My dear friends,
I was thinking today about how chaotic day to day life may become and how caught up we can get in people, places and things. I realised at work that I can learn so much from the elderly persons I take care of every day. Each day, each moment, sometimes each second is special. Ive learned to go with the flow so to speak, to stay in the moment. It doesnt really matter what happens yesturday or what I need to do tomorrow. Only that at this very moment everything is as it should be. That I need to cherish that. I need to love the people around me...I may not remember them moments later, they may pass away, move to another facility, they may not remember me.
Life is what we make it. Whether we are in flannel pajamas dependent on a walker, or a child picking his or her first dandeliion. Life is precious... and so cherish a babies cry and the soft wrinkled, age wizened hand of your elders...thes moments are priceless.

Peers provide an opportunity for teens to meet their needs, to feel capable, to belong, to be respected, and to have fun. While young people often experience these needs being met within the family, the peer group provides unique and different opportunities to meet these needs. The peer group encourages autonomy, mutuality, and experimentation with self guided roles. While many families assist teens to find out who they really are and to help teens feel proud and confident of their unique traits, backgrounds, and abilities, the peer group may often be more accepting of the feelings, thoughts, and actions associated with this search for self- identity.

Although there is a common perception that "peer pressure" is the reason for many negative behaviours of adolescents, in reality, peers are necessary and crucial in helping adolescents make successful transitions. Peers can and do act as positive role models. Peers can and do demonstrate appropriate social behaviours. Peers often listen to, accept, and understand the frustrations, challenges, and concerns associated with being a teenager.

Much research has shown that peer pressure has a much greater impact on adolescent behavior than any other factor. Think about it. Your teenager spends many more of his or her waking hours with peers than with family members. The interaction is direct, and much more powerful than the influence of teachers and other authority figures. Peer pressure tends to have more of an effect on children with low self-esteem. If a child feels compelled to fit in, the teen may do things that go against his or her beliefs simply to be part of the group.

Peer pressure can lead to experimentation with drugs and alcohol, sex, skipping school, and various high-risk behaviors. If you notice a sudden change in your child's appearance, clothing, and attitude, especially if accompanied by secretive behavior, he or she may be succumbing to the influences of peers. You should be especially alert to sudden changes in the friends who make up their core peer group. An unexplained change in the type of friends you child associates with would indicate that your child is vulnerable to new influences that may not be positive.

How can parents, who spend far less time with their children than do their peers, have an influence on their teens? Parents need to set clear expectations for behavior, establish rules about communicating where and with whom their teenagers are spending their time, and should pre-set consequences for lying about activities or where they are going. By communicating your expectations, your adolescent cannot claim they "did not know" that you would be upset.

One of the most difficult issues can be when a teen decides to hang out with the "wrong crowd." Parents often find it is difficult to control such behavior. They will lament that when they forbid their teen to hang out with certain people, those people become a virtual magnet for their teen. Often by simply setting the rules about communicating their whereabouts, you will limit the effects of any peer group. However, if you really believe that a particular peer group is negatively impacting your child, it is important to deal with the reasons your teen is being influenced in this direction. He or she may have problems with self-esteem and self-confidence and feel it is necessary to fit in anyway possible, even if it means fitting in with a negative peer group. Parents will not change the teen's attitude by forbidding access to these peers. They can only change the attitude by dealing with the primary issues that cause it in the first place. An adolescent is drawn to a particular group because it "feeds" them in some way. If they are choosing the wrong group, there is a fundamental core issue that needs to be addressed therapeutically before any significant change can occur.



Talk to your teen. State clearly that you do not have a problem with their friends as people. You understand that that your teen’s friends can make mistakes – just like your teen made a mistake. But you do have a problem with the risk-taking behavior and there needs to be a change on your teen’s part and on their friend’s part in order for you to be build an action plan with your teen. Address changing the behaviors that are concerning you in the plan and allow your teen to come up with different options to these behaviors. Learn more about the problem behavior and use your discipline skills as necessary. Limit your teens unsupervised time with the friends that were involved until you feel comfortable to slowly give back more of these privileges. You will need to be more involved with your teen at this time and offer more supervised activities with their friends.

Take caution: don’t allow your teen to place all of the blame at their friend’s feet. This is an easy out and may be the way to even bigger problems for your teenager down the road. Even if your teen’s friend was 90% accountable for the misbehavior, you still need to hold your teen accountable so that he can actively deal with the problem and move on. Part of learning how to make the right choices is learning how to deal with mistakes.



When Parents Don't Approve


You may not be comfortable about your son or daughter's choice of friends or peer group. This may be because of their image, negative attitudes, or serious behaviors (such as alcohol use, drug use, truancy, violence, sexual behaviors).



Here are some suggestions:



· Get to know the friends of your teen. Learn their names, invite them into your home so you can talk and listen to them, and introduce yourself to their parents.

· Do not attack your child's friends. Remember that criticizing your teen's choice of friends is like a personal attack.

· Help your teen understand the difference between image (expressions of youth culture) and identity (who he or she is).

· Keep the lines of communication open and find out why these friends are important to your teenager.

· Check whether your concerns about their friends are real and important.

· If you believe your concerns are serious, talk to your teenager about behavior and choices -- not the friends.

· Encourage your teen's independence by supporting decision-making based on principles and not other people

· Let your teen know of your concerns and feelings

· Encourage reflective thinking by helping your teen think about his or her actions in advance and discussing immediate and long-term consequences of risky behavior.

· Remember that we all learn valuable lessons from mistakes

It’s hard to fight drug use among teens, but it can be done. Young people are more intelligent than we often give them credit for being. If we talk with them about specific drugs and their negative effects, it will go a long way towards winning the battle against teen drug use
It’s also interesting and important to note that parental involvement plays a vital role. The strongest declines in drug use occurred during years when more parents and guardians were talking to their kids about the risks of drug use, and the kids were exposed to anti-drug messages in the media. Some statistics actually show an increase of drug use during years when parental involvement was down, even if anti-drug media exposure was up.

Factors associated with increased risk for any type of illicit drug use include at least one or more of the following:

Poor parent-child relations. Studies show that living in a stressful home environment with relatively little parental support and monitoring places adolescents at greater risk for drug use.
Family environments that model drug use. Adolescents are more likely to use drugs if someone in their home uses drugs. For example, parents who use drugs may practice poor parenting which may increase the risk of drug abuse for adolescents. Also, parental or sibling drug use sets a model of acceptable inappropriate behavior for teens, makes it seem like a normal part of life, and may encourage its acceptance by youth.
Peer drug use. During adolescence, peers become a major influence because of the increased time spent with them outside of the home. Some teens feel pressured to fit in and do what their friends are doing. Consequently, teens that have friends who use drugs are more likely to use drugs themselves.

High risk communities. Living in communities where drug use is widespread not only makes drug accessibility easier, but also normalizes the act of using drugs.
Low self-esteem. Adolescents who do not have positive views of themselves, or who lack support and encouragement from others are more likely to use drugs.
Poor school achievement. Teens who have negative attitudes toward school and low expectations of academic success are at increased risk of drug use. Also, teens who use drugs typically exhibit declines in grades, and inconsistent attendance at school.
What Are the Consequences
The effects of drug use vary by type of drug and frequency of use, however, some

consequences may include the following:

Mental and physical health problems. Teens who use drugs are at greater risk for developing a number of health problems including attention deficit disorder, anxiety disorders, phobias, and depression.

