Mainstreaming HIV into Water, Sanitation and Hygiene (WASH)

On the Road to HIV &
WASH Integration

Regional Management Team
Meeting
2 nd November 2012 Siavonga, Zambia

Rouzeh Eghtessadi (MPH)
Southern Africa HIV and AIDS Information
Dissemination Service (SAfAIDS)
479 Sappers Contour, Lynnwood, Pretoria, South Africa
Tel: +27 76 381 2425
Website: http://www.safaids.net
Email: rouzeh@gmail.com

HIV/AIDS INFORMATION : the power to make a difference
SAfAIDS - P O Box A509,Avondale, Harare, Zimbabwe, Tel: 263 4 336193/4, Fax: 263 4 336195, E-mail: info@safaids.org.zw, Website: www.safaids.org.zw Southern Africa
HIV/AIDS Information
Dissemination Service

Activity A: Quiz & Gallery Wall
Together:
Who has been affected by HIV ?
Who has taken an HIV test?
Who has disclosed their HIV status to another person ?
Who has integrated some aspect of HIV into their work?

Individual: Hesitations, Aspirations & Experiences Gallery
On yellow card share an experience you have had, either in the
WASH environment or in your personal life, related to HIV

On pink card share your hesitations, IF you have any, to linking HIV
and WASH for programmes (externally) and workforce (internally)

On blue card share your aspirations (positive), IF you have any, to
linking HIV and WASH integration


Intended Vision……
WaterAid to emerge as pioneer and role
model in sustainable integration of HIV into
WASH in the SADC region and beyond


Building the Case…….
• Main objective of comprehensive water, sanitation and hygiene
(WASH) interventions is to improve quality of life for individuals,
families and the community. With advent of HIV (WaterAid
positioned in epicentre of global epidemic) this becomes paramount

• WaterAid (Ethiopia, India, Nepal, Tanzania), early 2004/recent 2011,
shown evidence of benefits of mainstreaming HIV into WASH

• Integration (multi-disciplinary/sectoral) vs Silo practice is direction
the development sector/funding priorities is shifting – unavoidable!

• Like all sectors, WASH sector is susceptible to HIV – reality check !
– HIV can reverse gains made externally
– Capacity to delivery can be compromised internally


HIV Response Spheres
Response is developmental, not Health Sector
responsibility only :
• Prevention - ABC, gender based violence, VCT
• Care – home based care, positive living, health system monitoring,
nutrition & food security, access to water/sanitation
• Support – access to resources & services, peer support networks &
groups, capacity building
• Treatment – ART, opportunistic infections
• Advocacy – awareness raising, combat stigma & discrimination,
community and policy maker mobilisation, correct messaging
• Research – build body of evidence
• Mitigation & Litigation – legal aid for human rights violations,
willful transmission, building conducive environment


Links to Wateraid SA Strategy 2013-
• Principles
2015
– Equity and Inclusion (prioritise beyond disability, eg OVC, child and female
headed & PLHIV affected households etc)
– Community participation (strategic partnerships, advocate involvement of
community to represent those with greatest need eg women, PLHIV)

• Influence 3 levels through 5 Aims
– Organisational (culture, funding, development)
– Policy (legislative)
– Programme (service delivery, advocacy)

• Key shifts
– Cross-sector working & synergy building
– Systematic learning and documentation of BPs
– Collaboration & partnerships with SADC PF, SADC Sec Water Division
– Deepening learning (esp water security, disaster risk reduction)

Specific HIV and WASH
Linkages between HIV and
Perspectives categorizing linkages
WASH include:

• Consumer
• Health
• Human Rights
• Gender
• Community-driven development
• Poverty Alleviation

Institutional: internal capacity for WASH at community and
higher levels being lost, compromising delivery


Critical Consumer Links with HIV
• HIV affected households impoverished unable to pay
user fees forfeit right to quality water & sanitation

