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The Power to Change
HIV/AIDS Advocacy in India
Facilitator's Resources
The Power to Change: HIV/AIDS Advocacy in India - Facilitators' Resources
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Table of Contents
A: Introduction to HIV/AIDS Advocacy
A.2 About the EAR and a Rights Based Approach to Advocacy.
A.5 Examples leading to policy change
A. 6 Steps in the advocacy process
B: Introduction to Evidence Based Advocacy...
B.4 Analyzing Behavioral and Epidemiological Data
C: Understanding the policy process
C.l The policy process
E: Implementation - Advocacy Action Plans
E.l Implementation: Advocacy Action Plans
F: Advocacy messages and methods
....
F.3 An Advocate's Experience: Message and Methods
F.5 Written communication - Introduction to policy briefs
G: Evidence for Action: Using data for advocacy
.....................
G.l Policy briefs
Resources for Scenario 1: Access to services for MSM and transgenders
Resources for Scenario 2: Police raids hamper effective HIV prevention among sex
workers
Resources for Scenario 3: Resistance to harm reduction and a changing epidemic..
Guidance on feedback for policy briefs (G.l) and role plays (G.2)
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The Power to Change: HIV/AIDS Advocacy in India - Facilitators' Resources
A: Introduction to HIV/AIDS Advocacy
A.2 About the EAR and a Rights Based Approach to
Advocacy
Power point presentation is on CD provided.
Insert hard copy of PowerPoint presentation here - 4 slides per page
The Power to Change: HIV/AIDS Advocacy in India - Facilitators' Resources
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A.5 Examples leading to policy change
Guest Speakers talking points:
To:
From:
Re:
Speaker Invitation for "Examples leading to policy change"
EAP HIV/AIDS Advocacy Workshop on XX
Date:
The Essential Advocacy Project (EAR) will be holding an HIV/AIDS Advocacy Training
Workshop in xx on xx. The training will involve approximately XX participants from (state/
district/ local NGOs/ KPs etc). This workshop is part of Avahan - the India AIDS Initiative of
the Bill and Melinda Gates Foundation. The EAP works to strengthen the capacity of Avahan
partners, key stakeholders and people living with and affected by HIV/AIDS to advocate for
an evidence based approach to responding to HIV/AIDS, supported by effective policies and
practices that protect the rights of those affected and ensure effective programming.
We are hoping that you might be able to contribute your expertise by participating in a
session about your organization's advocacy work that has led to policy change. This would
involve your giving a 20 - 30 minute presentation. Your presentations will be followed by a
moderated discussion. This session is scheduled for xx.
The overall goal of the training is strengthen participants' understanding of advocacy and
build participants' skills to carry out advocacy in their work. The purpose of the session is to
provide real examples of how advocacy has led to policy change in India.
If you were available to make a presentation we would suggest that the presentation focus
on a specific example of an advocacy issue your organization has worked on, by addressing
the following questions:
• What was the advocacy issue or problem that you identified?
• What was the policy change you were seeking?
. Who were the targets for your advocacy efforts? Why?
• Did you work with other allies in your advocacy efforts? If so, who did you choose to
work together with and why?
• How did you inform yourself about the issue and the views of the target audiences you
sought to influence?
• What did your advocacy efforts involve?
• What were some of the outcomes of your advocacy efforts? What do you think you
achieved?
• What challenges did you face in bringing about change and how did they address these.
• What worked well and what would you do differently?
We hope that we will be able to benefit from your valuable experience and time. Please do
not hesitate to call if you have any questions. We will also plan to call you to follow-up on
this invitation.
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A.6 Steps in the advocacy process
Card templates
Designer to replicate card templates - steps in the advocacy process.
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B: Introduction to Evidence Based Advocacy
B.4 Analyzing Behavioral and Epidemiological Data
Guidance for session preparation
Data analysis exercises, using some of the epidemiological and behavioral data available at
the time of publication have been prepared and used in field testing this manual. The data
tables used provides the figures and a series of questions relating to each table. The Data
Analysis Exercise developed at the time of publication includes:
TABLE 1: HIV prevalence trends (%) in the anti-natal clinics (ANC) and STI clinics 2003 2005. This table includes percentages nationally and for the six states in which the Avahan
program is operating - Karnataka, Andhra Pradesh, Maharashtra, Tamil Nadu, Manipur and
Nagaland.
TABLE 2: HIV prevalence (%) among key populations 2003 - 2005. This table includes
percentages nationally and for the six states.