Increased likelihood of drug use later in life. Early drug use has been linked to positive attitudes toward drug use. Consequently, teens who begin drug use early are at risk for continued drug habits into and through adulthood.
Involvement in other illegal activities. Drug use has been linked to higher tolerance of deviant behavior among adolescents. This results in increased criminal activity for drug users compared to non-drug using peers.
Increased likelihood of death. Drug use increases the odds of death from accidental or intentional drug overdoses as well as engagement in other unsafe behaviors (e.g., driving under the influence).

What Can Parents Do

Communication is key in dealing with any type of risk taking behavior during the teen years. The hectic pace of work and school can sometimes estrange family members, especially parents and teens. But make the effort to keep in touch with your teen. Find out what's going on in his or her life. The best way to find out if your teen is using drugs is to just ask. During adolescence, parents may feel that their influence over their teen's life is waning, but in fact, you have more power than anyone to prevent your child from using drugs. Here are some things that you can do to encourage your child to "Just Say No."

Stay connected with your teen. Keeping up to date with your teen's interests and friends is an important step in creating a warm, communicative, and open environment. If your teen feels that you are available and easy to talk to, then he or she will be more likely to share concerns that might lead to risk taking behavior.

Begin an ongoing conversation with your teen (vs. giving a one time speech). Make it clear that drug use is not an acceptable behavior in your family and be sure to talk about the reasons why. Talk about the consequences of drug use. Help your teen visualize two futures, one that includes drug use and one that remains drug free. Where do these paths lead? Discuss your teen's life goals and how drug use can hinder them from reaching them.
Empower your teen. Teens tend to want to rebel against their parents' standards or advice. Rather than dictate what your child should or should not do, remind him or her that they have the power of choice and that you trust that they can and will make good decisions.
Teens sometimes abuse substances as a way of alleviating stress. Some experiences in life (e.g., not making the basketball team, breaking up with a girlfriend or boyfriend) are both stressful and painful. Drugs are often sought as a means of temporarily easing pain or stress. Talk to your teen about any stressful events that are going on in his or her life and ways they can effectively handle them.

Know your teen's friends. You can influence your teen's choice of peers by talking with them about the qualities that make a good friend.

Encourage your teen's self-esteem by praising their efforts and achievements. Help them to master the things that they are good at. Show them you care through your involvement in their lives/activities.
Take advantage of teachable moments. These include talking about scenes in movies or news headlines that deal with drug associated topics. Explain your position on these topics and ask your teen how they feel about what they are viewing.
Encourage healthy activities that promote the use of your teen's interests and talents. Most teens are curious and are eager to try something new and challenging. High school is the peak time for both beginning substance use and beginning lifetime habits that include using illegal substances. Your parental example, support, and monitoring has a great influence on your teen's behavior. Talk early and often about the consequences of and alternatives to using illicit drugs.

Even under stable family and societal conditions, an adolescent's passage into young adulthood is fraught with challenges. As adolescents move away from the prescribed moorings of family to stand on their own, they experience heightened vulnerability. Simultaneously, adolescents are bombarded by internal pressures and simulations. Under these pressures, they seek experiences and feelings of power, peer affiliation and certainty.

To reduce HIV&AIDS vulnerability among adolescents, there is a need to develop strategies and methods for effective curriculum focusing on sex education and life skills especially. Internalizing more participatory learning-teaching method, it is felt that a stronger integration of prevention education vis-à-vis sex & reproductive health approaches is essential for improving the high-quality HIV prevention & care. It is estimated that there are 1.2 billion adolescents in the world. Near about eighty seven percent of these adolescents live in the developing countries. More adolescents do not know what reproductive health is and how to practice safe sex. Most of them are not aware of how to undermine the vulnerability to HIV&AIDS. To make them free from such encumbrance as HIV&AIDS, we have to ensure a healthy and promising environment. It is believed that if the adolescents have qualitative reproductive health literacy ultimately HIV&AIDS prevention programs initiated by NGos will be successful.


Only effective education can ensure qualitative reproductive health literacy. This kind of literacy helps adolescents analyze thoroughly basic information, core messages, values and praxis related to HIV&AIDS prevention. Simultaneously they are able to inculcate caring and supportive attitudes towards people living with HIV/AIDS (PLHA). They possess the basic facts and information bringing about acquisition of knowledge and development of attitudes, values, skills and practices (KAVSP) as to undermining the spread of HIV&AIDS. Consequently they have profound awareness on practicing safe sex, use of condoms, gender equity, and harmful effect of early marriage, premarital sex and unplanned pregnancy.



Reducing HIV&AIDS vulnerability among adolescents may be promoted auspiciously through evaluating the attitudes and values within community based social norms/beliefs, cooperation and teamwork. From the salad days, adolescents have to be guided by active and participatory learning that they may analyze, study ideas, solve problems and apply what they learn. It is important to ensure that active learning would be fast-paced, enjoyable and personally engaging. In this regard, cooperative learning may play a vital role to make the adolescents aware of HIV&AIDS significantly. It is one kind of effective group approaches with a view to learning with common objectives, mutual rewards, shared resources and complementary roles. Through this approach, group members are stimulated to help each other to master the lesson or activity. Thus an atmosphere of mutual trust and respect are established. Eventually the learning environment is warm as well as adolescents are made to express their views, opinions, attitudes and behaviors freely.


Adolescence is the prime and sensitive period of so many physical, emotional and cognitive developments. So adolescents have to experience many changes unexpectedly. In most cases, they remain unaware of how to efficiently cope with these kinds of physical and psychological changes. Attitudes to sexuality are being developed gradually during puberty. In this time, if adolescents are misguided or deprived of acquiring reproductive health literacy they will suffer all the time in their lives. There is no doubt that sexual maturity leads to happiness and fulfillment in future personal and social relationships. So there is no alternative for adolescents to learn about issues related to reproductive health from parents, teachers and other elders for being able to understand and develop a healthy attitude.


Vulnerability to HIV&AIDS is skyrocketing in the developing countries jeopardized by lack of qualitative reproductive health literacy among the adolescents. But reproductive health literacy itself offers one of the key hopes against HIV/AIDS epidemic as well as its influential eventualities. In fighting the pandemic, reproductive health literacy comprising transfer of skills and attitudes to reduce adolescents’ vulnerabilities to HIV&AIDS is the most effective means. It is seriously necessary to reduce the fear of HIV&AIDS any how. Reproductive health literacy can do a lot to combat HIV&AIDS facilitating adolescents in attaining the knowledge, attitudes and skills that they need to delay sexual intercourse, reduce their number of sex partners, prevent illicit drug/substance use and avoid infection by using condoms.


The academic curriculum of the developing countries should provide adolescents with opportunities to learn and practice life skills, such as decision-making and communication skills, which can strengthen other important areas of early life development.

Occupational exposure to HIV
In many countries for many years health care workers have become infected with HIV as a result of their work. The main cause of infection in occupational settings is exposure to HIV-infected blood via a percutaneous injury (i.e. from needles, instruments, bites which break the skin, etc.). The average risk for HIV transmission after such exposure to infected blood is low - about 3 per 1,000 injuries. Nevertheless, this is still understandably an area of considerable concern for many health care workers.

Certain specific factors may mean a percutaneous injury carries a higher risk, for example:

A deep injury
Terminal HIV-related illness in the source patient
Visible blood on the device which caused the injury
Injury with a needle which had been placed in a source patient's artery or vein
If percutaneous exposure occurs then the site of exposure should be washed liberally with soap and water but without scrubbing. Bleeding should be encouraged by pressing gently around the site of the injury (but taking care not to press immediately on the injury site). It is best to do this under a running water tap.

