Leveraging Opportunities To Integrate Reproductive Health Services Into HIV and AIDS Programming: Integrated HIV and AIDS Response in Manica Province, Mozambique

Leveraging Opportunities to
Integrate Reproductive Health

Services Into HIV and AIDS
Programming
Integrated HIV and AIDS

Response in Manica Province,
Mozambique
Project Lessons Learned and Models of

Promising Practice
Kerry Zaleski
SRHR and HIV Advisor
Global Centre of Learning on HIV and AIDS
Oxfam GB
Table of contents
Summary.........................................................................................................................................5
Acknowledgements ......................................................................................................................6
Part 1. The project: 'Leveraging Opportunities to Integrate Reproductive Health
Services into HIV and AIDS Programming' ............................................................................8
Context ........................................................................................................................................8
Project change strategy ...........................................................................................................10
Lessons learned ........................................................................................................................11
Project design .........................................................................................................................11
District steering committees (DSCs) .....................................................................................12
STAR: 'Societies Tackling AIDS through Rights' ................................................................12
Gender mainstreaming...........................................................................................................16
Working with traditional healers ...........................................................................................17
Integration of services ............................................................................................................21
Traditional attitudes and beliefs among leaders .....................................................................22
Advocacy and policy...............................................................................................................23
Overall project lessons learned...............................................................................................27
Part 2. The deeper-rooted issues associated with sexual and reproductive ill-health and
HIV and AIDS .............................................................................................................................30
Gender inequality and the feminisation of HIV and AIDS................................................30
Unequal power relations.........................................................................................................31
The ABCs of marriage .............................................................................................................32
HIV and young people............................................................................................................33
HIV and older people..............................................................................................................34
Legal frameworks ....................................................................................................................37
The Family Law of Mozambique...........................................................................................37
Violence against women .........................................................................................................39
Sexual and reproductive rights..............................................................................................41
Multiple and concurrent partnerships ..................................................................................42
Stigma and discrimination......................................................................................................42
Part 3. Integrating SRH and HIV and AIDS services and programming .........................44
'One-stop-shop' model ............................................................................................................45
First points of contact ..............................................................................................................45
PMTCT Plus model..................................................................................................................46
Overall recommendations for integrated SRH and HIV and AIDS programmes ..........48
Summary checklist...................................................................................................................50
Bibliography ................................................................................................................................51
Appendices...................................................................................Error! Bookmark not defined.
I. Manica change strategy..................................................................................................56
II. Framework for priority linkages...................................................................................58
III. Key elements of STAR................................................................................................59
2 Integrated HIV and AIDS Response in Manica Province, Mozambique

Oxfam GB, August 2009
V. Resources .....................................................................................................................61
Notes.63

Abbreviations and acronyms
AIDS Acquired Immune Deficiency Syndrome

AMETRAMO Associacao de Medicos Tradicionais de Mozambique
(Mozambique Association of Traditional Healers)
ANC Antenatal care/clinic
CBO Community-based organisation
CEDAW Convention on the Elimination of all Forms of Discrimination
against Women
CSO Civil society organisation
DDS District Directorate of Health in Mozambique
DPS Provincial Directorate of Health in Mozambique
DSC District Steering Committee
DV Domestic violence
EC Emergency contraception
ExPo Expanding Potentials prototype
FBO Faith-based organisation
FP Family planning
GBV Gender-based violence
HIV Human Immuno-deficiency Virus
IDU Injection drug user
IEC Information, education, and communication
IPV Intimate partner violence
M&E Monitoring and evaluation
MCH Maternal and child health
MCP Multiple and concurrent partnerships
MDGs Millennium Development Goals
MOH Ministry of Health
MSM Men who have sex with men
NGO Non-government organisation
OVC Orphans and vulnerable children
PEP Post-exposure prophylaxis
PLHIV People living with HIV
PMTCT Prevention of mother-to-child transmission
SEA Sexual exploitation and abuse
SGBV Sexual and gender-based violence
SRH Sexual and reproductive health
SRHR Sexual and reproductive health and rights
STAR Societies Tackling AIDS through Rights
STI Sexually-transmitted infection
SV Sexual violence
TBA Traditional birth attendant
VAW Violence against women
VCT Voluntary counselling and testing

The overwhelming majority of HIV infections are sexually transmitted or
associated with pregnancy, childbirth and breastfeeding; that both sexual and
reproductive health initiatives and HIV/AIDS initiatives must be mutually
reinforcing; that both HIV/AIDS and sexual and reproductive ill-health are
driven by many common root causes, including gender inequality, poverty and
social marginalization of the most vulnerable populations.
UNFPA, The 2004 New York Call to Commitment:
Linking HIV/AIDS and Sexual and Reproductive Health
Summary
Oxfam GB, in partnership with the Ministry of Health in Mozambique and with
support from the William and Flora Hewlett Foundation, launched a two-year
project in August 2007 that aimed to increase access to and the quality of sexual
and reproductive health (SRH) and HIV and AIDS services, and to reduce the
vulnerabilities associated with sexual and reproductive ill-health and HIV and
AIDS, in Machaze and Mossurize Districts of Manica Province, Mozambique.
Project activities worked towards supporting and building the capacity of local
health workers and traditional healers, tightening the referral chain between
various HIV and SRH services, and strengthening overall systems to be able to
respond to the deeper-rooted issues identified by the community associated with
SRH problems and HIV and AIDS. The project used a rights-based approach
(based on human rights principles of equality, non-discrimination,
accountability, and participation) to empower community members to make
informed choices about their sexual and reproductive health and to demand their
right to essential services from their government. 1
One of the main objectives was to draw out lessons learned for Oxfams global
programming, with a particular focus on access to essential services. Throughout
the projects life cycle, a number of lessons conceptual, programmatic, and
advocacy-linked have been drawn out during implementation and monitoring
and evaluation. These lessons have been documented in order to learn, explore,
and share opportunities for improvement in future integrated sexual and
reproductive health and rights (SRHR) and HIV and AIDS programmes. They
are also intended to point out particular problems or challenges the project faced,
in order to avoid similar constraints in future projects.
Data were gathered from project reports and documents such as surveys, focus
group discussions, key information interviews, semi-structured interviews with
staff and partners, monitoring, evaluation and learning reports, training and
workshop reports, minutes of meetings, clinical records, observations made
during field visits, and secondary data.