TABLE 3: Data on knowledge and behaviour of female sex workers (2001). This table
include data for each of the six states.
TABLE 4: Data on knowledge and behaviour of MSM, 2002. This table includes data across
5 locations - Delhi, Mumbai, Kolkatta, Chennai and Bangalore.
TABLE 5: Data on knowledge and behaviour of IDUs, 2002. This table includes data across 5
locations - Delhi, Mumbai, Kolkata, and Chennai. In case of Imphal, Manipur data was used
as city data was not available.
These data tables need to be adapted and accompanying guidance notes for facilitators
prepared to ensure the relevance and currency of these data for each state. Gathering data
specific to each state and different key populations, including epidemiological, behavioral,
case studies, research findings on best practice, will be an ongoing process.
Data will also change over time and better data will become available. The EAR also intends
to update these data tables as new data become available, including the Integrated BioBehavioural Assessment (IBBA) by FHI for Avahan; National BSS 2006; National Family
Health Survey (2005).
As new data become available, data analysis exercises will be developed for specific training
workshops, so they are tailored to the needs of different states and different groups of
participants.
Given the need for relevant and current data, the data analysis exercises are not
provided as part of this manual. If you wish to conduct this session, you will need to
contact the EAR head office to discuss your specific needs. The EAR will make every effort to
assist you in conducting this session using data analysis exercises that have been developed
at that time.
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C: Understanding the policy process
C.l The policy process
Guidance for session preparation
A training module that provides a standard model for the policy process does not provide
this kind of insight both because the policy process in a given context rarely conforms to
such models in real life and the policy process varies considerably in different contexts.
The policy process is a dynamic and complex one. Participants need to be able to:
• understand how the policy process works in theory and in practice
• understand the array of factors that influence decision/ policy makers, and how to get to
know and work with them during the policy development process
• identify supporters and opponents both among those involved in the formal policy
making process and among those who have influence upon them and
• identify opportunities, both formal and informal, to influence them in a timely manner as
the policy process unfolds.
This session is important for giving participants an insight into the policy process in practice.
Preparation for this session is important. You will need to know whether participants are
likely to be advocating at national, state, district or local level. This will inform the guest
speaker you choose for this session.
The choice of guest speakers is critical. It is worth taking time to find the right people. One
speaker needs to be directly involved in the policy making process in government, preferably
HIV/AIDS or health related, as different department are likely to employ somewhat different
approaches to policy making. The second speaker needs to be involved in influencing the
policy making process, say a leader or policy advisor from an NGO. This way, through
hearing from both perspectives, the participants will be provided with an overview of the
policy process in that state/ district/ local context and insights into how the policy process
actually unfolds in practice.
Experience in using this session in practice has shown that it can be challenging to ensure
that the speakers speak to the topic. That is, to describe and analyze the policy making
process from their particular perspectives within government and in influencing government
policy processes. In order to assist you we have provided guest speaker's letters which will
need to be amended to suit your session. Where additions are needed is indicated by xx.
We suggest that you follow up with your speakers and discuss their presentations,
emphasizing what the session aims to achieve, the time allocated for each presentation and
that the presentations will be followed by a moderated discussion to explore:
• how the policy process works in theory and practice
• what kind of factors affect the views of policy makers in the policy process
• what opportunities both formal and informal are available to advocates in getting to
know policy makers and contribute to the policy development process
• what kinds of evidence and modes of delivery are seen as credible, using specific
examples where possible.
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Guest speakers talking points: Government representative
To:
From:
Re:
Speaker Invitation for "The Policy Making Process in xx" Session,
EAP HIV/AIDS Advocacy Workshop on XX
Date:
The Essential Advocacy Project (EAP) will be holding an HIV/AIDS Advocacy Training
Workshop in xx on xx. The training will involve approximately XX participants from (state/
district/ local NGOs/ KPs etc). This workshop is part of Avahan - the India AIDS Initiative
of the Bill and Melinda Gates Foundation. The EAP works to strengthen the capacity of
Avahan partners, key stakeholders and people living with and affected by HIV/AIDS to
advocate for an evidence based approach to responding to HIV/AIDS, supported by effective
policies and practices that protect the rights of those affected and ensure effective
programming.
We are hoping that you might be able to contribute your expertise by participating in a
session about the policy process in government. This would involve giving a 10 minute
presentation about the "The Policy Making Process in XX" and being part of a panel for a
moderated discussion. There will also be a speaker from xx who will present on their
experience in influencing the policy process in government. These presentations will be
followed by 40 minutes of moderated discussion. This session is scheduled for xx.
