Issue Contents    HIV prevention - keys to success Principles of prevention What works best? Prevention in practice More than a health issue Community support Overcoming prejudice Building solidarity Health worker stress Building on success Clinical update HIV-related diarrhoea The right psychology Resources

In this issue   What work best? Page 2 More than a health issue Page 3 Community support Page 4   Overcoming prejudice Page 5  Building on success Page 6  Clinical update: diarrhoea Page 7

Successful strategies 
A review of HIV prevention programmes worldwide shows that the most successful programmes:
  

	involve the community
	build partnership and trust between people
	involve people with HIV in all stages
	develop the skills and knowledge of the community
	create an open and accepting environment
	involve other sectors as well as health (multisectoral)
	win support from people in power
	are carefully planned and evaluated
	recognise that even well planned approaches sometimes fail.

Successful programmes have several components, which together make up a good prevention package:

information about HIV transmission 
activities to encourage people to assess risky behaviours
training in communicating about sex and drug-related issues 
access to resources such as condoms and appropriate health services.

People's concerns
HIV prevention is rarely a person's only concern. It is important to:
 

	begin with people's own interests and needs
	involve people in the design and implementation of the project
	recognise the realities that people face in their daily lives
	focus on the sexual health of men as well as women
	examine the positive aspects of sexual health, including pleasure and enjoyment, as well as problems such as unwanted pregnancy and sexually transmitted infections
	link sexual health to people's broader concerns.

Young people are often targeted with HIV prevention messages by adults. It is especially important to begin with their interests, encourage their participation, and link HIV issues into broader concerns, such as relationships, families and plans for the future.

Injecting drug users are at risk of HIV from both sex and sharing injecting equipment. HIV prevention strategies also include:

	stopping injecting drugs, which may mean switching to non-injected drugs (this is the safest option)
	using sterile needles and syringes, and not sharing them (safe if done every time)
	cleaning equipment between use (safe but difficult to do properly).

There is evidence that drug injectors can and will change their behaviour to reduce HIV-related risks. 

Sex workers and men who have sex with other men Sex work and sex between men are highly stigmatised and illegal in some countries. For these reasons, these groups can be difficult to reach. The best way may be through community-based outreach workers or peer educators.

Essential evaluation Evaluation is essential to the success of HIV prevention programmes. Evaluation can provide useful feedback for developing the project. Many projects are not evaluated because of pressure on time and resources. However, evaluation need not be expensive or time consuming if the aims and activities of the project are properly thought out and written down before the project begins.

New opportunities
New technologies are continually becoming available. Vaginal microbicides, which kill HIV and other sexually transmitted infections, are being developed. In some countries, the female condom is becoming more available and affordable, providing more choice, especially for women whose partners are reluctant to take responsibility for sexual and reproductive health.

Sources: HIV prevention works. In: Highlights from an official satellite symposium of the XI International Conference on AIDS, Vancouver. Ottawa: Canadian Public Health Association.

Sexual behaviour and HIV/AIDS: a review of the effectiveness of health education and health promotion. Aggleton, P. Utrecht: Landelijk Centrum GVO for the International Union for Health Promotion and Health Education and the Commission of the European Communities, 1994. 

Success in HIV prevention - some strategies and approaches (see page 8).

Peter Aggleton, Director, Thomas Coram Research Unit, Institute of Education, 27/28 Woburn Square, London WC1H 0AA, UK. 

Participants found that the HIV programme had not been working well, because it had been difficult for the committee to meet.

Sector heads were often not available for meetings. The PHC structure at community level was also weak, because it relied mainly on the health sector. 

So the workshop decided to set up a multi sectoral 'AIDS-Action' team, consisting of the district planning officer (chair); district AIDS control coordinator, who is from the health sector (secretary); and representatives of the planning, health, development, culture and education sectors and NGOs. The aims of the team are to:

	represent relevant sectors and NGOs
	plan and coordinate all AIDS-related activities at district level
	mobilise resources for HIV/AIDS prevention activities at district level
	meet quarterly and report to the district PHC committee.