• Indigenous knowledge in water and other natural resource
management lost leading inappropriate ways of utilisation

• Households sink further into poverty exploitation of
natural resources as alternative, result in water exploitation

• Shift in “care-economy” from institution to home-base care
(influenced by cultural pref); lack of skills on recycling and
multi-water use techniques excessive water usage
during home-based care; limited knowledge in hygiene
practices lead to opportunistic infections (OIs)


Critical Health Links with HIV (1)
• Quality, Quantity, Affordability, Access:
– Successful adherence to antiretroviral treatment
regimens , TB treatment etc
– Mixing powdered formula for infant feeding as well as
nutrition boosting for ill adults, need safe & ample water

• Technological design & infrastructural access
– Facilitate fetching water by children from HIV-affected
households or people living with HIV (pump handles too
low, too heavy, walls of the well too low etc)
– Distance and mobility capacity need regauging


Critical Health Links with HIV
•
(2) & sanitation practices:
Poor water handling, storage

– Personal hygiene, domestic hygiene (ARVs, OIs), food
hygiene (TB, diahorrea) and environmental hygiene
– Safe waste water disposal and drainage increase water
and sanitation related diseases- OIs

• Poor access to sanitation:
– Stds on closing distance gaps for fetching water by care-
givers or PLHIV who are weak; and disposal facilities and
access – revise to suit the population need
– Risk of rape while fetching water or relieving oneself in
remote places, thus increasing vulnerability to HIV

Mr. Singh’s Life Changing Experience
A driver in India, diagnosed with HIV, whose wife and 3 children also
have HIV. Wife passes (2009), leaving him alone to care for children.
His health deteriorates rapidly, with frequent episodes of diarrhoea.

WaterAid India, in partnership with AIDS Control Society in Uttar
Pradesh State, rolled out a project for PLHIV. Through the project
Mr.Singh and other PLHIV received
-Key hygiene messages and counseling, including information on hand-
washing, safe water handling, diarrhoea management and use of boiled
water for taking ARVs
-Hygiene kit containing soap, chlorine tablets, Dettol, a towel & pamphlet

“Before I was very ill, and now I suffer from diarrhoea less, can manage on
my own, and look forward to working and earning money I need to care for
my family” - testifies Mr. Singh

Critical Health Links with HIV(3)
• Burial issue and safety of transmission myths can be
strategically addressed by WaterAid

• Reverse erroneous beliefs that contribute to HIV
related stigma and discrimination (via advocacy) eg:
– “people can become infected with HIV due to groundwater
pollution near burial sites”
– “people (playing children) can become HIV infected through
poor waste disposal practices: condoms and sanitary pads”


Critical Gender Links with HIV
• Women burdened with care roles, once “labelled” they face
double-stigma and exclusion from community WASH
participatory activities – omitted from equitable access
• School enrolment rates for girls decrease in communities
with high HIV prevalence rates; they are required to take on
a wider range of household and domestic responsibilities
(fetching water and using it for domestic/agriculture/HBC)

• Water collection is time consuming – done by women/girls,
thus WLHIV’s health deteriorate - less time for self-care,
and gender practical needs. Often due to gender biases in
access to information, they don’t have hygiene knowledge


Critical Community-driven Links
• with HIV
HIV related stigma and discrimination compromises
participation of PLHIV and affected households , social
cohesion is weakened and traditional participatory channels
become dysfunctional . Community empowerment fails!