There are a small number of instances when HIV has been acquired through contact with non-intact skin or mucous membranes. Research suggests that the risk of HIV infection after mucous membrane exposure e.g. splashes of infected blood in the eye, is less than 1 in 1000. If mucocutaneous exposure occurs then the affected area should be washed thoroughly with soap and water. If the eye is affected, it should be irrigated thoroughly.

If intact skin is exposed to HIV infected blood then there is no risk of HIV transmission.

Post Exposure Prophylaxis
Research evidence seems to suggest that the use of anti-HIV drugs in combination with other anti-HIV drugs if given soon after an injury can reduce the rate of transmission. Such treatment is referred to as Post Exposure Prophylaxis (PEP). PEP is recommended for health care workers if they have had a significant occupational exposure to blood or another high risk body fluid which is likely to be infected with HIV. It is recommended that PEP should be commenced as soon as possible after exposure and ideally within the hour.

Although exposure through needle stick injuries can usually be avoided by following good working practices, health care workers should consider the implications of taking PEP. This will help them to make a swift decision in the event of an accident where an injury occurs.

What are Universal Precautions
Employing universal precautions means taking precautions with everybody. If precautions are taken with everyone, health care workers do not have to make assumptions about people's lifestyles and risk of infection. Health care workers should have the right to be able to protect them against infection, whether it is HIV, Hepatitis or anything else.

The following universal infection control precautions are advised by the World Health Organization3 to help protect health care workers from blood-borne infections including HIV:

Wash hands with soap and water before and after procedures.
Use protective barriers such as gloves, gowns aprons, masks, goggles for direct contact with blood and other body fluids.
Disinfect instruments and other contaminated equipment.
Handle properly soiled linen. (Soiled linen should be handled as little as possible. Gloves and leak proof bags should be used if necessary. Cleaning should occur outside patient areas, using detergent and hot water.)
Use of new, single-use disposable injection equipment for all injections is highly recommended. Sterilizable injection should only be considered if single use equipment is not available and if the sterility can be documented with Time, Steam and Temperature indicators.
Discard contaminated sharps immediately and without recapping in puncture and liquid proof containers that are closed, sealed and destroyed before completely full.
Document the quality of the sterilization for all medical equipment used for percutaneous procedures.

Stress is the “wear and tear" our bodies experience as we adjust to our continually changing environment; it has physical and emotional effects on us and can create positive or negative feelings. As a positive influence, stress can help compel us to action; it can result in a new awareness and an exciting new perspective. As a negative influence, it can result in feelings of distrust, rejection, anger, and depression, which in turn can lead to health problems such as headaches, upset stomach, rashes, insomnia, ulcers, high blood pressure, heart disease, and stroke. With the death of a loved one, the birth of a child, a job promotion, or a new relationship, we experience stress as we re-adjust our lives. In so adjusting to different circumstances, stress will help or hinder us depending on how we react to it. How Can I Eliminate Stress from My Life? As we have seen, positive stress adds anticipation and excitement to life, and we all thrive under a certain amount of stress. Deadlines, competitions, confrontations, and even our frustrations and sorrows add depth and enrichment to our lives. Our goal is not to eliminate stress but to learn how to manage it and how to use it to help us.



Insufficient stress acts as a depressant and may leave us feeling bored or dejected; on the other hand, excessive stress may leave us feeling “tied up in knots." What we need to do is find the optimal level of stress, which will individually motivate but not overwhelm each of us. How Can I Tell What is Optimal Stress for Me There is no single level of stress that is optimal for all people. We are all individual creatures with unique requirements. As such, what is distressing to one may be a joy to another. And even when we agree that a particular event is distressing, we are likely to differ in our physiological and psychological responses to it. The person who loves to arbitrate disputes and moves from job site to job site would be stressed in a job, which was stable and routine, whereas the person who thrives under stable conditions would very likely be stressed on a job where duties were highly varied. Also, our personal stress requirements and the amount which we can tolerate before we become distressed changes with our ages. It has been found that most illness is related to unrelieved stress. If you are experiencing stress symptoms, you have gone beyond your optimal stress level; you need to reduce the stress in your life and/or improve your ability to manage it.

How Can I Manage Stress Better Identifying unrelieved stress and being aware of its effect on our lives is not sufficient for reducing its harmful effects. Just as there are many sources of stress, there are many possibilities for its management. However, all require effort toward change: changing the source of stress and/or changing your reaction to it. How do you proceed?



1. Become aware of your stressors and your emotional and Notice your distress. Don't ignore it. Don't gloss over physical reactions. Determine what events distress you. What are you telling your problems. Determine how your body responds to yourself about meaning of these events The stress. Do you become nervous or physically upset? If so, in what specific Can you change your stressors byways



2. Recognize what you can change. Can you reduce their intensity avoiding or eliminating them completely Can(manage them over a period of time instead of on a daily or weekly basis) you shorten your exposure to stress (take a break, leave the physical premises) Can you devote the time and energy necessary to making a change (goal setting, time management techniques, and delayed gratification strategies may be helpful The here)



3. Reduce the intensity of your emotional reactions to stress. Stress reaction is triggered by your perception of danger...physical danger and/or emotional danger. Are you viewing your stressors in exaggerated terms Are you and/or taking a difficult situation and making it a disaster? Are you overreacting and viewing things as expecting to please everyone? Do you feel you must always prevail in every absolutely critical and urgent? Work at adopting more moderate views; try to see the stress as situation? Try to something you can cope with rather than something that overpowers you. Temper your excess emotions. Put the situation in perspective. Do not labour on the negative aspects and the “what if's.

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4. Learn to moderate your physical Slow, deep breathing will bring your heart rate and reactions to stress. Relaxation techniques can reduce muscle tension. respiration back to normal. Electronic biofeedback can help you gain voluntary control over such things as Medications, when prescribed muscle tension, heart rate, and blood pressure. by a physician, can help in the short term in moderating your physical reactions. However, they alone are not the answer. Learning to moderate these reactions on your own is a preferable long-term solution

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5. Build your physical Exercise for cardiovascular fitness three to four times a week reserves. (Moderate, prolonged rhythmic exercise is best, such as walking, swimming, Maintain your• Eat well-balanced, nutritious meals. •cycling, or jogging). Mix• Avoid nicotine, excessive caffeine, and other stimulants. •ideal weight. Get enough sleep. Be leisure with work. Take breaks and get away when you can. as consistent with your sleep schedule as possible.

6. Maintain your emotional • Develop some mutually supportive friendships/ relationships. •Reserves. Pursue realistic goals, which are meaningful to you, rather than goals others expect some frustrations, failures, and have for you that you do not share. Always be kind and gentle with yourself--be a friend to yourself sorrows.

Contrary to its name, the conflictive posture is actually about avoiding conflict by minimizing contact and insisting on boundaries. It is about refusal to accept abusive behavior by demanding reasonably predictable and rational actions and reactions. It is about respect for you and for your predilections, preferences, emotions, needs, and priorities.

A healthy relationship requires justice and proportionality. Reject or ignore unjust and capricious behavior. Conflicts are inevitable even in the most loving and mature bonds – but the rules of engagement are different in an abusive liaison. There, you must react in kind and let him taste some of his own medicine.

Abusers are predators, attuned to the subtlest emotional cues of their prey. Never show your abuser that you are afraid or that you are less than resolute. The willingness to negotiate is perceived as a weakness by bullies. Violent offenders are insatiable. Do not succumb to blackmail or emotional extortion – once you start compromising, you won't see the end of it.