The first section of this report discusses lessons drawn specifically from the
integrated SRH and HIV project in Manica Province, Mozambique. The second
part elaborates on some of the deeper-rooted issues that were identified by
project stakeholders (rights-holders, government representatives, health workers,
local leaders, and partners). Many of the issues overlap and are intricately linked
in the cycle of poverty, inequality, and HIV and AIDS. Research, models, and
interventions from other organisations, countries, and programmes are
mentioned in Part 3 to stimulate thinking and debate, as well as to suggest
promising practice for integrated SRH and HIV programming. Overall, this
paper highlights the progress made and challenges still faced by the international
community in addressing the complexity of issues associated with HIV and
AIDS in relation to SRHR, in a combined effort towards achieving the
Millennium Development Goals. 2
Acknowledgements
This project was made possible by the generous funding support of the William
and Flora Hewlett Foundation, Menlo Park, California. Oxfam would like to
especially thank Nicole Gray and Sara Seims of the Population Programme at the
Hewlett Foundation for their steadfast encouragement and support of this pilot
project, and this reflective publication.
Oxfam would also like to thank the following:
Communities of Machaze and Mossurize Districts, Manica Province,

Mozambique for their meaningful participation throughout the
implementation of this project;
The Ministry of Health in Mozambique for collaboration on this project;
The CNCS (National AIDS Council) of Mozambique especially for its

involvement in workshops and trainings and for leading the ExPo prototype;
District Administrators of both Machaze and Mossurize Districts for their

active engagement in meetings and workshops and for supporting this
important work;
Rudo Kubatana, a local partner organisation, for support in trainings and

special events;
District Steering Committees in Machaze and Mossurize for their active

engagement, ideas, and willingness to step outside of their comfort zones;

AMETRAMO, the association of traditional healers in Mozambique, for its
motivation to learn new skills and test out innovative ideas for fighting HIV
and AIDS and gender-based violence;
The entire IHARM (Integrated HIV and AIDS Response in Manica Province)
programme team.
Appreciation also goes to Kristen Uhler-McKeown, the projects Funding

Manager in Oxford, for her ongoing support, patience, and commitment to
ensuring the success of the project.
Finally, thanks to the Global Centre of Learning on HIV and AIDS for its ongoing
technical support and advice in steering the project in the right direction and for
providing funding for learning and innovation.

Part 1.
The project: Leveraging Opportunities to

Integrate Reproductive Health Services into
HIV and AIDS Programming
Context
Mozambiques population is estimated at 20.5 million, with a life expectancy at
birth of 37 years. 3 It is one of the 20 poorest countries in the world and ranks 175
out of 179 countries on the 2008 Human Development Index, which factors in life
expectancy, adult literacy, school enrolments, and GDP per capita. There is a
population growth rate of 1.79 per cent. Sixty-three per cent of the population
live in rural areas. 4 In 2007, the maternal death rate was 163 per 100,000 live
births and the infant mortality rate was 115 per 1,000 births. The fertility rate was
5.2 children born per woman. 5
Approximately half of the adult population lives in poverty and close to 58 per
cent of children live below the poverty line of less than $2 per day. Sixty-six per
cent of men and only 33 per cent of women are literate. 6
Mozambique has a high HIV prevalence, with 1.5 million people living with the
virus, including 100,000 children. Adult HIV prevalence is estimated at 12.5 per
cent of the population. 7 Sixty per cent of those infected are women. Infection is
significantly higher among young women and adolescent girls in the age group
1524 years. UNAIDS and WHO estimates for 2007 show HIV prevalence among
young women at 8.7 per cent, compared with 2.9 per cent for young men,
demonstrating how HIV is disproportionately affecting women and girls. The
multiple effects that make women and girls in Mozambique vulnerable include
low literacy; low use of contraceptives, particularly condoms; gender and power
inequalities, including sexual and domestic violence; early marriages in
traditional communities; poverty and lack of economic opportunities (which
contribute to girls and young women engaging in sexual transactions or abusive
relationships); multiple and concurrent partnerships; and cultural taboos against
discussing sex among young people, despite the fact that the median age for first
experience of sexual intercourse is 16 years.

Key challenges in fighting HIV and AIDS in Mozambique, listed by the UNAIDS
2008 report, include the following:
There are no HIV surveillance data for key at-risk populations.

Human resource constraints across sectors make scaling up services difficult.
Integration of HIV services with other essential services, including sexual and
reproductive health (SRH), remains challenging.
Civil society is fragmented and has weak capacity, and participation in
national co-ordination mechanisms is limited.
There is a lack of evidence about the drivers of the epidemic.
There is limited evidence about successful HIV programming and what
actually works.
Oxfams Integrated HIV and AIDS Response in Manica Province (IHARM)

programme aimed to overcome some of these challenges by supporting the
district-level AIDS Council to improve surveillance and monitoring and
evaluation of HIV and AIDS programmes; conduct research on drivers of the
epidemic, including stigma and discrimination; and strengthen civil society
organisations to demand their rights to essential services from the government.
This particular project aimed to improve integration of SHR and HIV services by
training health workers, empowering community members to make informed
choices about their sexual and reproductive health, and draw out advocacy
issues identified by the community to influence HIV- and SRH-related policy.
The project worked through two District Steering Committees composed of
multi-sectoral stakeholders, in order to take a holistic approach in addressing key
issues and to improve the overall functioning of systems.

Project change strategy
At the start of the project, Oxfam GB advisors and managers worked together to
draw up a strategy that explained, in their view, how change happens in
development settings, particularly in relation to complex problems such as HIV
and AIDS. The strategy was intended to guide the project implementation.
In summary, the phases and steps of the change process were as follows:
A) Start-up phase: making sense of the issues and building a platform for
change between key players
1- Building a platform, or holding space, around the intent of the project.
2- Scanning the field of change.
3- Joint reflection: revisit the information and kick off the project.
B) Building spaces for behavioural change and strengthening the capacity of

institutions to guide the process
1- Capacity building of institutions and alliance building.
2- Create awareness and empowerment (at the individual level).
3- Change individual behaviour.
4- Address belief systems and other systemic issues.
C) Consistently elevate the project quality and adjust it to circumstances

1- Linking and learning from other projects.
2- Monitoring of progress.
3- Scanning of context.
4- Adjust project accordingly.
This document highlights lessons from various phases of the change strategy, as
well as specific methodologies and approaches used throughout the process.

