Barriers To Synergy: The De-linking of Sex and AIDS

1. Barriers To Synergy:The De-linking of Sex and AIDS Caroline HaworthDirector Policy & ProgrammesInteract Worldwide

2. Structure of Presentation • Introduction to Intimate Links • Barriers to Synergy: an Overview • Institutional Barriers: The Health System… • Demand-Side Barriers: Sex, Gender, Power… • Intimate Links Call to Action

3. Barriers to Synergy: an Overview • Demand-Side Barriers: Sex, Gender, Power… • Institutional Barriers: The Health System… • Ideology & Global Power • Financing Barriers: Aid Architecture • Evidence Gaps

4. Institutional Barriers:The Health System… • Health system & HIV/AIDS infrastructure and planning • Service delivery infrastructure • Lack of coherent systemic role for CSOs • Human resource capacity; overburdening • Service mix: RH/MCH, SH and HIV/AIDS silos; lack of SRH services for people living with HIV/AIDS • Service quality: stigma & discrimination inhibits health equity; exclusion of positive and young people, males who have sex with males, sex workers, drug users • Strategic health communications: BCI

5. Evidence from Pakistan Shehla Zaidi & Susannah Mayhew London School of Hygiene & Tropical Medicine

6. Key Findings • Little integration in policy, programmes or services • HIV/AIDS identified as an independent issue, separate from the RH spectrum • Separate, compartmentalised communities identifying with different target populations • RH community has public health / medical approach targeting the general population as opposed to SRH approach (positive sexuality / rights based) • Narrow, donor driven HIV prevention agenda (condoms and needles); very limited understanding of SRH&R

7. Key Findings 6. HIV/AIDS community itself has ‘dynamic of isolation’: resistance to care-seeking 7. RH community see HIV/AIDS agenda as donor driven and diverting resources from RH 8. Lack of ‘bedding-in’ of HIV/AIDS agenda and deeply entrenched negative attitudes to vulnerable groups 9. Different NGO circles; different scale and management capacities, highly divided: low trust, high competition 11. But – NGOs from both ‘communities’ made tangible progress in last 2 years

8. Demand-Side Barriers:Sex, Gender, Power… • Strong demand-side and rights factors supporting integration, but also important, context and community specific demand-side barriers • These rooted in contexts of denial, stigma & discrimination, and severe inequities • Supply-side-only approaches to designing services inadequate; will fail re vulnerability and health equity • Most compelling current example of that: testing • Demand-side barriers are potentially mutable, and should form priorities for intervention

9. Evidence from Malawi

10. Key Findings • Clear implications of an underlying context of poverty, disempowerment and lack of control • Protecting children a significant motivator for VCT: single and married women face different decision factors • Barriers around VCT are very different from those around SRH: poor emotional care in the public health system is a significant barrier to VCT but not to ANC; waiting for SRH services is seen as opportunity to socialise, for VCT lack of assured privacy a major barrier • Issues around demand for VCT much more complex than SRH: fear of infection a major deterrent

11. Young Women’s Narratives “They say HIV is dangerous and deadly, it’s a disease with no cure. It can be spread through sexual intercourse – a disease from up above and also a disease from the spirits”. “There was this other woman who was found HIV positive and was advised by the staff not to be become pregnant, but she went ahead and became pregnant. When she went back to the hospital, the staff were rude to her, so she decided not to go back to the hospital and she ended up delivering at home. Her baby later died. As we are talking the woman is very sick”.

12. Young Women’s Narratives “…more people are visiting [private clinics] for antenatal care because they are afraid of getting tested at the government hospital…It’s different for women, because anyone who is pregnant, whether she likes it or not, she has to go for a test.” “When she went there it was found that she had already started suffering from HIV/AIDS. When she was told she fainted and died on the spot” “God is punishing them because of their bad behaviour of having careless sex; they are unfaithful people in their families. Women who go for VCT, they are despised by their friends”.

13. Call for Action • Increase global commitment and momentum • Strengthen the evidence base • Use existing mechanisms to maximise synergy and oppose / reduce institutional and financing barriers • Establish a Global Task Force • Strengthen capacity • Promote partnership

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15. Barriers To Synergy: The De-linking of Sex and AIDS Caroline HaworthDirector Policy & ProgrammesInteract Worldwide thank you