The overall goal of the training is strengthen participants' understanding of advocacy and
build participants' skills to carry out advocacy in their work. The purpose of the session is to
increase participants understanding of how the policy-making process works in practice.
During your presentation and the moderated discussion, we would like to explore the
following questions, drawing on your experience in policy processes in government:
• How are ideas or issues generated for new or revised policies?
• What sort of process is followed in making or revising policy?
• Where do policies get formulated (i.e., key committees, taskforce, etc)?
• How is a proposed issue introduced into the formal decision making process?
• What is the process for discussing, debating and, perhaps, altering the proposal? Who
are the players involved?
• How is the proposal approved or rejected?
• If approved, what are the steps to move the proposal to the next level of decision
making?
If you were available to make a presentation we would suggest that the presentation focus
on the questions outlined above, which we can also explore in the discussion. It may also
help increase participants' understanding if you could include a simple diagram of the
policymaking process followed at the state/ district/ local level (two samples are attached).
We hope that we will be able to benefit from your valuable experience and time. Please do
not hesitate to call if you have any questions. We will also plan to call you to follow-up this
invitation.
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Attachments: Overall Policy Process Map
3.
Entire
Parliament
Approved
2.
Committee
of Parliament
1.
Agenda
Setting
/
4.
Back to
Ministry for
Implementation
• President
• Prime Minister
• Ministers
The Power to Change: HIV/AIDS Advocacy in India - Facilitators' Resources
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Guest Speakers talking points: NGO representative
To:
From:
Speaker Invitation for "The HIV/AIDS Policy Making Process in xx" Session,
EAP HIV/AIDS Advocacy Workshop on XX
Re:
Date:
The Essential Advocacy Project (EAR) will be holding an HIV/AIDS Advocacy Training
Workshop in xx on xx. The training will involve approximately XX participants from (state/
district/ local NGOs/ KPs etc). This workshop is part of Avahan - the India AIDS Initiative
of the Bill and Melinda Gates Foundation. The EAP works to strengthen the capacity of
Avahan partners, key stakeholders and people living with and affected by HIV/AIDS to
advocate for an evidence based approach to responding to HIV/AIDS, supported by effective
policies and practices that protect the rights of those affected and ensure effective
programming.
We are hoping that you might be able to contribute your expertise by participating in a
session about the policy process in government. This would involve you giving a 10 minute
presentation about your experience in working to influence the policy making process in
government - "Influencing the policy making process in government: An advocate's
perspective. There will also be a speaker from xx who will present on the policy process in
government. These presentations will be followed by 40 minutes of moderated discussion.
This session is scheduled for xx.
The overall goal of the training is strengthen participants' understanding of advocacy and
build participants' skills to carry out advocacy in their work. The purpose of the session is to
increase participants understanding of how the policy-making process works in practice.
During your presentation and the moderated discussion, we would like to explore the
following questions, drawing on your experience:
•
•
•
•
•
•
•
How the policy process was intended to proceed and how did it take place in practice?
What kind of factors affected the way the policy process unfolding?
What factors affected the views of policy makers on the issue?
What opportunities both formal and informal were available to you to get to know policy
makers and contribute to the policy development process?
What was your role in the policy process?
What different strategies did you use to influence decision makers and those who had
influence with decision makers?
What kinds of evidence and modes of delivery were seen as credible to policy makers?
If you were available to make a presentation we would suggest that the presentation focus
on one or two specific examples of your work in influencing the policy development process,
in line with the above questions.
We hope that we will be able to benefit from your valuable experience and time. Please do
not hesitate to call if you have any questions. We will also plan to call you to follow-up this
invitation.
10
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E: Implementation - Advocacy Action Plans
E.l Implementation: Advocacy Action Plans
Implementation: Developing an Advocacy Action Plan
PowerPoint presentation on CD provided.