Lessons learned
Project design
Leveraging Opportunities to Integrate Reproductive Health into HIV and AIDS
Programming was designed to work with the provincial and district levels of the
Ministry of Health (MOH) in Mozambique as the key implementing partner. The
strategy focused on influencing change at individual, family, community, and
systems levels through: 1) training of health workers in areas of sexual and
reproductive health and HIV and AIDS service provision, 2) community
empowerment and 3) multi-sectoral collaboration and action
A multi-sectoral District Steering Committee (DSC) was set up to oversee the

implementation of a change strategy, which mapped out a process for change.
The MOH was responsible for carrying out trainings of health workers, while
Oxfam staff and partners trained community volunteers in the use of
participatory methodologies and facilitation skills for generating community
dialogue and collective action to address the deeper-rooted issues associated
with sexual and reproductive ill-health and HIV and AIDS. Monitoring activities,
workshops, trainings, and special events such as the 16 Days of Activism Against
Gender Violence 8 and World AIDS Day were carried out in collaboration with
the MOH, the National AIDS Council local partners, and community groups in
an effort to raise awareness and advocate for sexual and reproductive rights
throughout the two-year project period.
Lessons learned
1. Investing more in strengthening civil society to demand rights from
government is likely to be more cost-effective and sustainable in the long run
than providing direct grants to government.
2. Frequent turnover of MOH staff over the course of the programme
including four district directors of health, the provincial director, and five
district doctors/medical directors, who were key players during the design
of the project made continuity challenging. This turnover was partly due to
government policy of rotating staff every year. Future projects should
consider such challenges and how they will affect programming during
selection and initial discussions with partners.
3. Conducting a needs assessment is an important first step in being able to

characterise the capacity of partners at the outset of the project. Where
capacity is limited, it is important to allocate funds to cover the gaps and
develop a capacity building plan. Future projects of this nature might benefit

from seconding staff to the MOH or other partner organisations to support
on-the-job training and oversee the smooth running of the project.
District Steering Committees (DSCs)

District Steering Committees were established in Machaze and Mossurize to
serve as a sounding board for the project and to oversee the various stages of the
change strategy. The committees were meant to participate in the information
gathering and thought process in order to increase their understanding about the
actual situation on the ground and to start engagement with communities. The
belief was that using dialogue to bring the best out of the different actors might
be more effective than advocating for change within, for example, the ministries,
which often find themselves restricted by policies, infrastructural issues,
capacity, and funding.
The DSCs (one in each district) were made up of representatives from the MOH,
Ministry of Women and Social Welfare, police officers, womens organisations,
traditional healers, religious leaders, people living with HIV (PLHIV), the media,
the private sector (owners of guesthouses where transactional sex is commonly
practised), NGOs, district doctors, and peer workers (representing communities).
The DSCs discussed key issues presented throughout the lifespan of the project,
including domestic violence, sexual exploitation and abuse of minors, and
harmful traditional practices such as widow inheritance 9 , and developed action
plans to try and tackle the issues through a combined effort.
Lessons learned
1. DSCs were successful in bringing a number of actors from various sectors

together to discuss community-identified issues and problems associated
with HIV and SRH. This helped to clarify responsibilities and bridge some of
the gaps that result from sectors working in separate corners.
2. The political hierarchy and culture of chefe (boss) in Mozambique meant
that even an innovative idea had to wait for a bosss go-ahead. This seemed
to take pace away from good ideas.
Participatory methodologies
STAR: Societies Tackling AIDS through Rights
In an effort to strengthen civil society and empower communities to hold their
governments accountable with regards to essential services, the project team
originally sought to use Stepping Stones 10 as a community empowerment
approach to behaviour change.

Stepping Stones was designed by ActionAid as a participatory learning package
on HIV and AIDS that focuses on relationships and communication skills, with
the aims of reducing HIV transmission, improving SRH, and fostering gender
empowerment. Stepping Stones has been used in a number of countries to
improve sexual health by increasing gender equity through healthy relationship-
building and improved communication between partners. 11 It has been endorsed
by UNAIDS as an example of best practice in addressing gender aspects of HIV.
ActionAid also uses an innovative approach to adult literacy known as Reflect

(Regenerated Freirean Literacy through Empowering Community Techniques). 12
This tool builds peoples capacity to communicate through media that are most
relevant to their situations. It focuses on empowerment and social change and
enables people to plan their development activities based on local realities.
ActionAid recently started piloting an evolution of Stepping Stones and Reflect

known as STAR Societies Tackling AIDS through Rights in a number of
countries. STAR is referred to as an empowerment framework, borrowing
elements of adult learning through participatory methods from Reflect, as well as
elements of HIV and AIDS through participatory methods from Stepping Stones.
It aims to bring together key actors in adult learning/education and the HIV and
SRH sectors at local, national, and regional levels to plan and work together. The
overall goal is community empowerment in the face of HIV with a particular
emphasis on gender equity.
The aims of STAR are commensurate with the objectives of this project,
including:
Increase access to information and knowledge on HIV and SRHR;
Equip vulnerable populations with skills to negotiate and participate in

decisions relating to SRHR and HIV prevention;
Promote processes to enhance access to integrated SRHR and HIV services;
Facilitate processes that foster community involvement in design and

implementation of HIV-related policies.
After learning about STAR through research and a number of discussions with
partners who have had experience with it, the project team decided to test it out.
The idea behind the decision was that bringing together literacy and HIV and
AIDS prevention strategies would not only empower communities to make
healthier, informed choices about their sexual and reproductive health, but also
empower them to demand access to essential services from their government.
STAR was implemented in 10 communities, five in Machaze and five in

Mossurize. A total of 20 facilitators (peer workers)-one female and one male

from each community- were trained by Pamoja Africa Reflect Network on two
different occasions. 13
Peer workers were selected based on a set of criteria including:
Resident in the community or Open-minded; unafraid of change;

neighbouring community for at least willingness to challenge social norms
two years and attitudes
Able to read, write, and speak Non-discriminatory attitude towards

Portuguese and speak the local any population group or individual
community language based on gender, sex, ability, ethnicity,
religious belief, profession, education
At least 20 years of age level, age, or any other characteristic
Able to commit to a full 10-day Completed at least primary school

training as well as follow-up trainings education
throughout the year
Previous voluntary or work experience
Able to commit at least one day per related to sexual and reproductive
week (preferably more) for a minimum health and HIV and AIDS preferred
period of one year to facilitating
sessions for community members Capacity to talk about sensitive issues
in an open and non-judgemental way
Interest in community health and with people both younger and older
behaviour change than themselves preferred
After the initial training, there were a number of follow-up trainings to support
the ongoing roll-out of STAR in various skill and subject areas, including
participatory methods, gender analysis, advocacy, stigma and discrimination,
and documentation. Four of the 20 peer workers (one male and one female per
district) participated in an exposure visit to observe a local partner of ActionAid
in Malawi, and also represented communities at DSC meetings.
Peer workers expressed the feeling that change had taken place in their own
individual behaviours and relationships with spouses, as well as among
members of STAR circles with whom they shared information. For example,
some of the female peer workers said that, after the initial STAR workshop, they
themselves were able to take the information home and discuss with their
husbands how HIV is spread. Some of them even reported showing their
husbands how to use a condom, which was a big step up from the silence that
had previously existed around any topic that had to do with sex. Peer workers
said that their circles were increasing communities understanding of unequal
power relations and how this affected the overall health status of communities.
Successes
Exposure visit: Selected peer workers and partners visited SASO (Salima AIDS
Support Organisation), a local partner of ActionAid in Malawi, to observe the
facilitation of STAR circles in rural communities. This gave them an
opportunity to ask questions and discuss challenges as well as receive tips on
running the sessions effectively. The exposure boosted their confidence in
facilitating their own circle sessions.
Gender training: Peer workers participated in a number of gender trainings by