The abuser creates a "shared psychosis" (folie a deux) with his victim, an overwhelming feeling of "the two of us against the whole world". Don't buy into it. Feel free to threaten him (with legal measures), to disengage if things get rough- or to involve law enforcement officers, friends, neighbors, and colleagues.

Here are a few counterintuitive guidelines:

The abused feel ashamed, somehow responsible, guilty, and blameworthy for their maltreatment. The abuser is adept at instilling these erroneous notions in his victims ("Look what you made me do!"). So, above all, do not keep your abuse a secret. Secrecy is the abuser's weapon. Share your story with friends, colleagues, neighbors, social workers, the police, the media, your minister, and anyone else who will listen.

Don't make excuses for him. Don't try to understand him. Do not empathize with him - he, surely, does not empathize with you. He has no mercy on you – you, in return, do not harbor misplaced pity for him. Never give him a second chance. React with your full arsenal to the first transgression. Teach him a lesson he is unlikely to forget. Make him go elsewhere for his sadistic pursuits or to offload his frustrations.

Often the abuser's proxies are unaware of their role. Expose him. Inform them. Demonstrate to them how they are being abused, misused, and plain used by the abuser. Trap your abuser. Treat him as he treats you. Involve others. Bring it into the open. Nothing like sunshine to disinfest abuse.

There are a few techniques which work wonders with abusers. Some psychologists recommend treating repeat offenders as one would toddlers. The abuser is, indeed, an immature brat – though a dangerous one, endowed as he is with the privileges and capabilities of an adult. Sometimes ignoring his temper tantrums until it is over is a wise policy. But not very often – and, definitely not as a rule

The first-line antiretroviral regimens now being taken in resource-limited settings are based on nevirapine or efavirenz. Resistance to either drug can develop very easily if doses are missed, and studies have shown that patients need to take at least 95% of doses in order to have a good chance of maintaining viral suppression. That means missing no more than three doses a month for a twice-daily regimen, and maintaining that level of adherence year after year.

Given that many treatment programmes are reporting that between 65% and 80% of patients still have undetectable viral load after several years of treatment, it is clear that these demanding levels of adherence are being widely achieved.

However, maintaining good adherence among patients requires vigilance. Research in Nigeria conducted by the University of Abuja Hospital and the University of Maryland Institute of Human Virology found that one in five patients reported adherence of less than 95% (judged by how promptly people came back for more tablets, the so-called refill rate) (Farley).

At Kericho Hospital in Kenya , around one in twenty patients on ARVs reported missing doses within the previous three days. In 29% of cases it was because they had run out of tablets and couldn’t afford to get to the clinic to get more. But in another 29% of cases it was because, after a median ten months of treatment, they felt better and didn’t see the need to carry on taking medication.

This study found that the single most important factor in deterring whether patients kept taking their medication was the belief, cited by 80% of adherent patients, that ARVs work. However only 29% mentioned that they knew adherence was critical in making ARVs work.

Individual barriers to good adherence

A systematic review of all the published studies looking at adherence in developed and developing countries found a striking universality of barriers to adherence – and facilitators of good adherence among individuals around the world (Mills 2006).

Barriers
Facilitators

Forgetting to take tablets or too busy
Fear of disclosure
Disruptive to everyday life or away from home
Don’t understand treatment
Side effects – real and anticipated
Depression / hopeless
Concurrent substance abuse
Suspicious of medicines
Belief that the drugs work/seeing positive results
Disclosure/social support
Twice daily dosing or less, fewer pills
Good relationship with health care provider


Katherine Semrau of Boston University reported at the 2007 HIV Implementers’ meeting on reasons why women in Zambia refused or stopped HIV treatment. Her findings were strikingly consistent with findings from qualitative research among Africans living in the United Kingdom .

Reasons for not starting when treatment offered
Reasons for stopping treatment

“ARVs are bad”
Stigma
Fear of divorce
“Not enough food”
Fear of permanent lifestyle changes such as avoiding alcohol
Taking medicines indefinitely when there is no cure
Lack of accurate information about the drugs and HIV treatment aims


Her focus groups told her that people stopping or refusing treatment were repeatedly receiving inaccurate information from trusted figures such as pastors, traditional healers, teachers and respected elders which undermined the authority of information received from nurses, doctors and community-based organizations. A classic notion in circulation was the belief that ARVs must be taken with food to be effective.

It was clear, she said, that treatment information needs to be adjusted to the cultural context, and it was important to identify the information gatekeepers who are providing misleading information and work to re-educate them.

Community barriers and community empowerment

But stigma, and the inability to disclose one’s HIV status, remain particularly important barriers to good adherence in most communities, and indicate the need to integrate treatment literacy within a community-based approach that seeks to address stigma.

The International HIV/AIDS Alliance carried out a two-year Programme in Zambia from late 2004 at sites in Lusaka and Ndola to promote community preparedness for treatment.

The team’s evaluation of lessons learned during the first six months of the project highlighted that “even in the hardest hit communities, stigma continues to be the most profound barrier to effective community-based responses.”

The ACER treatment support Programme aimed to reach 60,000 people in two low income urban areas, to provide community education on ART, voluntary counseling and testing, prevention messages and stigma reduction. It also set out to establish a two way referral system between the health system and the community, using community volunteers and treatment support workers living openly with HIV. The aim of the Programme was to engage the whole community, to build on existing community structures, and break down barriers that might impede the success of ART roll-out – particularly stigma.

Full evaluation of the project isn’t completed, but there has been a clear increase in the uptake of VCT in the community, recognition from the Ministry of Health of the key role that community organizations are playing in adherence support and linkage between clinics and communities, and a high degree of appreciation among patients for the support provided by peers within the clinic.

The experience in Zambia led to the funding by USAID of a larger and more ambitious community mobilization Programme managed by the Alliance in Uganda . The Programme has recruited over 80 `network support agents` based in 43 health facilities across seven districts. The network support agents – people with HIV – have been chosen by their PWHIV support groups to act as links between the health facility and the group, and are trained to support delivery of prevention, treatment and care services, including VCT, disclosure, treatment education and adherence support. They carry out community follow-up of ART patients on bicycles provided by the project, and provide feedback to health facilities on community barriers to testing, treatment and adherence.

The project is also measuring success by measuring the number of PWHIV support groups which apply for project grants to expand their community services; 215 asked for money but only 45 could be funded.

In 2006-7 alone, the Programme reached 94,500 people with education, including provision of adherence support to over 9,000 and ART literacy training to over 19,000.

The two projects show the difficulty of disentangling `adherence support` and `community engagement`, and the value of integrating adherence support within a larger community mobilization.

Structural barriers

Numerous studies have now shown that the most important structural barrier to adherence is the charging of fees for medical care or medicines. The second biggest barrier, as identified above, is transport to the clinic.

“What are the total out of pocket costs, not only of coming to the clinic, but of not staying at home to dig your cassava?” asked Alex Coutinho of TASO in Uganda during the HIV Implementers’ meeting.

An extensive qualitative study of barriers to adherence in Botswana , Uganda and Tanzania showed that transport costs, user fees for accessing health services and lost wages were all important financial barriers to good adherence. The researchers recommended that ART programmes provide transport and food support to patients who are too poor to pay, and that recurrent costs to users should be reduced by providing three-months, rather than the one-month supply of medication once optimal adherence levels have been achieved (Hardon 2007).

Loss to follow-up

Speaking at the 2007 HIV Implementers’ meeting Alex Coutinho of TASO, Uganda , highlighted the challenge that adherence support has posed for treatment programmes. In the early days of treatment roll out, programmes adopted either an enrollment or an adherence model of scale-up. While the enrollment model focused on starting the maximum possible number of people on treatment, the adherence model focused on preparing people thoroughly for the challenge of adherence to daily antiretroviral treatment.

