Challenges in HIV Prevention: Experiences from Mozambique

1. Challenges in HIV Prevention: Experiences from Mozambique Rebecca J. Vander Meulen, MPH Diocese of Niassa Anglican Communion rvandermeulen@fastmail.fm +258 82 668 9990

2. 300 Anglican congregations 29 active priests 600 lay leaders 35,000 congregants area of 175,000 mi2 5% of congregations in urban or peri-urban areas; 95% in rural areas 104 active congregational teams responding to HIV and AIDS since first training started in 2004 Diocese of Niassa

3. Diocese of Niassa project area: northern Mozambique (provinces of Niassa, Cabo Delgado, Nampula, Zambezia, with particular emphasis in Lake District, Niassa Province) Africa • project area distant from capital, Maputo • particular project communities distant even from provincial capitals (5% of congregations in urban or peri-urban areas; 95% in rural areas)

4. Church as Partner: Deep Reach

5. Objectives: • Mobilized local congregations work towards • Reduction and mitigation of the negative consequences of HIV (psychosocial, physical, and emotional) and • Reduction in HIV prevalence • HIV and AIDS response teams (Equipas de Vida) are community groups that respond to the challenges they identify related to HIV and AIDS

8. Baseline data, among church HIV activists, April 2005 • participants report an average of 2.0 partners in past year (maximum 6), and an average of 6.0 lifetime partners (maximum 24) • average age at first sexual intercourse: 16.6

9. Sexual Debut among Church Youth, Niassa • “Girls start having sex at an early age, around age 13, because they want partners that can take them out, buy them hair extensions, and make them look beautiful.” • “Normally you have to have at least 3 partners, both boys and girls, no one has only one, so there would be no reason to have only one partner.”

10. Sexual Debut among Church Youth, Niassa • “At about 13 or 12, when your body begins to change, you’re curious and want to explore, so you have sex then just to try out what you’ve heard or seen in TV shows” • “When adolescence starts, we are really stimulated and you really want to grow up, and the only way to prove that you are grown up is by having sex.”

11. Common Biological Misconceptions • “Sex is a biological necessity that you can’t live without.” • “No one normal can live without having sex.” • “When boys don’t have sex they develop big breasts; when girls don’t have sex their breast don’t develop.” • “When girls don’t have sex they become sick and weak and even get pimples on their face.” • “When boys don’t have sex their sperm rots inside them and they can go crazy.”

12. Cultural Factors • unhago (initiation rites): girls and boys of the Yao people group participate in initiation rites between ages 8 and 14, boys are encouraged to have sex, and girls aren’t encouraged not to say no, at least the first time they are asked

13. Behavior Change Promotion • Appropriate for the church: • Low resource • Connected with morality • Requires integrated approach • Difficult for the church: • Talking about sex (particularly addressing one’s own sexuality) is not natural! • Requires a solid understanding of HIV, and a comfort in discussing it

14. Foundations for Behavior Change Promotion • Combating stigma: • Equipas de Vida, not Equipas de SIDA (Life Teams, not AIDS Teams) • “In Christ there is no difference between positive and negative.”

16. Foundations for Behavior Change Promotion • Addressing stigma • Education about how HIV is (and is not!) transmitted, and how to prevent it

17. “Biology Basics” booklet • 40 pages, made from 5 A4 pieces of paper • Responds to the local misunderstandings about HIV

18. Door-to-door mobilization campaigns

19. Foundations for Behavior Change Promotion • Addressing stigma • Education about how HIV is (and is not!) transmitted, and how to prevent it • Care and support

20. Church as Partner: Tradition of Caring

21. Key teaching: Sex is a gift from God, not a result of sin So God created man in his own image, in the image of God he created him; male and female he created them. God blessed them and said to them, "Be fruitful and increase in number; fill the earth and subdue it.” . . . God saw all that he had made, and it was very good. For this reason a man will leave his father and mother and be united to his wife, and they will become one flesh. The man and his wife were both naked, and they felt no shame. From Genesis 1-2 For you created my inmost being; you knit me together in my mother's womb. I praise you because I am fearfully and wonderfully made; your works are wonderful, I know that full well. Psalm 139:13-14

22. Key teaching: appropriateness • Fuel—great for making a car run, bad if we drink it when we’re thirsty • Fire—cannot live well without it, but it has the power to destroy and kill • Sex—a gift from God that can be used marvelously or destructively

23. Key teaching: your life has value!

24. Key teaching: HIV is like a thief, and our response should be as comprehensive

25. Strategy: Basic Education Though education about HIV often has little impact on behavior, its impact tends to be great where there had previously been no knowledge of HIV.

26. Strategy: Include everyone

27. Strategy: engage church leaders as active members of the Equipas de Vida • Priests receive an HIV component during every clergy training session • Priests receive sermon notes and bible study guides addressing HIV

28. Strategy: Engaging Youth in Support for People Living with HIV • HIV becomes real • Youth gain sense of purpose

29. Strategy: Peer Education

30. Strategy: “Estrelas de Vida” (“Stars of Life”) • “I never even thought about abstinence before. It sounds like a good idea but I didn’t know it was possible”

31. Condoms: Exposing Myths • “Condoms transmit HIV. After all, when you fill it up with water and let it sit, after a few days the little bugs start swimming around.”

32. Condom/drinking water analogy • drinking water from a public borehole: SAFE and “LEGAL” • drinking water from a public mud puddle: UNSAFE, though “LEGAL” • drinking water from the governor's borehole (inside his fence/quintal): SAFE, though “ILLEGAL” • drinking water from the governor's mud puddle (inside his fence/quintal): UNSAFE and ILLEGAL

33. Not a “jeito” campaign! ‘. . . the messages they gave at 12 o’clock when the whole family was gathered around the lunch table was “when you have sex next time with your lover do not forget to use a condom”. Those songs, dramas made the churches close up even more as they felt that the way sex was talked about, the way it was promoted encouraged immoral behavior. . . . So the way PSI came in and talked about HIV/AIDS prevention and condoms made it more difficult for us to talk about the issue in the church’ (Pfeiffer 2004: 92).

34. Condoms: placing them in a broader medical context Where good family planning education has occurred, condoms become far more acceptable (as they are not simply related to HIV).

35. Condoms: specific teaching depends on local context

36. Cautious Promotion • “Our children are just used to having sex. It’s the main type of entertainment. It wasn’t like this. With my wife, it was just when we got married. But today, it’s sex. It’s worth explaining to our children how to use condoms.” • A priest whose daughter died of AIDS