Xx Insert hard copy of ppt here
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F: Advocacy messages and methods
F.3 An Advocate's Experience: Messages and Methods
Guest Speakers talking points: Advocate's experience
To:
From:
Re:
Speaker Invitation for "An Advocate's Experience: Messages and Methods"
EAR HIV/AIDS Advocacy Workshop on XX
Date:
The Essential Advocacy Project (EAR) will be holding an HIV/AIDS Advocacy Training
Workshop in xx on xx. The training will involve approximately XX participants from (state/
district/ local NGOs/ KPs etc). This workshop is part of Avahan - the India AIDS Initiative
of the Bill and Melinda Gates Foundation. The EAR works to strengthen the capacity of
Avahan partners, key stakeholders and people living with and affected by HIV/AIDS to
advocate for an evidence based approach to responding to HIV/AIDS, supported by effective
policies and practices that protect the rights of those affected and ensure effective
programming.
We are hoping that you might be able to contribute your expertise to the workshop by
giving a 30 minute presentation titled "An Advocate's Experience: Messages and Methods,"
followed by 30 minutes of questions and discussion. The presentation would be scheduled
on xx.
The overall training workshop goal is to strengthen participants' understanding of advocacy
and build participants' skills to carry out advocacy in their work. The purpose of your
presentation is to give participants an insight into how to go about effective advocacy
communication.
We would like you to focus on sharing a specific example of a successful advocacy effort you
have been involved in - with an emphasis on the particular advocacy methods and
messages used.
We also suggest that it might be helpful to address the following questions.
1. What was the problem?
2. What was the advocacy objective? (What did you want to achieve?)
3. Who decided to advocate to address the problem (who was involved)?
4. Who did you advocate to?
5. What were your key messages? And what methods did you use? (main
focus)
6. What difficulties did you face and how did you overcome these?
7. What were the results of your advocacy?
8. What sources of support did you find most useful?
9. What did you learn from doing this advocacy?
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We hope that we will be able to benefit from your valuable experience and time. Please do
not hesitate to call if you have any questions. We will also plan to call you to follow-up on
this invitation.
The Power to Change: HIV/AIDS Advocacy in India - Facilitators' Resources
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F.5 Written communication - Introduction to policy
briefs
Sample policy briefs
Sample policy briefs are on CD provided.
XX insert hard copies of the five policy briefs here
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G: Evidence for Action: Using data for
advocacy
Guidance for preparation and conduct of module
Module G. is designed to provide experienced advocates with the opportunity to examine
different types of data, identify how the information can be used to support the arguments
they will make for specific policy changes they seek and to practice using the data. For
these sessions to work effectively, this module requires thoughtful preparation.
Preparation: Compile data sets for each scenario
You will need to compile a set of documents (data sets) for each scenario, ensuring you
have sufficient copies for each participant to receive a set of documents at leasts the
scenario they will be working on. So, if there are 30 participants, you will need 10 data sets
for each of the three scenarios. In field testing the manual, we provided enough data sets
for participants to take away sets related to all scenarios. This was well received, so this
approach is encouraged. Alternatively you might distribute the suggested documents list
below, so that participants can download the resources from the Internet.
The suggested documents for each scenario are provided in resources below. The website
links are provided and documents are also on the enclosed CD. A range of resources are
provided.
Preparation: Review scenarios and data sets
Review each scenario and the data sets thoroughly before commencing this module. In
order to provide feedback on the use of the data for both the policy briefs and face to face
role plays, you will need to be clear about what the main advocacy issues are in each
scenario and what information in the data sets can be used to make the case for policy
change related to each of these issues.
You do not need to include all of the suggested documents. You can choose a selection, but
you will need to make sure that materials provided offer enough data that is relevant to and
useful for each advocacy issue in a specific scenario. Once you have reviewed each scenario
and the related documents, you'll be in a position to choose which data you want to include.
Conducting sessions
As participants are working in small groups planning, reviewing data and writing policy
briefs, and during preparation of face to face role plays, you will need to play an active role
in guiding, advising and providing critical feedback. This is as important for the participants
as are the formal feedback sessions at the conclusion of each session.
You may want to schedule session G.l to conclude at a lunch break or at the end of a day,
to allow you time to review the summary policy briefs in preparation for providing feedback.
See guidance for feedback sessions for G.l Policy briefs and G.2 face to face communication
for each scenario, set out below.
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G.l Policy briefs
Sample policy briefs
Sample policy briefs are on the CD provided. See hard copies of policy briefs above in
materials for session F.5.
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Resources for Scenario 1: Access to services for MSM
and transgenders
Scenario 1
Akash, an NGO in Bangalore, provides a range of HIV prevention services. As part of their
outreach activity, Akash staff is becoming increasingly aware that men who have sex with
men (MSM) and transgenders are at particular risk of the HIV infection and that many in the
city are already living with HIV. Yet, there seem to be barriers to access to mainstream
health services. There is very little information available about sexual behaviour and HIV/STI
risk among MSM and transgenders, and impact of HIV on people living with the condition.