Although the adherence model often proved slow to swell the number of patients of treatment, it has proved better at retaining patients on treatment. The enrollment model often saw 30% loss to follow-up rates, said Alex Coutinho.

As the 2007 HIV Implementers’ meeting heard, it is difficult to separate the issues of adherence and loss to follow-up. After all, if a patient is lost to follow-up, they are by definition non-adherent to treatment

Spotting loss to follow-up starts with good systems for record-keeping, and reliable ways of finding patients who are lost to follow-up. As Colin Shephard of I-TECH Ethiopia explained, this can be pretty challenging.

I-TECH was working with the Felege Hiwat hospital in Bahir Dar, in the northern Amhara region, which had started over 3600 patients on ART by the end of 2006. However 22% of those patients were lost to follow-up, and in 41% of cases there was no contact information for the patient. In a further 47% of cases, the only information available was the name of a local landmark.

The clinic recruited and trained three patients already on ART to locate patients lost to follow-up, and to obtain accurate address information for all newly registered patients, together with consent for home visits if they missed a clinic appointment.

Home visits and other enquiries were able to locate just 6% of patients, with a further 44% of the LTFUs discovered to be dead, and the remainder still missing.

In South Africa , Klerksdorp Hospital in the North-West province has also employed default tracers since it became apparent that the loss to follow-up rate had reached 21%. The vast majority of those lost to follow-up defaulted during the first six months of treatment, but an audit of 300 patients lost to follow-up could only identify 126 deaths from local death records. The remainder were still out there somewhere, but, said Dr Ebrahim Variava, either their address details weren’t complete, or they weren’t answering their mobile phones.

“We think cell phones are a blessing and a curse [from the adherence point of view]. People change numbers constantly because the cheapest way to run a phone is to buy a starter pack with a new number.”

Some programmes require that a home visit to verify residency in the district takes place before treatment can begin. In addition to phone and complete address, the International Center for AIDS Programmes’ Clinical Manual recommends attempting to obtain names, addresses and phone numbers for close family and/or friends, and places where the patient spends time (work or recreation — as well as permission to make home visits or to contact family and friends.

In Tanzania ICAP found significant differences in loss to follow-up rates between four clinics in the Pawn region south of Dar es Salaam . Although adherence support was delivered through a standard model of three sessions of adherence counseling prior to treatment, reinforced with counseling at each visit to the drug dispensing point, loss to follow-up ranged from 3 – 4% at two clinics up to 25% at another site.

ICAAP discovered that the higher loss to follow-up rates were associated with inadequate staff resources for defaulter tracing together with inadequate community sensitization about the need for adherence. Stigma and lack of disclosure also played a part. The other big barrier was transport to the clinic.

In order to improve retention in care and adherence to treatment, ICAAP’s clinics took the following steps:

· They encouraged family-based counseling in order to promote HIV testing and disclosure

· They began to provide transport from rural health centres to ARV clinics with high loss to follow-up rates, and established satellite clinics at local health centres too.

· Patients with an excellent record of adherence were permitted to take three months supply of drugs rather than having to return each month.

· Local awareness campaigns about the importance of adherence to ART were mounted.

Preparing the patient for treatment

Treatment programmes take differing routes to determine which patients will start treatment, as Alex Coutinho noted, with some concentrating on quantity rather than quality in order to reach national and regional targets. Some also regard extensive adherence preparation as too demanding on sick patients, and see the priority to be getting them onto treatment.

On the other hand, adherence-focused programmes tend to take their lead from the pioneering model developed over the past five years by MSF in Khayelitsha , South Africa , and many other treatment sites around the world.

It’s a model that places the patient at the centre, and which eschews the frankly punitive attitudes of public health TB programmes, which assume that the patient will be irresponsible, in favor of an approach that assumes that, armed with sufficient knowledge and support, the patient is the one who is responsible for the long-term success of her treatment.

The model comprises thorough patient education on the benefits and side effects of ARV treatment prior to treatment initiation, and continuous support with participation in support groups, self-nomination of a treatment supporter and the availability of adherence counselors for one-to-one sessions. Adherence to tablets is verified by regular pill counts on return dates at clinics. Pill boxes and printed material are provided as adherence aids.

ICAP stresses that “adherence is more than taking medications” but also must include (and generally begins with) “adherence to care:” Does the patient make all of her or his scheduled appointments, participate in education and counseling, and attend support groups? Are they receptive to the idea of home visits or other outreach? Have they come in and completed ordered tests, modified his or her lifestyle and made a commitment to keep from transmitting HIV to others?

In many clinics patients are judged to be ready for treatment only when they have been through a preparation process, and their cases are reviewed by a selection group. In Vietnam for example, the selection group at Family Health International-managed treatment projects consists of clinic and home-based care team staff, as well an elected representative of local people with HIV.

Adopt a Participatory Approach:



Create a Steering Committee that includes representation from key stakeholders, beneficiaries and relevant Programme staff. The Steering Committee can act as the main decision-making body during Programme planning, design and evaluation



Conduct regular focus group sessions with beneficiaries throughout various phases of Programme implementation and evaluation. The findings from the discussions can be used to review and adapt Programme interventions and activities


Implement peer education programmes with vulnerable groups


Enhance the Scope of Outreach
Implement peer education programmes with vulnerable groups

Conduct awareness raising programmes on HIV&AIDS and human rights with individuals connected with people living with HIV/AIDS and vulnerable groups. For example, programmes targeting injecting drug users can conduct interventions with their families, peers and partners as well as with law enforcement authorities


Ensure Universality of Healthcare and Reduce Stigma


Facilities providing HIV&AIDS-related services to vulnerable groups can also offer general health care services to the surrounding community. This strategy improves the accessibility of services by reducing stigma associated with approaching the facility


Ensure Sustainability

Implement income generation programmes with targeted communities and help them develop partnerships with micro-finance institutions. Since individuals most vulnerable to HIV infection tend to be those with the least social and economic power, this strategy can help vulnerable communities increase their resources and build their capacity to mobilize

Identify Vulnerable Groups

When conducting a situational analysis of community needs, disaggregate data according to gender, ethnicity, religion, social status, etc. in order to determine which categories of people are able or unable to enjoy their human rights. Disaggregated data helps Programme designers and other staffs identify the vulnerable groups within a particular community and to reveal HIV&AIDS-related discrimination

Four Key Principles



The following four principles have been derived from international human rights law (reviewed in Patterson, 2004; Ljungman, 2004). Their integration in the plans and processes of development is crucial to implementing a rights based approach. The sections below provide a brief explanation of each principle, drawing on the ideas and concepts articulated in several international publications



1) Participation and Inclusion: Participation is a critical feature of the human rights-based approach. Every individual is entitled to participate, contribute to and enjoy civil, economic, social and political development. A rights-based approach acknowledges that without the participation of targeted communities, development programmes and activities are unlikely to be effective for the individuals who need them. According to a rights-based approach, participation must be free, active and meaningful



Free means participation that is not forced


Active means a participation process that leads to action


Meaningful means that the participation process has an impact on goals achieved


2) Equality and Non-Discrimination: The principle of equality and non-discrimination entails that all persons are equally entitled to the resources required to fulfill their basic human needs, without discrimination of any kind. This means that development efforts should target marginalized and excluded groups as these individuals often suffer from stigma and discrimination and are, consequently, less able to enjoy their human rights. Stigma and discrimination reinforce social marginalization and inhibit the meaningful participation of marginalized groups in social and political life. For instance, man and woman are equally entitled to all human rights but in our society women have been kept backward and deprived of their basic rights. Keeping in view this situation if we allocate more resources for women than it would be termed as equity.