the Oxfam GB Mozambique Country Programme Gender Advisor. This was
extremely helpful in opening up discussion about gender inequality, as well
as increasing awareness about legislation in Mozambique. The Gender
Advisor did an excellent job in tackling common myths as a first step to
changing harmful and discriminatory attitudes and beliefs associated with
HIV and AIDS.
STAR tool kit: A user-friendly tool kit was produced for peer workers to guide
them in conducting circle group sessions. The tool kit contains worksheets
including an introduction to STAR, energisers, exercises, fact sheets, and key
points.
During STAR circle groups, both men and women revealed that by learning
to use a condom correctly and understanding its purpose in preventing HIV
and STIs, the uptake of condoms was increasing as a means to prevent HIV,
as well as enabling child spacing among married couples. This was an
achievement, as the baseline survey results from Machaze and Mossurize
Districts showed that only 13 per cent of respondents (aged 1549) had used
a condom during the previous year.
Lessons learned
1. Follow-up trainings on various skill and subject areas are essential to

building the capacity of peer workers as community change agents.
2. It is important to counter-check selection criteria when recruiting peer

workers, and complementary arrangements should be made to address the
gaps. For example, some of the peer workers did not know how to read and
write, which made it difficult to document their circle sessions. In this case,
adding on a literacy component would have been helpful.

3. A number of powerful case studies were shared orally during workshops
about experiences people had had, particularly in areas of stigma and
discrimination, human rights violations, and sexual and gender-based
violence. Case studies can serve as a powerful advocacy tool, but they must
be documented and must follow ethical standards of confidentiality,
privacy, and consent.
4. Orientation should be designed in a way that enables facilitators to look for

local solutions and work closely with civil society organisations and
government institutions. In future projects of this nature, recruiting peer
workers from local CBOs or NGOs might help to sustain the project
activities, facilitate regular meetings between peer workers, and continue
advocacy efforts once the project ends.
5. Time management became problematic during trainings due to the

unexpectedly long time it took to translate workshops into Portuguese and
local languages. Some terminology used in STAR did not make sense if
translated directly, and therefore needed further explanation for example,
unpack the issue. Future projects should consider this, and ensure that
enough time is allotted for the translation of key concepts.
Gender analysis and mainstreaming

Equal participation of women in all activities was key to addressing the deeper-
rooted issues of gender inequality and unequal power relations. Women with
small children were accommodated during trainings and workshops through the
provision of child care, food, and diapers. Time was given during breaks and
lunch for breastfeeding, which allowed women to participate fully in important
activities such as the power analysis and values clarification exercise.
Gender analysis framework: A gender analysis framework, which looks at control

and access to resources, was adapted to explore control and access to sexual and
reproductive health resources. Peer workers, partners, and DSC members
participated in sessions that analysed how power relations dictate sexual and
reproductive health. For example, women tend to have more access to family
planning clinics than men. However, at the end of the day, it was men who made
the decisions about if, when, and which family planning methods were used.
Men, therefore, had more control over family planning than women. In a number
of sessions, it was revealed that rejection of family planning by husbands was
common, and that women were often afraid to initiate discussions around the
subject. This framework was valuable in understanding the disparities in power
and control that exist between genders with respect to sexual and reproductive
health decision-making and hence access to rights.
Lessons learned

1. As a result of these basic and low-cost provisions, womens active
participation was an important contribution to the success of this project in
addressing the deeply embedded attitudes and beliefs that fuel gender
inequality, poverty, and HIV.
2. Gender trainings using gender analysis frameworks for all stakeholders,

including DSC members, partners, and Oxfam staff, were vital in
challenging the traditional attitudes and beliefs that fuel inequalities.
3. Adapting the gender analysis framework to explore access to and control of

sexual and reproductive health resources highlighted the need for
increased access to SRHR information for men, which can lead to better
understanding about the choices and options available and encourage
mutual decision-making between partners.
Working with traditional healers

Although some traditional healers and traditional birth attendants have found
accommodation in formal health system structures, for the most part they are
still left out of referrals, networking, and training opportunities. Traditional
healers, whose remit and methods of operation go well beyond conventional
treatment, are a potential resource for SRH and HIV prevention, treatment, and
care. Not only do they heal physical ailments with herbal concoctions; they are
also trusted for their abilities to treat mental illnesses and spiritual
maladjustments.
HIV and AIDS is perhaps one of the biomedical conditions that, because of the
perception of it as a terminal illness and its association with death, often evokes
mental as well as spiritual anguish among those affected by it. It is therefore not
uncommon for HIV and AIDS patients to turn to traditional healers in the same
way that people with mental illnesses do or those with any other health
problem for which modern medicine has yet to find a cure.
In Oxfams Situational Analysis of Mozambique in 2006, a report by UNESCO is

cited:
Traditional doctors curandeiros have been reluctant to participate in government

programmes aimed at increasing awareness of the epidemic. However, since
traditional healers are generally respected and because they strongly influence the
behaviour of persons in their communities, they are important cultural references in the
combat against HIV/AIDS. Increasing their understanding and securing their
participation to effect positive changes in behaviour remains a big challenge for
Mozambique. 14
A study conducted by Concern Worldwide in Machaze District in 2006 showed

that 81 per cent of people in the locality of Chitobe visited traditional healers for
one or more health concerns. 15 Most people with HIV in rural communities rely
on traditional medicine when they first start experiencing HIV-related
symptoms. Even if they eventually seek care at a health facility, it is often too late
to start antiretroviral therapy (ART) and suppress the replication of HIV.
Normally, people who have already developed full-blown AIDS by the time
they start ART do not survive.
There are a number of herbal remedies that are effective in strengthening the
immune system, increasing appetite, and treating opportunistic infections
associated with HIV, including thrush, skin diseases, sexually transmitted
infections (STIs), and chronic diarrhoea. 16 It is possible to link traditional healers
in a comprehensive HIV care and treatment approach if enough research is done
to identify and educate traditional healers and medical providers about, for
example, interactions between specific traditional treatments and ART.
Traditional healers are important participants in all aspects of integrated SRH