With Akash's support, some MSM and transgenders formed an advocacy group called
'Hamare Haq' (Our rights). Members of Hamare Haq and Akash outreach workers have been
talking to MSM and transgenders and documenting their experience such as their access to
condoms, lubricant, HIV prevention information and services to meet their HIV treatment
and care and/or sexual health needs. Together Akash and Hamare Haq have run four focus
groups, in all seventy people attended these group discussions. They also conducted thirty
individual interviews. A total of 100 people reported about their experiences.
They found that many MSM and transgenders report a lack of access to condoms and
lubricants. Forty percent report having had the symptoms of one or more sexually
transmitted infections (STIs) in the last twelve months. Of these forty people, only eight
(20%), sought treatment for the infection. Fifteen people reported that the staff at one of
the city's largest public hospital's Out Patients' Department are known to be dismissive of
MSM and transgenders and often have no experience in handling oral and anal STIs
affecting the community. There is also evidence about breach of confidentiality about
sexuality and HIV status by health workers leading to family and community harassment or
rejection. As a result many people say that they will not go there.
Together Akash and Hamare Haq discuss what action they could take to improve the
situation for MSM and transgenders. They build partnerships with other NGOs who want to
work on these issues and agree to set up a coalition, Transgender and MSM Advocacy
Coalition (TRAM), to work together on an advocacy agenda. The coalition meets and agrees
to focus their advocacy efforts on:
• access to condoms and lubricants, and
• access to non discriminatory and good quality HIV prevention, sexual health, HIV
treatment and care services.
In addition to their own research, there is also some data that can be used to make the case
for their advocacy goals.
Target audience for policy brief: SACS
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Scenario 1: Suggested documents
These documents are on the CD accompanying this manual.
.
National baseline high risk and bridge population behavioural surveillance survey, 2002
(MSM and IDU), NACO 2002. www.nacoonline.org
o Tables used: Self reported STI prevalence, MSM sex with female partners, MSM
condom use.
•
HIV/AIDS epidemiological surveillance and estimation report for year 2005, NACO, 2006.
Comparative year-wise and state-wise HIV prevalence among IDU populations (2002 2005)., www.nacoonline.org
.
Containing HIV/AIDS in India: the unfinished agenda, Chandrasekaran etc al. Lancet
Infect Dis 2006; 6: 508 - 21, www.thelancet.com
.
MAP Report 2005: Male-Male sex and HIV/AIDS in Asia,
www.mapnetwork.org/reports.shtml
•
Sexual behaviour of men who have sex with men ands risk of HIV in Andhra Pradesh,
India, Dandona et al, AIDS 19(17):2033-2036, November 18, 2005. www.aidsonline.com
•
Resource pack for interventions with MSM and Hijra, NACO, 2006. www.nacoonline.org
•
MSM and HIV/AIDS risk in Asia: What is fuelling the epidemic among MSM and how can
it be stopped, TREAT Asia, 2006 www.amfar.org (selected extracts).
•
UNAIDS: www.unaids.org
o Policy Position - Condom and HIV Prevention, UNAIDS 2004
o Policy Brief: HIV and Sex Between Men, UNAIDS, 2006
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Scenario 1: Roles
Policy makers
• Senior policy advisor from the Health Department
• Representative of Karnataka SACS
Advocates
• Representative of Hamare Haq
• Representative of the Transgender and MSM Advocacy Coalition (TRAM)
• Representative of NGO, Akash
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Scenario 1: Instructions for policy makers
These instructions are to provide some guidance to your team about how you should play
your roles. Please do not share these details with the advocates, as it is important that they
learn to adjust their approaches as the meeting unfolds.
Senior policy advisor for Health Department
You are generally not well informed on issues, and initially, you do not appear to be that
interested. However, as meeting progresses and advocate make a number of points you
think are important, you become more attentive and engaged. You start to see the
consequences of inaction, particularly the fact that HIV is likely to spread rapidly if
transgender/MSM's sexual health and prevention needs are not meet, given the extent of
MSM who also have sex with women.
Representative of the SACS
You are impressed by the arguments about why better data is needed on sexual behaviour,
supportive of the need for more programming efforts and open to ideas.