3) Universality and Indivisibility: The universality of human rights means that all persons are entitled to human rights. Human rights are inalienable; they cannot be taken away or voluntarily given up. In addition, human rights are indivisible, interdependent and interrelated - no one group of rights is more important than the others, and the realization of one right often depends on the realization of others.

Although all rights are equally important, certain rights can be given priority depending on the context. However, the prioritization of any one right should not directly prevent the realization of other rights. E.g. Education and information are both inter linked rights if a person is given education but deprived of information; it would mean that both his rights are being compromised. Similarly no country claim that she would give some rights and withhold others as these rights are universal.

4) Accountability: The principle of accountability is rooted in the relationship between rights and responsibilities. Every human right is associated with a corresponding responsibility (see Table 3). Accountability means duty-bearers are answerable for fulfilling their human rights obligations. Demanding accountability of duty bearers is at the core of a rights-based approach and distinguishes this approach from traditional development strategies. Accountability requires that the government, as the legal and principle duty bearer

How does transmission occur
Parent-to-child transmission (PTCT) of HIV, also called prenatal or vertical transmission, occurs when HIV is spread from an HIV+ woman to her baby during pregnancy, labor and delivery or breastfeeding. For an HIV+ woman not being treated for HIV, the chance of passing the virus to her child is about 25% during pregnancy, labor and delivery. If she breastfeeds her infant, there is an additional 12% chance of transmission.

Approximately 800,000 children also became HIV infected; the majority of them via PTCT.A large proportion of people newly diagnosed with HIV worldwide are between 15-24 years old. A very important component of PTCT prevention must be HIV prevention for young people, especially girls and young women before they become sexually active, and treatment for those already infected.

Are all parents equally at risk for PTCT

More than 95% of HIV+ women in the world live in developing countries and most HIV+ children are born in developing countries. Global societal and economic inequities create a wide gap between women in developing nations and women in developed nations with regard to HIV prevention, voluntary counseling and testing and access to drugs which treat HIV infection and can prevent PTCT.

Can PTCT be reduced
Yes. Advances in treatment and new classes of drugs have provided the opportunity to greatly reduce rates of PTCT worldwide. However, these advances have not made their way to developing countries to the extent that is needed, and we have still not addressed the root cause of PTCT, mainly heterosexual HIV transmission. The best way to prevent PTCT is to prevent HIV transmission in the mother and father.

In order to reduce PTCT, all pregnant women should have access to free or low-cost prenatal care and voluntary HIV testing and counseling. If a pregnant woman is HIV+, she should have access to antiretroviral treatment both to treat HIV and improve her own health, and to decrease the chances of HIV infection in her infant. Treatment options for preventing PTCT include giving antiretroviral drugs to the mother after the first trimester of pregnancy and during labor, and to her infant for the first six weeks of life.

PTCT can be further reduced to less than 2% if a woman is on antiretroviral drugs, has a low viral load, follows the recommended PTCT treatment regimen and does not breastfeed. However, little is known about the long term impact of these drugs on the child. Taking greater care during labor and delivery can also help reduce PTCT, for example not artificially rupturing membranes or doing routine episiotomies, and providing cesarean delivery when indicated.

In developing countries, several studies have tested shorter and less complicated AZT regimens and found them to be effective, although less so than standard US regimens. Other studies have found that using a single dose of nevirapine, a drug that is far less expensive than AZT, for the mother and the infant can also significantly reduce PTCT.

The ultimate goal is to find the most effective and sustainable regimens for HIV treatment and PTCT prevention worldwide. Economics, politics, and poor infrastructure all pose significant challenges to providing this standard of care everywhere. Governments and pharmaceutical companies have begun to address these challenges by providing free or low-cost drugs, and should be encouraged to do more.

What are barriers
Pregnant women face many difficult decisions, including decisions around HIV testing, treatment options and infant feeding. A woman's male partner(s), extended family, greater community and health care setting all influence her decision and ability to take advantage of PTCT prevention.

In the developing world, there is a lack of access to medications in general and antiretroviral drugs in particular. In addition, there is very little access to good health care for women both before and after birth, limited HIV counseling and testing and high stigma and discrimination against HIV+ women.

What about breastfeeding
Breastfeeding is usually the healthiest choice for both infants and mothers. However, HIV transmission can occur during breastfeeding, with chances of transmission increasing the longer the infant is breastfed. 10-20% of HIV- infants breastfed by HIV+ mothers will become infected. In the developed world, it is recommended that HIV+ mothers do not breastfeed, as formula feeding is safe, well accepted and readily available.

Formula feeding requires clean water for mixing formula. Many women in developing countries do not have access to clean water or sanitation and cannot afford formula, and therefore cannot avoid breastfeeding. In developing countries where breastfeeding is the norm, formula feeding may alert a woman's family or community that she is HIV+, which may result in stigma or other negative repercussions.

The World Health Organization recommends that HIV+ mothers avoid all breastfeeding when replacement feeding is “acceptable, feasible, affordable, sustainable and safe.” Otherwise, exclusive breastfeeding (not combined with formula feeding) is recommended during the first months of life.

What still needs to be done
HIV is a preventable disease. PTCT is best prevented by effective, accessible and sustainable HIV prevention, diagnosis and treatment programs for women, men and their children. Structural interventions are also needed that increase access to HIV treatments, clean water and formula.

All women have a right to be treated for HIV infection, not simply because they are bearing a child. Education and empowerment for all women in every country are essential, as are access to good medical care and nutrition for women and their children, whether they are HIV+ or HIV-.

Despite substantial progress against AIDS worldwide, we are still losing ground. The number of new infections continues to dwarf the numbers who start antiretroviral therapy in developing countries. Most infections occur in widespread or generalized epidemics in heterosexuals in just a few countries in southern and eastern Africa . Although HIV incidence has fallen in Uganda , Kenya , and Zimbabwe , the generalized epidemic rages on. Something is not working. Ten misconceptions impede prevention.



1. HIV spreads like wildfire—Typically it does not. HIV is very infectious in the first weeks when virus levels are high, but not in the subsequent many-year quiescent phase. Only of people whose primary heterosexual partners have the virus become infected each year. Thus Kenya has more couples in which only one person is infected than couples in which both are This low infectiousness in heterosexual relationships partly explains why HIV has spared most of the world's populations. However, the exceptional generalized epidemics in Africa seem largely driven by concurrent partnerships, in which some people have more than one regular partner. This pattern allows rapid dissemination when a new infection is introduced6 and probably involves more frequent risky sex than in sporadic or exclusive relationships.



2. Sex work is the problem—Formal sex work is uncommon in these generalized epidemics. In Lesotho , fewer than 2% of men reported paying for sex in the previous year, although 29% reported multiple partners. Nuanced economic support is an important enabler of regular concurrent partnerships and transactional sex, but the targeting of sex work in prevention campaigns has limited usefulness.



3. Men are the problem—The behaviour of men, including cross-generational and coercive sex, contributes substantially to the establishment of generalized epidemics. But a heterosexual epidemic requires some women to have multiple partners. The importance of women in generalized epidemics is evidenced by the high proportion (sometimes the majority) of discordant couples in which the woman, not the man, is HIV positive



4. Adolescents are the problem—Generalized epidemics span all reproductive ages. Although adolescent women are affected through sex with older men, HIV incidence increases in women in their 20s and later in life. Men are infected at even older ages. Thus interventions in young people, including abstinence, although important, have limited usefulness



5. Poverty and discrimination are the problem—These factors can surely engender risky sex. But HIV is paradoxically more common in wealthier people than in poorer people, perhaps because wealth and mobility support concurrent sexual partnerships. Moreover, HIV has declined without major improvements in poverty and discrimination, notably in Zimbabwe (notwithstanding substantial economic and social distress).





