unacceptable remaining burden of maternal and newborn mortality in the post-Millennium Development Goals context. The guidelines also prompted renewed discussion among Pathfinder staff about respectful care, specifically with regard to government accountability, community engagement, and a rights-based approach. The guidelines are both appropriate and comprehensive. But what will it take for them to be embraced and implemented universally? It will first require, of course, a combination of persuasion and improved conditions—for the mothers and babies, but also for the providers and staff charged with caring for and safeguarding them. Several measures will be necessary—e.g. provider education and staff training that infuses a rights-based approach to maternity care; high-quality mentoring that continually promotes the same; integrated supervision whereby providers are trained and motivated to ensure continuous quality improvement themselves through collective responsibility and true provider-client partnership; and communities that are capacitated to continually intervene around quality and rights, particularly respectful care (e.g. community-facility co-management committees). FIGO’s guidance spells out enabling measures, but how can we guarantee that the necessary changes are made and sustained within countries? Currently, there are no consequencesfor noncompliance to ensure accountability by governments—either national or local—that are ultimately responsible for providing the necessary resources and other support to make the needed changes by allocating more of their budgets to maternity care and health in general. FIGO’s suggested solution lies largely in the hands of the professional associations within countries and entities like the White Ribbon Alliance, International Pediatricians Association, and WHO to push governments to comply. There must be real consequences for governments who do not vigorously and successfully address this current unacceptable abuse of fundamental human rights and the resulting loss of life and health. As implementers, we must also determine how we will help health workers and health systems respond to the needs of communities and clients, which will require more than adoption of static clinical policies. Dynamic feedback mechanisms that allow individual clients to report cases of abuse or poor treatment (and positive experiences too) are an important part of identifying problems and holding providers accountable. To be effective, feedback mechanisms must be accompanied by education for clients on their rights so that they know that demeaning care is not acceptable, and by an administrative system capable of acting on the reports of bad (and good) service experiences to provide censure, recognition, or support in response to client feedback. Furthermore, broader community feedback on the quality of maternal and newborn health services should occur through co-management structures (e.g. health committees) and requires both that communities become aware of their right to respectful care and an administrative commitment by the health system to respect community preferences, including traditional birthing practices, when they do not put the mother or baby at risk. Finally, theguidelinesframedisrespectandabuse asarightsissue—a position Pathfinder agrees with wholeheartedly. Unfortunately, in debates and literature on disrespect and abuse in childbirth, the bulk of the responsibility for demanding and ensuring that these rights are fulfilled is often placed on individual women themselves. What is really needed is for communities to rally in support of women and hold the system accountable. Since so many of the causes of disrespect and abuse—such as prejudices related to gender, class, education, ethnic origin, and age—are socially rooted, it is absolutely essential that the community be fully engaged in preventing disrespect and abuse and demanding respectful care. A rights-based approach to respectful care has to be about meaningful community mobilization and social change. Pathfinder would like to reiterate its appreciation for FIGO’ sc ontribution to this critical issue and looks forward to continued discussion and collaboration on ways forward.