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Resources for Scenario 2: Police raids hamper effective
HIV prevention among sex workers
Scenario 2
There is a district election coming up in the north west of Karnataka and there has been
considerable community pressure about cracking down on sex work in a number of blocks in
the area. In the last two months, police have been regularly rounding up street sex workers
and conducting random raids on brothels, arresting sex workers. In 2004, the Director
General of Police in Karnataka issued a circular explaining what the police powers are under
the Immoral Trafficking Prevention Act (ITPA). These raids do not comply with the circular
and therefore with ITPA.
The sex worker collective, Mahila Sangha, is spending much of their time trying to assist sex
workers who have been arrested and charged with soliciting. They report that many sex
workers are being fined and are unable to pay the fine. In their experience, many men
demand, and are willing to pay more for sex without condoms. Many sex workers are being
forced to do so, just to make more money to pay back these fines. They report that sex
workers are increasingly worried about carrying condoms or being identified as sex workers.
The NGO, Prajal Foundation runs a number of sexual health clinics for sex workers in the
north west of Karnataka. They work in partnership with Mahila Sangha providing outreach to
brothels and street sex workers, to ensure their access to condoms, HIV prevention
information and sexual health services. In the last two months, staff have noticed a sharp
drop in the numbers of sex workers attending their clinic.
Brothel madams in the area are increasingly worried about these raids, and the effect of
them on their businesses. Prajal Foundation and Mahila Sangha are finding that their
working relationships with many madams have deteriorated as a result. Some madams
refuse to provide condoms and safer sex resources, because they will be used as evidence
that the premises are being used as a brothel.
It is more difficult to locate brothels and street sex workers. A number of brothels have
moved premises to avoid police exposure. Some madams are colluding with the police
offering them sex with their workers in exchange for agreeing not to raid their brothels.
Frequently police insist on not using condoms and the sex workers are powerless to refuse,
exposing both workers and officers to the increased risk of HIV infection.
The Avahan State Lead Partner, Prajal Foundation and Mahila Sangha meet to discuss how
to take action to address these issues. They want to advocate for police to comply with the
Police circular and the ITPA and to improve understanding about how the raids impede
effective HIV prevention efforts.
Target audience for the policy brief: Police Department of Karnataka
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- SOCH^.A^
I {,07-0
Scenario 2: Suggested documents
These documents are on the CD accompanying this manual.
.
Police circular on interpretation of the Immoral Trafficking Prevention ActtfWK) for
Karnataka, 2004
•
National baseline high risk and bridge population behavioural surveillance survey, 2001
(Female sex workers), NACO 2001 www.nacoonline.org
o Tables used: Awareness of STI and STI symptoms, STI prevalence; treatment
seeking behaviour
•
HIV/AIDS epidemiological surveillance and estimation report for year 2005, NACO, 2006.
Comparative year-wise and state-wise HIV prevalence among IDU populations (2002 2005). , www.nacoonline.org
•
Sex work and HIV in India, Essential Advocacy Project, Constella Futures, August 2006
•
Containing HIV/AIDS in India: the unfinished agenda, Chandrasekaran etc al. Lancet
Infect Dis 2006; 6: 508 - 21 (In Participants' Resources) www.thelancet.com
.
Sex Workers of Keraia, India: Moving beyondHIV/STIprevention, Subhash
Thottiparambil, www.kit.nl
•
India: Eviction of Sex Workers Boosts HIV Risk, Human Right Watch 2004, www.hrw.org
•
World Health Organization (WHO): www.who.int
o Fact sheet: Sexually transmitted infections, www.who.int/reproductivehealth/stis/docs/sti factsheet 2004.pdf
o Sex Work: Key facts and figures
•
UNAIDS: www.unaids.org
o Policy Position - Condoms and HIV Prevention, UNAIDS 2004
o Sex work and AIDS, Technical Update, UNAIDS 2002
o Extracts from Female sex worker HIV prevention projects: Lessons learnt from
Papua New Guinea, India and Bangladesh, UNAIDS Case Study, November 2000,
(Extracts: Cover through to page 18 and case study on Sonagachi pages 57 - 90)
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Scenario 2: Roles
Policy makers
• Member of the District Assembly
• Head of District Police
Advocates
•
•
•
Director of the Karnataka State Lead Partner
Director of Prajal Foundation
Representative Mahila Sangha
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Scenario 2: Instructions for policy makers
These instructions are to provide some guidance to your team about how you should play
your roles. Please do not share these details with the advocates, as it is important that they
learn to adjust their approaches as the meeting unfolds.