6. Condoms are the answer—Condom use, especially by sex workers, is crucial to the containment of concentrated epidemics, and condoms help to protect some individuals. But condoms alone have limited impact in generalized epidemics. Many people dislike using them (especially in regular relationships) , protection is imperfect, use is often irregular, and condoms seem to foster disinhibition, in which people engage in risky sex either with condoms or with the intention of using condoms.



7. HIV testing is the answer—That learning one's HIV status (hopefully with counseling) should lead to behavioral change and reduced risk seems intuitive. However, real-world evidence of such change is discouraging, especially for the large majority who test negative. Moreover any changes must be sustained for years. And very newly infected people, who are highly infectious, do not yet test HIV-positive.



8. Treatment is the answer—Theoretically , treatment and counseling might aid prevention by lowering viral levels (and infectiousness) in those treated, reducing denial about HIV, and promoting behavioral change. However, no clear effect has emerged. Indeed these salutary effects might be outweighed by negative effects, such as resumption of sexual activity once those on antiretroviral feel well, and disinhibition when people realize that HIV might no longer be a death sentence.



9. New technology is the answer—Many resources are devoted to vaccines, microbicides, and prophylactic antiretroviral. Unfortunately any success appears to be far off. Moreover, such innovations might be mainly targeted only at very high-risk populations, rely on behavioral compliance, and engender disinhibition. Similarly, treatment of sexually transmitted infections to prevent HIV has been disappointing even male circumcision, an already available, unmistakably effective, and compelling priority will take years to have additional substantial effect.

10. Sexual behaviour will not change—Actually, facing the prospect of deadly illness, many people will change. Homosexual men in the USA radically changed behaviour in the recent years. And the reductions in HIV incidence in Kenya and eastern Zimbabwe were accompanied by large drops in multiple partners probably largely as a spontaneous reaction to fear.



Truthfully, our priority must be on the key driver of generalized epidemics—concurrent partnerships. Although many people sense that multiple partners are risky, they do not realize the particular risk of concurrent partnerships. Indeed, technical appreciation of their role is recent.6 But partner limitation has also been neglected because of the culture wars between advocates of condoms and advocates of abstinence, because it smacks of moralizing, because mass behavioral change is alien to most medical professionals, and because of the competing priorities of HIV programmes.

Fortunately we can enhance partner-limitation behaviour, akin to the behaviour change that many people have adopted spontaneously. State-of-the-art behaviour-change techniques, including explicit messages, that are sensitive to local cultures, can raise perception of personalized risk. Even modest reductions in concurrent partnerships could substantially dampen the epidemic dynamic. Other prevention approaches also have merit, but they can be much more effective in conjunction with partner-limitation. Now, more than 20 years into HIV prevention, we have to get it right

.



References



1. UNAIDS, WHO. AIDS epidemic update. December, 2007:
http://data. unaids.org/ pub/EPISlides/ 2007/2007_ epiupdat. ..
(Accessed

Nov 21, 2007)

2. World Health Organization, UNAIDS, UNICEF. Towards universal access: scaling up priority HIV/AIDS interventions in the health sector. Progress report, April 2007. April 17, 2007:
http://www.who. int/hiv/mediacen tre/univeral_ access_prog. ..
(accessed Nov 21, 2007)..

3. Cassell MM, Surdo A. Testing the limits of case finding for HIV prevention. Lancet Infect Dis 2007; 7: 491-495.

4. Wawer MJ, Gray RH, Sewankambo NK, et al. Rates of HIV-1
transmission per coital act by stage of HIV-1 infection, in Rakai,
Uganda. J Infect Dis 2005; 191: 1403-1409.

5. Central Bureau of Statistics, Ministry of Health Kenya , Kenya Medical Research Institute, Centers for Disease Control and Prevention Kenya , ORC Macro. Kenya demographic and health survey 2003. 2004:
http://www.measured hs.com/pubs/ pub_details. cfm?ID=462& c...
(accessed Nov 21, 2007)..

6. Halperin D, Epstein H. Concurrent sexual partnerships help to explain Africa 's high level of HIV prevalence: implications for Pevention. Lancet 2004; 364: 4-6.

7. Ministry of Health and Social Welfare Lesotho , Bureau of Statistics Lesotho , ORC Macro. Lesotho demographic and health survey 2004. 2005:
http://www.measured hs.com/aboutsurv eys/search/ metadata. ...
(accessed Nov 21, 2007).

8. Shelton JD. Confessions of a condom lover. Lancet 2006; 368: 1947-
1949.

9. Shelton JD, Cassell MM, Adetunji J. Is poverty or wealth at the root of HIV?. Lancet 2005; 366: 1057-1058.

10. Imrie J, Elford J, Kippax S, Hart G. Biomedical HIV prevention—
and social science. Lancet 2007; 370: 10-11.

11. Gray RH, Wawer MJ. Randomized trials of HIV prevention. Lancet 2007; 370: 200-201.

12. Gregson S, Garnett GP, Nyamukapa CA, et al. HIV decline
associated with behavior change in eastern Zimbabwe. Science 2006; 311: 664-666.

Affiliations

a. Bureau for Global Health , US Agency for International Development, Washington , DC 20523 , USA

The HIV& AIDS pandemic is not just a public health issue; HIV&AIDS presents an obstacle to all human rights, for example, the right to education, the right to work and the right to safety and protection from abuse and violence.

Protecting human rights is therefore crucial to responding effectively to HIV& AIDS. A rights-based approach does this by integrating international human rights principles in health policy, planning and legislation.

Adopting a rights-based approach means providing people with the power, skills, knowledge and resources to protect them from contracting HIV&AIDS. Rights-based approaches to prevention do not just provide information, they seek behavioral change for example by ensuring that all people have the power and resources to refuse sex and access safe medical practices. Prevention programmes should identify the needs of those particularly vulnerable to HIV& AIDS infection, such as sex workers, drug users and mobile populations.

A rights-based approach aims to guarantee access to treatment and care to those affected by HIV&AIDS. At the policy level, this means ensuring that States are held accountable for the consequences of exclusionary health policies. At the Programme level, rights-based approaches seek to provide psycho-social support, medical treatment and nutritional support.

Tackling discrimination is fundamental to rights-based approaches to HIV& AIDS. The stigma attached to HIV&AIDS stifles education and knowledge. This causes the virus, and panic, to spread faster. Rights-based approaches address discrimination by working with parents, teachers the media and religious organizations, to address attitudes about sex and sexuality.


Large numbers of deaths caused by HIV&AIDS have heavily reduced labors, skills and knowledge. Rights-based approaches can help to mitigate this by encouraging a multi-sectoral response and fostering strong political and community support. This can help to assess and monitor the impact of AIDS on industry and macro-economic stability.

Example:

Studies have found that major transmission of HIV occurs along transport routes. This is because mobile populations, such as truck-drivers, away from their families for long periods of time, are more likely to have multiple sexual partners at different truck stops along the highway. In response, World Vision and the Australian Government’s overseas aid program set up The National Highway One Project in Vietnam to prevent the spread of infection by increasing awareness of HIV and prevention among truck drivers and communities.