The new arrangement works much better. The secretary of the AIDS-Action team liaises directly with heads of departments of the various sectors. The district planning officer, as chair, provides a strong link with the district council, since he also plans council meetings and proposes the council budget. 

The team's main contact with the local community is through the social services committees (part of the village government, responsible for water, education and health). These committees run activities such as local drama groups and contribute in cash or kind to HIV prevention campaigns.

Supporting councillors
District councillors have often found it difficult to know how to spend their limited budget. The AIDS-Action team has helped to identify priorities by organising a 'mapping' programme to identify areas of high HIV risk. The team asked separate groups of men and women, including young people, to draw a map of their community, showing places where they felt at risk of getting HIV. This was done in about 1,000 communities. The maps were used to start discussions about the problems people  faced when trying to avoid risky behaviour.

Problems and proposed solutions were discussed with the whole community, using the local drama groups. The mapping groups then proposed actions for change, which they discussed with community leaders. These included by-laws to regulate opening hours of bars, video shows and dances, and restricting petty trading to daylight hours. Punishment for forced sex has been A district AIDS-Action team is strengthening HIV prevention increased. Condom distribution has been Improved. 

Because of its link with the district council, the AIDS-Action team has succeeded in mobilising 3 per cent of the district council budget for HIV prevention programmes. Magu is the first district council in Tanzania to make such a contribution.

Change is slow
The team has had some problems, such as delayed transfer of funds from the district council. The team had to lobby the councillors and show them the mapping plans to get the funds transferred. They also needed to develop the confidence of the village social services committees to become involved in HIV prevention. 

District HIV programme officers need to keep in close contact with village communities to keep up people's enthusiasm for the programme. Exchange visits between villages, organised by the programme officers, have helped to do this. The programme is being evaluated in one ward of the district. Early results suggest a noticeable reduction in the number of partners of both men and women, although condom use does not appear to have increased.

Dick Schapink, Dr Ng'weshemi, Betty Chiduo, Deus Mayunga, Venance Nyonyo, TAN ESA, PO Box 434, Mwanza, Tanzania.

The session starts with a discussion about the health situation in the village. The discussion inevitably leads to HIV and how the community is coping. Members of the group then draw a map of the village. They discuss people and organisations from whom medical, psychological and economic support may be sought for HIV-affected families. They draw these on the map. Resources may include:

	medical support (including home-based care) - district hospital, village primary health care centre, traditional healer, places to obtain herbal medicines, village volunteers, local drug store, Buddhist monks, family members
	psychological support - religious institutions, teachers, local groups of people with HIV, respected people in the village, health centre staff, district doctor, family, neighbours
	economic support - existing groups such as sewing groups or farmers, village heads, local employers, village revolving funds, provincial public welfare office, relatives, schools, projects that provide assistance for children or occupational support (such as grants or revolving funds, technical advice or marketing support).

The groups are asked three questions about each resource: 
 

	Is it being used?
	If not, what is preventing it from being used?
	If it is, how can it be made more useful?

Making plans
The discussions may take several sessions to complete, depending how interested the group is and how detailed the discussions are. In villages with a group of people with HIV, separate discussions are held with this group.

By the last session, the group is more aware of the needs of affected families and the potential role of the community in helping to meet those needs. The discussions lead to action plans to make better use of the resources.

Results of the discussions are entered onto the map or listed on newsprint paper kept in the village. The maps and lists are reviewed from time to time to see whether use of local resources has improved.

After the mapping exercise, the community's awareness of sources of support, and ways in which the community itself can help affected families, has grown significantly, particularly among families with HIV-positive members. Greater awareness has also led to positive attitudes to families affected by HIV.

Prom boon Panitchpakdi, CARE International in Thailand, 185-187 Phaholyothin Soi II, Phaholyothin Road, Bangkok 10-100, Thailand.

Project Arayé ('to be alive') was started in 1996 to tackle issues of race and HIV. It recognises that Afro-Brazilians contribute to the country's culture, but do not benefit from their contribution. It is staffed by Afro-Brazilians with a knowledge of health issues and Afro-Brazilian culture. They include an Afro-Reggae percussionist, a youth worker from a shanty town, and a priest who is also a community health worker. 