Member of the District Assembly
You start by raising the issue of community concerns about sex work, and your need to be
responsive to community views on this (as that is what you are directly concerned about).
You are surprised to hear about the police circular and you want to know more about it. As
the discussion unfolds, and you start understanding that the raids will not reduce sex work,
they will only move somewhere else in the area. Meanwhile STIs and HIV infections will rise.
Towards the end of the meeting you openly make suggestions about the way forward and
are open to ideas about what you can do to raise these issues with other members of the
District Assembly.
Head of District Police
You became head of District Police about six months ago and only became aware of the
circular in preparation for this meeting. You are open to hearing what the advocates have to
say. You acknowledge that more needs to be done to ensure that officers in your district
know about the circular and comply with it. You express concern about the allegations of
police corruption, and want to know what evidence they have to support the allegations.
When they have made their case on this point, you say you are prepared to look into the
matter, but you'll need to document some case for investigation. You are concerned that
your police officers may be exposing themselves to risk of HIV and indeed, some may
already be infected. You are open to hearing and discussing options for action.
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Resources for Scenario 3: Resistance to harm reduction
and a changing epidemic
Scenario 3
There is a high HIV prevalence among injecting drug users (IDUs) in Manipur. There are a
number of NGOs working to implement a range of strategies to reduce HIV infection among
IDUs and address the treatment and care needs of those living with HIV. Ukhzul Foundation
is an NGO that provides Needle and Syringe Programmes (NSPs), peer outreach, IEC,
advocates for access to appropriate and non-discriminatory drug treatment and HIV
treatment and care, as well as increasing community awareness about the effectiveness of
harm reduction approaches to injecting drug use and the contribution that this makes to
reduce HIV transmission.
Ukhzul also works with an IDU network, of current and ex-users, that they have been
training as peer educators. Through the network's work with their peers, they want to take
action about the many challenges that IDUs are facing. Together they started to document
the challenges that the IDUs are facing through focus group discussions and one on one
interviews. Eighty people participate. The work reveals that most IDUs have poor access to
appropriate drug treatment services such as drug substitution programmes. While 50% of
those surveyed had been detained and forced in to detoxification programmes, with no
support or follow up upon release. The survey also found that 45% of those surveyed were
HIV positive. Of these, 90% had experienced discrimination in accessing HIV related health
care.
There is also considerable community resistance to the harm reduction work of NGOs
particularly by a vocal women's group that is advocating that the NSP will increase injecting
drug use. This is building community resistance, and created a climate of fear and violence
against IDUs. Increasingly, IDUs are not carrying injecting equipment because they fear this
will lead to their arrest by police or violence from 'pressure groups'.
Ukhzul has gathered data in Manipur that show a trend of increasing STIs among women,
which suggest that they are increasingly exposed to HIV, likely through their male IDU
partners. There is inadequate evidence to confirm this trend, but Ukzhul and MAC are aware
that few programs exist that address the HIV prevention needs of partners of IDUs or
HIV/AIDS treatment and care needs of IDUs, partners and others living with HIV/AIDS.
Existing programs and services do not necessarily have the capacity to expand their work
without additional funding and support to meet these emerging needs.
Ukhzul and the Network find other allies and form an advocacy group, called the Manipur
Action Coalition (MAC) to take action together. MAC meets to discuss what action they could
take to address these issues. They want to:
• increase understanding of harm reduction and how it contributes to preventing the
spread of HIV;
• ensure access to appropriate drug treatment, HIV related treatment and care for IDUs
and their partners;
• address stigma and discrimination by pressure groups and services and
• address programs gaps, particularly the needs of female partners of male IDUs.
Target audience for policy brief: SACS
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Scenario 3: Suggested documents
These documents are on the CD accompanying this manual.
National baseline high risk and bridge population behavioural surveillance survey, 2002
(MSM and IDU), NACO 2002, www.nacoonline.org
•
Tables extracted from this document for data sets: Last time condom use with
commercial, non regular and regular partners; Needle and syringe sharing behaviour knowledge of availability of new/unused needles and syringes; Needle and syringe
sharing behaviour - frequency of sharing cooker, vial, container in past month;
Treatment for drug use; Treatment for drug use - type of treatment/ help received.
•
HIV/AIDS epidemiological surveillance and estimation report for year 2005, NACO, 2006.