and HIV services, including family planning. For example, in the baseline survey
conducted at the start of this project, 33 per cent of women mentioned traditional
herbs as a way to prevent pregnancy. This suggests the influential role of
traditional healers in serving SRH needs. In resource-poor settings like the
communities in Machaze and Mossurize Districts, poor people turn to traditional
healers for a number of reasons. These include the convenience of proximity i.e
not having to travel for hours on foot to reach the clinic; no waiting in long
queues; the fact that many traditional healers make house calls; and affordability
traditional healers often accept in-kind payment such as chickens or goats,
unlike formal health facilities, which require cash.
Considering the important role that traditional healers play in treating

opportunistic infections associated with HIV and AIDS and other SRH problems,
and the potential to maximise options and informed choices for SRH and HIV,
the project made efforts to involve traditional healers in areas of training,
capacity building, and networking. Health worker trainings led by the MOH
included refresher trainings for traditional birth attendants (TBAs) on clean and
safe deliveries and HIV and AIDS. Additionally, the project worked with the
association of traditional healers in Mozambique (AMETRAMO) to expand the
roles of healers to include HIV and STI prevention, as well as advocacy and
referrals for sexual and gender-based violence. This was part of a pilot
prototype, developed as a result of a workshop on a leadership process known
as the U-Process. The workshop was convened in order to help project
stakeholders identify and test out new and innovative strategies for combating
HIV and AIDS.
Theory-U
As part of the adaptation of the project and the space given within it to respond
to changing needs in order to make it meaningful to the communities, key

stakeholders were trained in Theory-U, a leadership approach to dealing with
complex issues, led by Oxfam GBs Global Centre of Learning Capacity Building
and Leadership Advisor, Martin Kalungu-Banda.
Theory-U forms the philosophical and practical underpinning of the U-Process:

the socio-technology used to facilitate deep or profound change at
organisational, community, or personal levels (for more on the U-Process, see
Annex IV). As a tool for bringing about change, the U-Process can be used to
shift systemic forces of complex problems that keep recurring after other
approaches have been tried. The process creates an environment in which new
possibilities and insights are discovered and tested out quickly and practically by
a technique known as prototyping. A prototype is a small-scale representation
of the larger reality. The argument in favour of prototyping is simply that many
initiatives fail because they start out too ambitious, or too big. When the initiative
begins with a prototype, wisdom is acquired through learning by doing. The
actual experiences throughout the implementation help to identify new insights
and elements that work well. Scaling up on the basis of this learning has more
promise of success than starting out big, without really knowing what to expect.
One of the outgrowths of the U-Process workshop was the development of a

prototype entitled Expanding Potentials (ExPo), which aimed to engage
traditional healers in the fight against HIV through training of trainers, job
shadowing, construction of a resource centre, and an inventory of SRH and HIV
resources in Machaze District. Male and female traditional healers from
AMETRAMO were trained as trainers by local partner organisation Rudo
Kubatana in STIs, HIV and AIDS, and referral mechanisms. They learned to
screen and refer cases of sexual and gender-based violence (SGBV) to the health
facility and to the Gabinete de Atendimento (Centre for Assistance, located
within police stations, which provides support services to victims of violence), as
well as mechanisms to document their services through the use of pictures and
checklists (specially designed for healers who are unable to read and write).
A network of traditional healers, protection officers from the Gabinete de

Atendimento, and HIV counsellors was established to discuss key issues
associated with HIV, SRH, and SGBV. The group continues to meet every month.
Finally, an inventory of all SRH and HIV services (traditional, private, and
public) throughout the district was conducted by a representative from the
district-level AIDS Council to be disseminated to all service providers in order to
improve collaboration and increase referrals and utilisation of services.
Positive feedback from community members, traditional healers, and medical

providers demonstrated the benefits of involving traditional healers in efforts to
improve SRH and access to HIV prevention, care, and support.
Lessons learned

1. Training of traditional birth attendants on maternal and child health is
valuable. The baseline survey showed that only 37 per cent of women
received prenatal care at health units. The training emphasised the
importance of antenatal care, clean and safe deliveries, and how to handle
complications, including prompt referral to a clinic or hospital. District
doctors and nurses reported experiencing an increase in referrals from
traditional healers for STIs and antenatal cases as a result of the training. This
can also help reduce mother-to-child transmission (MTCT) of HIV, when
integrated with antenatal care (ANC) and maternal and child health (MCH)
programmes.
Before this programme one of our health facilities in an area where traditional
birth attendants are the norm used to attend to an average of about 12 births per
month. Now that has gone up since this project started to an average of 30 per
month, most of whom are referred by the traditional birth attendants in this
programme.
District Director of Health, Mossurize District Hospital 17
2. Although the project helped to bring traditional healers into the networks,
they still reported challenges in engaging meaningfully in a structured way
that would make the partnership a two-way rather than a one-way
relationship.
We have referred many patients to the health centres, but we never get the
health workers refer any to us, why? We do not even get feedback.
Traditional healer in Chipopopo, Machaze District 18
3. Traditional healers reported feeling empowered by their new roles as

promoters of HIV prevention as well as advocates for survivors of gender-
based violence and people affected by HIV and AIDS. They expressed a
desire for more training so that they could continue to enhance their skills
and contribute to HIV and AIDS efforts.
4. Many traditional healers said that, as a result of the project, they had started
modifying traditional practices, such as avoiding the use of cutting
instruments on more than one patient, and promoting safer sex, including
condoms, as a regular part of their service.

Members of AMETRAMO and partners during an HIV and AIDS training in Machaze
District, 2008
Integration of services
A plan of action on SRHR was put together in the Maputo Plan of Action report
by the African Union Commission (2006), where it was agreed that all African
countries should have SRH and HIV integration in all key national health policy
documents and plans, including health management of GBV in the curriculum of
health workers. However, there are a number of challenges around the definition
and operationalisation of integration that must be ironed out in order for the
concept to work in practice, particularly in resource-poor environments.
The project in Manica is no exception to these challenges. However, the overall

response from the project, particularly as a result of trainings of health workers
and delegation of new SRH health staff, was positive. Community members
expressed the feeling that the quality of services had improved, and health staff
felt that they were better able to treat the comprehensive SRH and HIV and AIDS
needs of patients.
Through the assistance of this programme the Health Ministry posted an

obstetrician and gynaecologist to this health centre to attend to sexual and
reproductive concerns of female patients. This has increased the number of early
diagnoses of STIs. We also have many expectant mothers on ARVs under the

PMTCT programme as well as children who are taking ARVs. We are glad that
out of 70 children born to HIV+ mothers, four have now been tested after
attaining the age of 18 months and they are all HIV-negative. The rest will be
tested as soon as they are 18 months old.
District Health Director, Machaze District 19
Lessons learned
The project operated in a policy vacuum in the sense that local health workers
did not seem to clearly understand how to put integration of services into
practice. They were expected to incorporate new practices into existing
frameworks, with no real understanding of how that would work. There is
currently no existing national framework or document with guidelines for
integrating SHR into HIV programming in Mozambique, 20 and this poses
challenges for health workers on the ground.
Two resources that might be useful to future programmes of a similar nature, in

order to address the challenges of service integration, are:
A Framework for Priority Linkages, WHO/UNFPA/UNAIDS/IPPF (2005).