• What in WASH sector is known as “community
management” can be compared to “community HIV
competence” environmental sustainability
– Placing communities in the driver's seat
– Requires government & civil society to be demand-
responsive, to build capacities and to create an enabling
environment by providing technical support, formation of
partnerships and supportive policy frameworks


Critical Human Rights Links with
HIV (1)
• Stigma & discrimination of HIV affected/infected families
becomes exclusion factor for participation in community-
based WASH related decision- making

• Access to safe water and sanitation is considered not only a
basic need but also a human right – For ALL! (advocacy)

At the Johannesburg World Summit for Sustainable Development, delegates
of the "The Civil Society Action Programme on Water" launched a statement
saying that secure access to sufficient safe water and sanitation to meet basic
human needs, including water for small-scale productive use to support
livelihoods strategies, must be considered a human right


Critical Human Rights Links with
HIV (2)
• Actively involving people affected by HIV (PLHIV) proven
– To be an effective strategy to tackle S&D and create
more openness, in all sectors including WASH
– That PLHIV can also be employed as effective &
productive workers eg as WASH community
mobilisers/peer educators (supermarket house-to-
house approach sharing HIV and WASH information)

• Promoting MIPA necessary to ensure that the voices of
people living with HIV are heard within WASH circles


Critical Poverty Alleviation Links
•
with HIVas education, health
Poor access to basic services such
care and water and sanitation, are the same factors that are
driving vulnerability to HIV infection

• Adequate water supply, and access to sanitation and
hygiene service and technologies
–saves labour and energy;
–contributes to diversification of income;
–generates nutritional value;
–reduces expenditure on health
……… thus implicating sustainable livelihoods


“Having no proper sanitation means that there is a vicious cycle of poverty,
diseases and bad hygiene…… The cycle of epidemic is at a stage where many
people are falling sick. Through home based and palliative care, people are
looked and cared for. One of the important ingredients of care is water…”
Nkululko Nxesi (Director, South African National Association of People living with AIDS (NAPWA)


Activity B: Mainstreaming HIV into WaterAid Regional
Strategic Aims (2012-2015)

Group Guide:
•How is HIV related to the programme objectives under
this Strategic Aim?
•Would addressing HIV contribute to meeting targets of
each objective under the Aim?

Group 1 = Aims 1 and 2
Group 2 = Aims 2 and 3
Group 3 = Aim 5 and ideas on penetrating HIV sector


Defining Mainstreaming (1)

Mainstreaming is a process that enables
development actors to address the causes and
effects of HIV in an effective and sustained
manner, both through their usual work and
within their workplace (UNAIDS)


Defining Mainstreaming (2)
• Internal Mainstreaming (IM pre-requisite for EM
effectiveness) involves
– Changing organisational culture - policy and practice - to reduce the
susceptibility to HIV infection and vulnerability to the impact of AIDS
– Preserving workforce well-being and organisational productivity
– Building synergy with HIV expertise for capacity building internally

• External Mainstreaming (EM) refers to
– Adapting programme work to take into account susceptibility to HIV
transmission and vulnerability to the impact of AIDS
– Keeping HIV on the agenda of core programme work in the
changing context of WASH needs and gaps
– Advocating WASH into HIV interventions


Mainstreaming
Assumes
Internal sphere
(workplace, your
•multi-disciplinary organisation) Mainstreaming
HIV
•multi-level and
&
•multi-sector
approaches External sphere
(your
cooperation
activities)


Mainstreaming HIV is not …….
• Changing core functions and responsibilities in order to turn
all organisational activities into HIV programmes

• Simply introducing HIV awareness raising in all activities -
should be more systematic

• All staff having to become HIV specialists

• Business as usual …………


“Turning the Tide” of WASH
Organisational Culture ‘main’ stream’

EXTERNAL
INTERNAL

… automatic flow into all core
business offshoots… ‘process’
not ‘event’

Mainstreaming HIV (1)
– Context & Organisational Profile (HIV
Audit/Situational Analysis) - How is HIV affecting your
organisation? Your work?

– Impact of HIV on WASH– activity map tracking HIV influence

– Impact of WASH on HIV – risk, vulnerability, responses &
entry point identification

– HIV Transformative Strategy/Policy/ Costed
Program: awareness raising-reflection-action, advocacy, S&D
combated, universal access, policy and support mechanism
establishment, budget review, M&E plan, research & documentation,
knowledge sharing ; synergy building with HIV sector actors


Mainstreaming HIV (2)
• Simply : let’s ask ourselves Four Key questions:
– How does HIV affect my organisation ?