Community members in frequent contact with the drivers, were trained to distribute condoms and information, including leaflets, and audio-cassettes containing songs interspersed with conversations between truck drivers. Young men and women in roadside locations took part in education sessions and produced colorful murals and billboards which reinforced the message that HIV&AIDS threatens everyone, not just 'high-risk groups' By educating the wider community, the project aimed to encourage behavioral change.

Venue: AHO sub office: St # 2 Sher-e-Rabbani Town, Okara.

Date: 9th December 2007

No. of Beneficiaries: 100


Participants: -
 Transgender (Hijra’s)
 Men having sex with men.
 District Government Officials
 Active Help Members

Sponsored By:-
APACHA PAKISTAN (Asian People’s Alliance for Combating HIV & AIDS)


World AIDS Day, observed December 1 each year, is dedicated to raising awareness of the AIDS pandemic caused by the spread of HIV infection. AIDS has killed more than 25 million people. The concept of a World AIDS Day originated at the 1988 World Summit of Ministers of Health on Programmes for AIDS Prevention. Since then, it has been taken up by governments, international organizations and charities around the world. The focus of the day will be the dissemination of basic information to general public regarding HIV & AIDS and ultimately bringing about reduction in stigma and discrimination associated with this issue.
So, Active Help Organization also planned to celebrate it. Active Help Organization celebrate “World AIDS Day” every year this year we decided to celebrate it with some of vulnerable community. Transgender, MSMs were invited to celebrate the activity.
The activity was started with the name of Allah (Tilawate Qalam-e-Pak) and followed by Naat by the focus population.

The stage secretary Dr. Hameed Bhatti who is the General Secretary of Active Help Organization firs of all told the participants that why they came here and told them the importance of the World AIDS Day. Then Dr. Hameed Bhatti as a stage secretary call some guests on the stage Dr. Nool-ul-Zaman from APACHA Pakistan, Dr. Kulsoom Akhtar (Chairperson Active Help Organization), Dr. Muhammad Hanif (Finance Secretary Active Help Organization.
The discussion started at 11 in the Morning. All of the participants introduced their selves. Dr. Kulsoom then highlighted the issue of HIV & AIDS and the vulnerability of the focus population towards it. She highlighted that MSMs are unaware and unconscious regarding their health specially transgender. They are less empowered with a bundle of responsibilities over them. In almost cases they are not socially accepted so that they don’t have access to services to their basic health, knowledge and care & support.

Then the stage secretary invited the Finance secretary Dr. Muhammad Hanif of Active Help Organization.
He told that the issue of HIV and AIDS is also the problem of transgender like other people. Then he gives a presentation on Basic HIV and AIDS by IEC material. He told the focus population what is HIV? What is AIDS? How it does spread? How could we prevent ourselves from HIV and AIDS?
Then he told that the focus population they can do better for the prevention and control of HIV and AIDS.
Then Dr. Noor-ul-Zaman came front of the participants he focused on the rights of Transgender and told how can they improve their livelihood and can achieve their rights. Dr. Noor-ul-Zaman further said that “Transgender are less empowered because they have no social acceptance, less resources, less access to services and most of the important they are not considered equal to human in our daily life and so their rights, dignity and respect is violated at every step of life”
The he asked to speak the focus group to share their daily problems with the help of Mr. Muhammad Imran Shahid who is the Program Officer of Active Help Organization.
After that the chairperson of Active Help Dr. Kulsoom Akhtar invites the Program Officer of Active Help M. Imran Shahid.
We receive some valuable comments from the focus group they said

They have not Identity Card of Pakistan.
After their performance the police disturb them and they get feared.
They have no proper job
Their parents and other relative don’t behave them like a human.

After that the controller of the city government (City Nazim) Mr. Afzal Paiji come on the stage and said the he will try his best to resolve the problems of the transgender. He advised the focus group to come his office with their problems.
He also appreciate Active Help Organization to organize such events to aware the people and every person regarding HIV and AIDS. And also to view the problems of the Transgender so closely.
After this the focus population performed dance
In last the discussion was packed with an aim to change the negative behaviors so to ensure the better access to the health facilities and preventive methods. After that refreshment was served to the participants.

Ignored infections, repeated abortions, multiple sex partners and women’s anatomical vulnerability are just some of factors contributing to an alarming incidence of reproductive Tract Infections (RTIs) and Sexually Transmitted Diseases (STDs), and of course; there is growing spectrum of AIDS.

How does the average woman react?


She feels alarm worries a bit but more often than not, there are so many reasons why she does nothing more about it .There is so much to worry about anyway: The children, their studies the Rat race at work, the never quite done chores at home, the endless rounds of parties and social events. The city women can well find reasons to push that out of sight infection out of mind. Beside the fact it affects her embarrassingly private areas: as of her anatomy makes it all more convenient to ignore it, cross her fingers and hope it will go away.

Maybe she will try an over the counter ointment or take a course of self prescribed antibiotics. But chances are; she won’t see her gynaec unless the problem reaches a do or die situation.

The ruler woman has as many reasons for ignoring her very private problems. Her life is as busy as, her day as full the demands made on her time and energy leave her little time to worry about a niggling infection. Besides, admitting to a sexual problem brings forth suspicion about her chastity. Women were born to suffer women’s problems anyway, and when one has lived with chronic lower backache, or gone burning is like a flea bite. Besides, even if she wished to turn to a doctor for help, she couldn’t see a male with her yet that her health matters, too. In her list of priorities, after food and shelter, children and husbands and maybe in-laws, her health comes last.


NO MIRACLE CURES

Most STDs and RTIs are not treatable, but can be prevented. A little awareness, some health education and dose of caution in one’s sex life can make a major difference in statistics.


Perhaps the first step towards cutting down on the woman’s silent misery is health education at any early age. The most advanced school education often ignores this aspect; and entire generations of young people grow into the reproductive age group with little factual knowledge of how their bodies work, and the things that can go wrong.



Second, the importance of seeking out a doctor when something does go wrong whether it’s an infection, a series of missed periods, or an unwanted pregnancy must be brought home to both mothers and their daughters.


Antibiotics and screening procedures can cure almost all infections if women will seek medical help.


The population pyramid as it is structured today shows that the base is made up of the under-teens, all of whom will grow to be sexually active teens and adults within the first few year of millennium. Unless they are granted access to health education that teaches them, among other things, the importance of personal hygiene and safe sex, the specter of STDs and HIV will continue to grow. Doctors across the country emphasize the need to set aside outdating taboos about discussing sex and importance of introducing health education at school level.

A change in gender balance will also help eradicate the silent enemy from the Indian women‘s life. Greater freedom between men and women in discussing contraceptive choices and the right to insist on a man using condom being granted by her partner to the woman, are other milestones woman from RTIs. Ands yet these basic avenues of mutual communication are not accessible to many urban educated women.

Also important is education about the correct use of sanitary napkins and tampons which more urban young women are adopting. Plus awareness that synthetic underwear, leotards and very tight jeans could give rise to conditions that make girls more susceptible to vaginal infections. Associability to better health services, especially in slum areas in the cites and in the villages can ensure safer Tran cervical procedures. Diagnostic and treatment options need to be improved; services need to be made accessible and acceptable. Most important the stigma associated with seeking help for genital complaints should be done away with among the educated as well as the illiberal especially in the adolescent group. Also regular screening is a must to prevent cervical cancer. Through the city woman has access to screening facilities at affordable rates, it is amazing how many women avoid resources to this safe and inexpensive preventive measure.

This will come with an awareness of the fact that sexual and reproductive health is total well-being and a vital aspect of a woman’s health.