Comparative year-wise and state-wise HIV prevalence among IDU populations (2002 —
2005). , www.nacoonline.orq
•
Containing HIV/AIDS in India: the unfinished agenda, Chandrasekaran etc al. Lancet
Infect Dis 2006; 6: 508 - 21 (in Participants' Resources) www.thelancet.co m
•
Drug injection and HIV/AIDS in Asia, MAP Report 2005,
www.mapnetwork.org/reports.shtml
•
Asian Harm Reduction Network (AHRN): www.ahrn.net
o Evidence based HIV/AIDS prevention
o Evidence for harm reduction
•
WHO, Evidence for Action Series 2004, www.who.int
o Policy Brief: Provision of sterile injecting equipment to reduce HIV transmission
o Policy brief. Reduction of HIV transmission through outreach
o Policy
z Brief: Reduction of HIV transmission through drug dependence treatment
Fact sheet: Harm reduction approaches to injecting drug use, WHO
www.who.int/hiv/topics/harm/reduction/en/#what
•
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Scenario 3: Roles
Policy makers
• Senior advisor from the Health Department
• Representative of Manipur SACS
Advocates
• Ukzhul Foundation - Executive Director
• Representative from the Manipur Action Coalition
• Representative from the IDU network, who is an experienced IDU peer outreach worker
and was central in the survey that Ukzhul and the network undertook.
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Scenario 3: Instructions for policy makers
These instructions are to provide some guidance to your team about how you should play
your roles. Please do not share these details with the advocates, as it is important that they
learn to adjust their approaches as the meeting unfolds.
Senior policy advisor. Health Department
Initially you are concerned about community outcry about NSP because of the political
implications, given the Meirapibies' lobbying against harm reduction approaches. On hearing
the advocates' case, about the evidence of effectiveness of NSPs, drug treatment and
outreach approaches, you are more inclined to listen to the advocates and are open to at
least discussing strategies for increasing acceptance of harm reduction within the
community.
Representative of the SACS
You focus your attention on the issue about the changing epidemic in Manipur and the fact
that different approaches are needed to meet emerging needs.
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Guidance on feedback for policy briefs (G.l) and role
plays (G.2)
Scenario 1: Access to services for MSM and transgenders
When providing feedback on summary policy briefs and on the content of the role plays for
this scenario consider whether teams used available data to make the case for resources
and programming to address the needs of MSM and transgenders and address barriers in
accessing services.
For example did they use data to support or illustrate the following issues:
• MSM disproportionately affected by HIV in India compared with general population
(NACO 2005; compare MSM and ANC national data)
• While available data shows high prevalence among MSM in India; there is a need for
better data, both epidemiological and behavioural to understand and address HIV risk
among MSM, and transgenders (e.g. Lancet; NACO 2005; Dandona)
• Effectiveness of condoms (UNAIDS 2006), yet lack of access to condoms and lubricants
and/or lack of use with male partners (e.g. NACO Resource Pack; NACO BSS 2001;
Dandona; own research study)
• High rates of STI among MSM (e.g. NACO BSS 2001)
• Untreated STIs, and how this increases risk of HIV transmission (e.g. MAP 2005)
• MSM often also have female sexual partners and implications for spread of HIV
(Dandona)
• Stigma and discrimination impedes efforts to respond effectively to HIV risk and impact
among MSM and transgenders (e.g. UNAIDS 2006; TREAT Asia; MAP 2005; own
research)
• Role that addressing stigma and discrimination has in responding effectively to HIV and
sexual health needs of MSM and transgenders (e.g. UNAIDS 2006; TREAT Asia; MAP
2005).
Scenario 2: Police raids hamper effective HIV prevention among
sex workers
When providing feedback on summary policy briefs and on the content of the role plays for
this scenario consider whether teams used available data to make the case for police
compliance with the ITPA circular and specific strategies to improve police understanding of
how these raids impact on the rights of sex workers and the effectiveness of HIV prevention
efforts.
For example did they use data to support or illustrate the following points:
• District police practices are inconsistent with State police policy and ITPA (e.g. Circular;
EAP Sex work brief; Thottiparambil)
• Data on HIV prevalence among female sex workers in Karnataka shows that sex workers
still disproportionately affected by HIV compared with the general population (NACO
2005; compare FSW and ANC national data)
• Effectiveness of condoms in HIV prevention (UNAIDS 2004), but access to condoms
reduced by raids
• Evidence of successful HIV prevention in brothel setting is also being undermined by
raids (WHO Sex work fact sheet)
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