– How does HIV affect my work?

– How can harm due to HIV be avoided?

– How can I contribute to responding to HIV by limiting the
spread, and mitigating the impact of the epidemic?

– What HIV sector activity can I showcase WASH at?


Step 1: Baseline Analysis
INTERNAL SPHERE EXTER
NAL S
PH ERE
Organisational analysis:
Contex
– How are staff and their t analy
 Wha sis:
families affected? t is gen
eral HI
situatio V
– Impact of HIV on human n in co
 Im p mmuni
resources in the sector? acts of ty ?
HIV
on the
– What institutional WASH
 Poli sector?
instruments are available cies an
d majo
to respond? respon r
ses?
– What resources are  Stak
eholde
r
available to respond? analys
is?
 Res
ource a
nalysis
?

Step 2: Use Baseline Analysis Results to
answer how HIV affects your organisation
and your work
Assess the impact of HIV on:
• The workplace and your organisation

• The beneficiaries of your programme

• What you want to do (including whether your objectives
and activities are relevant and feasible in the HIV context)

Then discuss how vulnerable your cooperation activity is to HIV
and what changes need to be made?


Step 3: Analysis of Potential Negative
Implications of “ignoring the HIV agenda”
How to do “no harm”? Do your cooperation
activities increase:
• Population mobility

• Gender inequalities

• Exclusion of PLHIV or other vulnerable groups

• Risk situations for gender based violence/ sex work/unsafe
sexual practices/compromised access to services

Then plan corrective actions

Step 4a: Develop an HIV Workplace policy &
programme

Source: ILO


Step 4b: Plan and implement your contribution
to responding to HIV
Assess, where your comparative advantage is highest for
making a difference, and design costed plans in terms of:
• Risk: helping people to behave safer and avoid risk
situations

• Vulnerability: acting on developmental factors that increase
the vulnerability of population groups to HIV

• Impact mitigation: help affected people and communities
to cope with the effects of HIV


Step 4c: Monitoring - develop indicators to
measure change
– Outcome: Has behaviour of beneficiaries and/or way of
working of staff/partners changed in the intended way

– Impact: What impact did this make in terms of changing
the HIV epidemic and its context? (BUT: avoid the pitfall
HIV prevalence or mortality!)

– Process: Which process did you use - with what effect?
What works and what doesn't? what has been learnt ?


Essential Principles in HIV
Mainstreaming (1)
• Adapted to your context- no standard approach (varied
combinations of organisational, sociology, logframe elements)
• Relevant at all stages of the epidemic, also in low
prevalence contexts
• Continuous and integrated
• Gender sensitive approach
• MIPA involving people living with HIV
• Networking & coordination
• Advocating
• Sharing of good practices and lessons learnt
• Generating evidence through continuous monitoring


Mainstreaming (2)
To be successful :
• Consider HIV as a development issue

• Commitment and support of decision makers

• Clearly defined objectives for mainstreaming

• Knowledgeable, compassionate and skilled staff

• Document and share experiences through knowledge
sharing systems, appropriate messaging and packaging


Mainstreaming (3)
To be successful (cont) :
• Expertise and support available and made use of; explore
penetrating HIV sector events (International AIDS
Conferences, ICASA, National HIV Strategic Planning
Forums, etc)

• Sufficient allocation of resources (human, financial,
technical)

• Willingness to learn, reflect and share


Activity C: Back to Our Gallery Wall

-How do we feel about the
- Hesitations?
- Aspirations
- Building on our experiences?

-Roadmap: reaching the HIV & WASH
Integration “destination”


Thank you …..
Zikomo


Mainstreaming HIV into Water, Sanitation and Hygiene (WASH)

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