Pathfinder International Technical Guidance Series Number 6

Ellen Israel
Carlos Laudari
Cecilia Simonetti
Publication Date
June 1, 2008

Pathfinder International (Israel) and Pathfinder do Brasil Association (Laudari, Simonetti)

This 45-page publication describes approaches to working with populations especially vulnerable to HIV/AIDS. The document outlines strategies effective in prevention of HIV/AIDS among sex workers (SW), men who have sex with other men (MSM), and injecting drug users (IDU). Programmes described include peer education, comprehensive health services and quality of treatment, provider referral networks, and in-service training and sensitisation.

According to the Executive Summary, these three vulnerable populations, despite stigma and discrimination, as well as discriminatory legal frameworks in many countries, have been among the most efficient players in slowing the HIV/AIDS epidemic, where they have been given, or demanded, a voice. "Based on several thorough situational assessments of the levels of individual, programmatic, and social vulnerability in which they live, effective HIV prevention strategies for these groups should integrate three key elements: 1) identify, develop, and pursue community-determined and -led actions to change individual and social behaviors that reduce risk of HIV infection; 2) guarantee equal access to comprehensive quality health services; and 3) promote respect of fundamental human rights." This technical guidance document is a guide to understanding the vulnerability of these groups and to planning practical action and intervention based on full participation and guidance of each group, as a client-centred approach to prevention and treatment.

The document states that vulnerable groups must develop their own civil society organisations (CSOs) for prevention and rights recognition that can give voice to their community and develop a network of partnerships with other community-based and government entities. This is supported by the community empowerment model, which fosters social integrations and group cohesion, builds social capital, and increases social inclusion.

As stated here, behavior change communication (BCC) programmes "focusing on the dissemination of information related to “healthy” behaviors, which is usually designed without the participation of vulnerable group members, ... fail to change attitudes and mold behavior by simply providing large amounts of information." Focusing on the "must do's and must not do's ... seldom ha[s] meaning in the priorities and daily struggles of vulnerable communities...Cultural sensitivity within the AIDS epidemic means listening to and respecting the cultural diversity of individuals vulnerable to HIV/AIDS: their life styles, sexuality, values, norms, and rules for daily living. The process of developing communication campaigns and educational materials absolutely must include the participation of the groups to be reached, if they are to be relevant and effective."

Two tools that are cited as examples are the Talking Points booklet and Hot Spot calendar created by Pathfinder's Mukta Project in Pune, India. The former is a palm-sized flip book talking tool for peer educators with messages and pictures identified by the community. The latter was created in conjunction with the SW community as a planning and vulnerability and risk tracking tool.

The role of peer educators among SWs requires group acceptance for a face-to-face approach favouring real change in behaviours, beliefs, and attitudes. A problem in the peer approach is that educators sometimes cease to see themselves as prostitutes and risk stigmatising their group as they distance themselves from the profession. "Someone chosen as a peer educator must be able to withstand stigma and continue to stand with her peers and be given ongoing project support for that role."

Establishing regular sex worker community meetings to facilitate discussions about work, safety, and life issues affecting members of the group (police violence, inaccessibility of health services, safety with clients, care for children) can lead to the development of action plans to confront these issues collectively. This activity, as stated here, is the most likely to guarantee the spontaneous formation of self-help groups. Meetings might include experts from related areas of interest (lawyers, social workers, beauticians, policy makers, and journalists) and "a balance of light issues (like beauty and fashion tips, and healthy cooking) with more substantial ones (safer sex practices, partner negotiation for condom use, legal assistance, gender-based violence)" in a neutral safe haven. Encouraging artistic expression, including plays involving sex workers as actors and production of videos and films, as well as viewing commercial films with sex workers as main characters, may raise self-esteem and self-acceptance. The document suggests that "the establishment of sex worker community radio is an easy, agile, dynamic and efficient channel for the dissemination of information to the community."

Working with brothel owners can give workers more permission to participate in groups. If helped to recognise that the health of their workers and clients is key to profitability, owners can also be recruited as peer educators. Attempts to reach street workers not connected to brothels or groups can be made through peer educators and leaflets. Male group discussions might be conducted through community organisations, unions, or associations.

Advocacy projects to claim rights in society may be possible out of collective spaces established for the interaction of various groups (like women's or human rights groups) or social spaces open to students, artists, teachers, and members of social movements for interacting with members of vulnerable groups. These can include marches and days of celebration.

The particular needs of MSM are related to the differences among them in their orientation or self-identification. Educational and informational materials must address these differences and their rights alongside the health issues. Community meetings and workshops initiated from within the communities may only reach openly gay men. Sensitising teachers and law officers through training is an important aspect of addressing vulnerability in this group, particularly among adolescents.

Suggested strategies for addressing the IDU group include: community mobilisation (e.g., soccer tournaments and music workshops); training of peer educators, sensitisation of health workers to stigma, meetings of parents and spouses of IDU; and sensitisation of police to curb both unnecessary violence and discrimination towards IDU, along with harm reduction

In addressing societal change, communication strategies include "collective action (meetings, campaigns, advocacy, social mobilization) to overcome stigma and prejudice associated with vulnerable populations, questioning the social and religious norms that perpetuate gender inequalities, as well as traditional views about what it means to be a man or a woman." Message channels for those who do not affiliate with a group or those who prefer anonymity include hotlines, websites, and large awareness-raising events.