A key challenge has been to over-come denial of HIV and encourage Afro-Brazilians to recognise that HIV affects them. Community leaders are supported to link sexual health and HIV with other health concerns that affect Afro-Brazilians, such as sickle cell anaemia, diabetes and leprosy. Leaders range from religious leaders to rap musicians, artists and people respected by their peer group - often the most rebellious and anti-establishment people.

The project builds on religious and cultural traditions. Activities include visits to samba dance schools, Umbanda and Candomblé temples (the two main Afro-Brazilian religions) and street youth groups, to provide information about HIV. A project newsletter is distributed to Afro-Brazilians who may not be aware of HIV. A health education campaign, using positive images of Afro-Brazilians, is run in magazines read by Afro-Brazilians.

Project Arayé has developed some useful links. A local hip-hop group has asked it to work with them on HIV prevention. Religious leaders are looking at herbal remedies for treating HIV infections and alternatives to razors for ritual cutting, and have started showing solidarity with HIV-positive people by giving them spiritual and practical support.

Jose Marmo da Silva, Jacinto Correa, Veriano Terto, ABIA, Av. Rio Branco 43/22, Centro, 20090-003 Rio de Janeiro RJ, Brazil.


Building solidarity
In a poor part of San José, Costa Rica, young men who have been rejected by society are learning how to build trust.

EI Salon is a centre where, each night, 20-40 young men gather. These are the 'sharks' of the street, rejected by their family and friends. They are on drugs and rely on stealing and sex work to pay for them.

Inside EI Salon, the young men settle into a routine of washing their clothes and taking a shower. Board games, puzzles and other entertainment fill their time, but they are wary of each other. There have often been disputes. 

After eight months, however, there is a growing feeling of belonging among the more regular visitors. EI Salon may be beginning to be seen as a place that cares. The project can now turn more attention to HIV prevention. A common fear is 'dying alone, with no one to care for me'. EI Salon has started to introduce the idea of making a friend or two, just in case, who would take care of you if you became sick. To gain a friend, you have to treat someone as you would like to be treated. This can be a struggle for those who have been rejected. EI Salon does not have the answers, but at least provides opportunities.

Antonio Bustamante, EI Salon, Apartado 102 42, San Jose - 1000, Costa Rica.

Activity What does a project need?  In a group, brainstorm the elements that enable a project to keep going. Ask people to write three elements on three pieces of paper. They might include:    community participation in planning the project  recognition by the community that there is a need for the project  range of funding sources competent staff  budget that the community can raise gradual growth of the project well planned activities with enough time to carry them out collaboration with other agencies.  Pin up all the pieces of paper. Ask the group to put them into three categories:  project sustainability financial sustainability managerial sustainability. Divide the group into three smaller groups. Ask each group to consider one category. Ask them to spend half an hour thinking about what your organisation needs to do in this category to enable it to develop.

Activity Who should you work with?  Thinking about who is affected by your project can lead to useful local partnerships.   Put a large sheet of paper on the wall. Write your group's name in the middle and draw a circle round it. Draw two wider circles around the circle, labelled 'community'  and 'external audiences'. Ask the group to brainstorm which groups they should be working with (such as mothers, local shopkeepers, national AIDS programme staff, donors and religious  organisations). Write them in the appropriate circles. You could also rank how important these partners are.

 

HIV-related diarrhoea

Diarrhoea is a common problem for people with HIV. AIDS Action outlines ways to prevent and treat it.

Diarrhoea is the passage of loose stools three or more times a day. Persistent diarrhoea (lasting more than two weeks) is more common in people who have advanced HIV disease than in those who do not. For many it is a major problem.

The main dangers of diarrhoea are dehydration and malnutrition. People with HIV-related diarrhoea can become malnourished and lose weight quickly, mainly because they do not eat well because of poor appetite. Also, because weight loss ('slim') is associated with HIV, a person with diarrhoea may be assumed to have HIV, and be stigmatised.