The framework proposes a set of key programme and policy actions to
strengthen linkages between SRH and HIV and AIDS programmes (see
further description under Resources section). The resource would of course
need to be adapted to national and local contexts, and a plan put in place to
operationalise it.
Sexual and Reproductive Health and HIV: Linkages Evidence Review and
Recommendations, WHO/UNFPA/IPPF/UNAIDS/USCF (2009). A
literature review of promising practice for linking and integrating SRH and
HIV services, with key recommendations for policy-makers, programme
managers, and researchers. Available at:
http://www.who.int/reproductivehealth/topics/linkages/en/index.html
Traditional attitudes and beliefs among leaders

One of the projects goals was to challenge traditional attitudes and beliefs at
individual, family, and community levels in order to influence positive
behaviour change and tackle the deeper-rooted issues associated with HIV, such
as gender inequality. It was discovered during the first District Steering
Committee meetings that some of the traditional attitudes and beliefs that the
project was striving to change were strongly held by many of the key
stakeholders themselves. For example, during a values clarification exercise, the
majority of male attendees from government ministries, NGOs, and the private
sector argued that domestic violence was justified in certain situations, and that
women should never refuse sex from their husbands.

Lessons learned
1. Activities such as the values clarification exercise are useful in assessing the
attitudes and beliefs that exist not only in communities but among those who
are expected to lead change throughout the project (in this case, the DSCs).
2. It is important not to make assumptions about the mindset of any of the

project stakeholders, including those charged with the role of guiding
change. It was discovered early on that most of the leaders and partners of
this project, including Oxfam staff, still hold the view that tradition grants
men certain rights over women. In light of this notion, special activities
designed to challenge this thinking were added on to the original plan of
activities, targeting the DSC members and traditional leaders.
3. Innovative tools can help challenge the social norms and purpose of
tradition, but must be adapted to specific local contexts. It is also important
to remember that change will not happen overnight, or as a result of just one
or two workshops or activities.
Advocacy and policy

In order to influence change at all levels, including overall systems, there is a
need to reinforce the groundwork of district- and local-level projects with
advocacy and policy at national level. This project aimed to bring about change
at individual and community levels through STAR to trigger community
movements and campaigns that would eventually lead to wider campaigns and
influence national policy. As part of this effort, project stakeholders actively
engaged in activities during World AIDS Day and the 16 Days of Activism in
2007 and 2008.
World AIDS Day

World AIDS day is a special event that takes place around the world every year
on 1 December, to raise awareness and address key issues associated with the
HIV and AIDS pandemic. It is a day to reinforce the sense of leadership required
to reduce HIV transmissions and the impacts of HIV and AIDS on individuals
and communities. In Machaze and Mossurize Districts, youth drama and theatre
were used to spread messages about HIV and AIDS prevention and about stigma
and discrimination, and contests (posters, songs, quizzes) were held to raise
awareness during World AIDS Day in 2007 and 2008.
16 Days of Activism Against Gender Violence

The 16 Days of Activism Against Gender Violence is an international campaign
started by the Centre for Womens Global Leadership in 1991. It takes place
annually from 25 November (International Day for the Elimination of Violence
Against Women) through to 10 December (International Human Rights Day),

two dates that were symbolically chosen to link VAW and human rights. The
campaign is used as an organising strategy to call for the elimination of all forms
of violence against women. It involves groups all over the world who speak up
for support services for survivors of violence, call for stronger prevention efforts,
advocate for legal and judicial reform, and use international human rights
instruments to address the issue.
Both of these events were successful in raising awareness about HIV and AIDS,
as well as generating community dialogue about underlying issues associated
with them. Activities included collaboration with youth and theatre groups in
promoting positive messages about HIV prevention and stigma and
discrimination; STAR circles and participatory methods used to encourage
communities to analyse power relations, identify the underlying causes of
community problems, and come up with their own solutions; public speakers on
issues related to gender-based violence and HIV and AIDS; and dissemination of
anti-violence and safer sex messages through radio, posters, t-shirts, marches,
and music.
Poignant stories were shared by community members, which helped elucidate

the existing inequalities that contribute to the burgeoning HIV and AIDS
situation.
I was weaned off from my mother at a very young age and sent to live with
another family. I grew up thinking that I was being cared for by my mother and
father. When I was 13, the family built a hut and told me to go and sleep in it. I
remember the man, who I thought to be my father, coming in and forcing himself
on me sexually. It was so painful and I was devastated. I had heard stories of
fathers raping their daughters, and thought I was a victim of incest. The next
day my real parents came to see me. They had not been allowed to see me until I
lost my virginity. I was the last wife of this man, and the senior wives were
unkind to me. I am now miserable living in this household.
Cecilia from Mossurize District
Cecilia shared her story in a session on early and forced marriage during the 16
Days of Activism. She had been sold off as a child to become a wife of an older
man at a very young age and raped when she reached puberty. She had been
denied an education and wanted more than anything to build her skills so that
she could make her own money and not have to remain economically dependent
on her abusive husband, with whom she now had three children, and she asked
how the programme could help her.
This is just one example of gender inequality and rights violations that was
drawn out through the use of participatory methods and awareness-raising
forums. It buttresses the argument for overall systems change through legal
protection and enforcing legislation related to SRHR and HIV, as well as change

at community levels, particularly the cultural practices and behaviours that
undermine efforts to overcome poverty, inequalities, and HIV and AIDS.
Lessons learned
1. Special events that create environments for relaxed, non-threatening, and

informal discussions are an excellent way to mobilise communities and
leaders to reflect on their realities and to put ideas together. For example,
during the 16 Days of Activism in Mossurize, community leaders stayed up
until 2am one night, discussing the underlying problems associated with HIV
and AIDS in their respective communities.
2. STAR and community-based activities during the 16 Days of Activism and

World AIDS Day drew out a number of human rights issues such as child
rights abuses, sex with minors, early and forced marriage, and domestic
violence. However, there seemed to be a lack of clarity in protocols,
procedures, and channels for addressing these types of case at community
level.
3. Project findings suggest a need to more effectively bridge community and

clinic activities. For example, project co-ordinators said that they felt
burdened by an overwhelming amount of work in clinics and the need to
oversee community activities at the same time, without being able to fully
connect the two aspects of their work.