Preventing diarrhoea
Good hygiene and nutrition are the best ways to prevent diarrhoea. Drinking boiled water is best, but is often not practical. Washing hands frequently with soap is more practical. Other strategies are to: store food under a cover; wash eating and cooking utensils; wash raw fruit and vegetables; dispose of waste properly; keep anything dirty, such as soiled bedding, out of reach of children. 

To prevent and treat diarrhoea, people with HIV need nutritious food that is easy to digest (see box: 'Eating well').

Treating diarrhoea 
Common causes of persistent diarrhoea in developing countries include protozoas (microscopic organisms) such as cryptosporidia, isospora and microsporidia. Other causes include bacteria such as shigella, and probably viruses. The HIV virus might cause diarrhoea, although there is no conclusive evidence. 

The cause of HIV-related diarrhoea varies from one area to another, and is often quite localised. It is useful to identify common causes in an area, and draw up treatment guidelines for the area. Ideally, these should cover the major causes, so that people need not be investigated individually.

Adults with diarrhoea should: 

	Drink more fluids than usual.
	Continue to eat (see: 'Eating well').
	Take vitamin supplements such as folic acid and vitamins C and A, if available.
	Treat dehydration with oral rehydration salts (ORS).
	Relieve symptoms with codeine phosphate, loperamide or diphen-oxylate. These drugs reduce the pain, volume and frequency of diarrhoea, although possible side-effects include dryness of the mouth, sleepiness, loss of coordination, blurred vision and distended abdomen.
	Treat the cause of the diarrhoea with treatments such as TMP/SMX (Isospora); metronidazole (giardia); albendazole (microsporidia, crypto-sporidia). However, resistance can develop. For example, salmonella and virtually all Shigella in Zambia are resistant to these drugs, so people with HIV in Zambia who have bloody diarrhoea should take nalidixic acid and metronidazole. Also consider TB as the cause. Some traditional herbal remedies control diarrhoea.

People who do not respond to these treatments are seriously ill. The main aim should be to relieve their distress, using codeine phosphate or loperamide, and offer fluid - oral rehydration or intravenous fluids in hospital. For someone with fever, try systemic antibiotics such as intravenous or intramuscular cephalosporins. It is important to keep the area around someone with diarrhoea clean, to prevent infecting other people.

Dr Paul Kelly, Research Fellow, Digestive Diseases Research Centre, St Bartholomew's and Royal London School of Medicine and Dentistry, Turner Street, London EI 2AD, UK.

Children
Do not give anti-diarrhoeal drugs to children under five years of age. Give children plenty to eat and drink (see: 'Eating well'), plus vitamin and mineral tablets if available. Children will continue to need extra food after the diarrhoea has gone, to enable them to regain any lost weight.

For further information see 'Caring with confidence'. Details on Page 8. 

Eating well People with diarrhoea need plenty to drink and plenty of easily digestible, bulky foods containing a lot of nutrients and calories. Make foods easier to digest by cooking them well or mashing them. Encourage people with low appetites to eat small amounts often. Take plenty of:   water, soups and diluted juices cereal (such as rice) with beans, meat or fish; oil can be added to increase energy . yoghurt, eggs, bananas other bulky or juicy foods such as potatoes, water melon, barley, paw-paw, rice water, millet or sorghum porridge, steamed fruit.   Avoid:    high-fibre foods such as whole-grain cereals, or fruit and vegetable peel  sugary foods or drinks, such as commercial soft drinks, which can worsen diarrhoea (and provoke thrush) raw foods, cold foods, acidic fruit such as oranges irritating foods such as pepper. Sources: AIDS home care handbook, Global Programme on AIDS, WHO, Geneva, 1993; Food for those with HIV/AIDS. L Epstein, Cape Town, Hope Productions, 1995.

Caring with confidence: practical information for health workers who prevent and treat HIV infection in young children covers HIV transmission and prevention, diagnosis, caring for children with HIV, treatment of common illnesses, and supporting families caring for children with HIV. It is intended for health workers, educators, NGOs and those working with community organisations. who are involved with HIV prevention and with the management and care of young children with HIV and AIDS.  Free to indigenous organisations in developing countries (£10/US$20 elsewhere) from Healthlink (formerly AHRTAG).

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