Key issues raised that require longer-term strategies and commitment by all
stakeholders, particularly government and civil society, include:
Violence against women, including domestic violence and intimate partner

violence;
Sexual exploitation and abuse of minors, especially in schools, by teachers
and other people in positions of power;
Inter-generational sex;
Early and forced marriage before the age of 18;
Selling and trafficking of children;
Denial of education for girls;
Virginity testing of adolescent girls;
Widow inheritance;
Sexual cleansing and purification rituals; 21
Poor livelihoods leading to high-risk behaviours (sex for subsistence,
increased mobility);
Payment of dowry used as a justification for marital rape and domestic
violence;
Social pressures put on men to have multiple and concurrent partnerships;
Alcohol abuse and its linkages to domestic violence;
Lack of understanding and application of constitutional laws;
Weak enforcement of legislation designed to protect human rights;
Lack of availability of prevention materials, including both male and female
condoms, particularly in rural communities.

Overall project lessons learned
Project design
Starting small, with one or two localities and a few key activities, is likely to be more
cost-effective and easier to measure in terms of impact than trying to cover too much
over a short period of time.
It is important to think of ways to support government ministries with strategies to
build human resource capacity and not merely by providing additional funds. This
includes looking for ways to incentivise and motivate health workers, particularly in
rural areas; linking with and recruiting health staff from national medical schools; and
developing capacity-building plans that go beyond trainings (e.g. job shadowing,
mentoring, exchange visits, secondments, and piloting new initiatives).
Outreach, mobile clinics, and networking between traditional healers and leaders,
civil society, medical staff, and government ministries are all important in addressing
the gaps in accessing comprehensive SRH and HIV services.
Health worker trainings

Training health workers in SRH and HIV and other related issues is a good start to
integration. For example, training more nurses to provide HIV counselling and testing
will help Mozambique to implement the WHO provider-initiated testing and
counselling recommendations. However, this must also go alongside training on how
this will work in practice, and national frameworks need to support integrated
services. Such a strategy must also be accompanied by a clear strategy and plan on
access to treatment.
Deep-rooted issues associated with HIV

Projects need to continuously explore power and gender relations and human rights
issues.
During the course of the project, it became evident that personal protection was not
being accessed and that justice was not being served where it should be. This was
likely due to existing laws not being enforced and low levels of knowledge and
understanding about human rights instruments. For example, the early and forced
marriage of girl children is a common practice that occurs without prosecution, even
though on paper it is prohibited. The involvement of the Ministries of Women and
Social Action, and Education, as well as the legal sector, is crucial in any project
aimed at addressing the deeper-rooted issues associated with SRH and HIV.
Strategies for ensuring the effective implementation of human rights laws and codes
should also be adopted and strengthened.
The incidence and prevalence of violence against women are high in both Machaze
and Mossurize Districts. SRH and HIV services must be able to respond to the needs
of victims, as well as collaborate with health, protection, and other
agencies/services/departments to prevent and reduce the rates of these incidences.
Increasing awareness is a start, but as this project demonstrated, the entrenched
attitudes and traditional practices that are often used to validate domestic violence
are difficult to break.
Integrated SRH and HIV projects should also address issues of violence against
pregnant women. Focus group discussions revealed that many women had
experienced domestic violence at some point during their pregnancy, often resulting
in miscarriages and pre-term deliveries. Integrated SRH programmes in Mozambique
need to address the issue of domestic violence as part of antenatal care, including
training health workers to screen for cases of all forms of sexual and gender-based

violence.
Involving teachers and the Ministry of Education in steering committees on issues of
sexual exploitation and abuse can be valuable in addressing the issue of sexual
exploitation and abuse (SEA) in schools. Focus group discussions suggested that
teachers often coerce girl students into having sex by threatening to give them bad
grades.
Communication
It is important that prevention approaches go beyond ABC. Many of the issues
drawn out of surveys and focus group discussions related to gender inequality and
the inability of women and girls to control their own sexual and reproductive health.
For example, abstaining from sex was not an option for girls who had been married
off to older men; women in polygamous marriages might be faithful to their husbands,
while the behaviours of their husbands put them at risk; women who are expected to
have children require a new technology that will prevent the transmission of HIV but
not prevent pregnancy; and violence against women and girls was a common
response to them even suggesting that their partners use a condom.
Monitoring and evaluation

Strong monitoring and evaluation (M&E) is a vital component in making clear links
between interventions and the attributable, resuting changes. It is important to carry
out rigorous and participatory evaluations that make clear links between the
programme and its impacts.
M&E is vital in advocating for resources and measuring the cost-effectiveness and
benefits of programming. It is important to ensure that staff are trained and well-
equipped to carry out regular monitoring and that documentation is prioritised.
Adequate training for enumerators is essential in surveys that gather information on
sensitive subjects. This will help to avoid high incidences of non-response (a problem
in this projects baseline survey), as well as to ensure that research ethics are
observed, including confidentiality, privacy, informed consent, and referral provision if
needed.
Advocacy and policy

Collaboration with PLHIV as champions in the fight against HIV helps to reduce
stigma and discrimination and demystify false attitudes and beliefs about HIV and
AIDS.
Life stories and case studies are excellent advocacy tools. Regular documentation of
peoples experiences and the sharing of these stories are key to influencing policy at
national and global levels.
Local health workers did not seem to clearly understand how to put integration of
services into practice. Advocating with government to ensure that the linkages
between SRH and HIV and AIDS are addressed in national development plans and
budgets, including decentralisation processes, poverty reduction strategy papers
(PRSPs), and sector-wide approaches, can facilitate the operationalisation of service
integration at local level.
Community engagement
Working with communities requires a strong relationship built on trust. Agreement to
carry out surveys and regular activities (e.g. the implementation of STAR
methodology) from community leaders is an essential first step in getting their buy-in
from the beginning. This will also help in the development of stronger leadership,
ownership, and longer-term sustainability of the project.

Partnerships and collaboration
Although staff based in health clinics reported increased referrals from traditional
healers as a result of trainings, traditional healers felt that they should also receive
referrals. This should be explored as a strategy for increasing the number of HIV and
AIDS care and treatment options based on clinical evidence.
Capacity building is most effective when it comprises multiple forms of learning, such
as exposure visits, job shadowing, secondments, access to information and
resources, and team-building activities, as well as training sessions.
Exit strategy
A clear exit strategy was lacking but one is necessary for a successful phase-out of the
project. Continuity and sustainability of the project requires a well thought out and
articulated strategy that enforces the commitment and responsibilities of all stakeholders
after the departure of Oxfam.

Part 2.
The deeper-rooted issues associated with sexual

and reproductive ill-health and HIV and AIDS
Project stakeholders identified a number of factors that fuel SRH problems and
exacerbate the HIV and AIDS situation in Mozambique. A robust analysis of
these issues is necessary in any SRH and HIV programme in order to tackle HIV
and AIDS at their roots. The following section discusses some of these issues and
suggests ways to effectively address them in SRH and HIV programmes.
Gender inequality and the feminisation of HIV and AIDS

In sub-Saharan Africa, over 60 per cent of people infected with HIV are women. 22
Over the past 25 years the entire world has seen a trend in increasing HIV
infections among women and girls, leading to what is now known as the
feminisation of HIV and AIDS.
Factors that contribute to the feminisation of HIV include:
Greater biological risk due to high concentrations of HIV in semen and

fragile genital mucous membranes in females;
Cultural factors:
- Early sexual initiation and female genital cutting;
- Lack of control over SRH from force and non-consensual sex and
inability to negotiate condom use;
- Discriminatory property and estate laws that make women
economically vulnerable and more accepting of unsafe sexual
relationships;
- Acceptance and expectations put on men to have multiple and
concurrent sexual partnerships;
- Denial of education for girls (evidence shows that women and girls
who are educated have an increased probability of knowing how to
prevent HIV, delay sexual activity, and take protective measures
against STIs, HIV, and pregnancy; 23
Violence against women, or fear of violence, prevents women from
requesting safer sex from their partners;

Lack of effective social and legal protection systems to tackle some of the
drivers of HIV infection, including all forms of sexual and gender-based
violence (e.g. early and forced marriage, domestic and intimate partner
violence, rape, sexual exploitation and abuse, female genital cutting, etc.).
Unequal power relations

The STAR training of facilitators uncovered a number of cultural attitudes and
beliefs around power relations in Mozambique. The following table provides
examples of statements made during the workshop, demonstrating the
challenges that the project faced in equalising the balance of power between
women and men.
Quotes from participants in a STAR workshop:

implications for gender, HIV, and rights
Said by Gender, HIV, and rights

Quote
whom implications
Women dont show men when they Male NGO Used to try and justify human
are ready for sex, so we dont know worker rights violations (husbands
(i.e. that is why we use force) forcing their wives to have sex
against their will)
A wife is considered a prostitute if Male Demonstrates cultural attitudes
she initiates sex with her husband government that discriminate against
representative women, fuel gender inequalities,
and disempower women in
controlling their own sexual and
reproductive lives
Timber workers are not the Male peer An approach that tries to place
problem, the problem is our girls worker blame on women and girls
who go there to seduce them without looking at the underlying
issues such as gender inequity
To talk about it is not allowed for Female peer The culture of silence around
women worker SRH and HIV and AIDS
prevents dialogue about healthy
relationships, safer sex, family
planning, and other sexual and
reproductive health decisions
I choose which channel to listen to Male peer Demonstrates unequal power

on the radio, I use my power. I Worker relations through control and
decide when my wife and I have access to resources. In this
different choices case, radio used for health
promotion, including HIV
prevention messages, may not
reach the most vulnerable

populations (women)
In our tradition, the power is in the Male Using tradition and money to
hands of the man who is the owner government validate unequal power relations
of the home I pay for it representative
In my culture women are not Male NGO Trying to use culture as an

allowed to sit at the table. A worker excuse for gender
womans place is on the mat discrimination, when in fact it is
people who shape culture, not
the other way around
That is what my father, grandfather, Male NGO Using tradition to validate
and great-grandfather did That is worker gender inequality without looking
just how it is at the reasons behind these
traditions and the current
implications for overall health
and development
This type of dialogue points to the difficult position that women find themselves
in trying to support themselves and their families, abide by culturally defined
values, and protect themselves and their children from HIV and AIDS, all at the
same time. It also demonstrates the challenges involved in breaking down these
deeply rooted attitudes that are so entrenched in many societies, and why it
takes time, innovation, and persistence to overcome these attitudes and beliefs as
a first step towards behaviour change.
The ABCs of marriage

Abstain from sex until married is a common message for young people in
preventing unwanted pregnancy as well as HIV. However, it is not only
unmarried men and women or young people who are at risk of HIV infection.
This was highlighted during focus group discussions and STAR circles in
Machaze and Mossurize Districts. Married women reported an inability to
negotiate condoms or discuss any matter at all related to sex with their husbands.
At the same time, they voiced fears of becoming infected with STIs, including
HIV, knowing that their husbands were regularly engaging in extra-marital
affairs.
Women in many parts of the world have limited power to negotiate condom use
with their husbands. This has to do with expectations of having many children,
fear of domestic violence, and economic dependency on the man to provide basic
needs. In fact, in some societies married women in monogamous, heterosexual
relationships are at the highest risk of HIV infection. 24

The belief that women have no right to ask their husbands to use condoms is
especially strong in situations where husbands have paid a dowry (bride price)
for their wives and therefore think of them as possessions rather than mutual
partners. In a study in Zambia, only 11 per cent of women said that they had the
right to ask their husbands to use condoms, even if they knew their husbands
were HIV-positive or had been unfaithful. A study in Zimbabwe found that
being married or having been married in the past was listed as one of three HIV
risk factors. 25
Married women and women in long-term relationships have typically not been
listed as a risk group for contracting HIV, and therefore have not benefited as
much from public education and sensitisation campaigns such as the ABC
approach.
The ABC approach focuses on A = Abstinence, B = Be faithful, and C = use

Condoms consistently and correctly every time you have sex. However, because
many married women do not control their own sexual health, these ABCs do
them little good: abstinence is usually not an option; being faithful does not
protect a woman from HIV if her husband has multiple wives or multiple sex
partners. Requesting ones husband to use a condom often results in violence, or
pressures to have many children prevent women from suggesting condom use.
Discussions on the ABC approach took place at a number of forums throughout

the Manica project. Community leaders, government representatives, and
various members of the DSCs discussed the effectiveness (or lack) of preventing
HIV infection in married women in Mozambique. As a result of these
discussions, STAR circles began considering married women as a most-at-risk
population group. STAR circle sessions aimed to dissect the cultural attitudes
and beliefs around the concept of marriage, from both mens and womens
perspectives. Questions that generated interesting discussions included:
Can a girl who has been forced to marry refuse sex with her husband who
has paid lobolo (bride price)?
If a person is faithful to his or her spouse, is he or she safe from HIV

infection? What if her spouse has multiple sexual partners?
What happens if a married woman insists that her husband wear a condom?
HIV and young people

There are a number of factors contributing to the increase of HIV transmission
among young people, including issues of early and forced marriage, denial of
education, and inability to access SRH services. Adolescents must have easy

access to SRH and HIV services that are sensitive to their needs and
circumstances. Programmes should provide comprehensive SRH and HIV
information to young people through appropriate channels.
The Manica project was able to reach young people with messages about safer
sex, stigma and discrimination, and preventing unwanted pregnancy, as well as
rights issues, including sexual exploitation and abuse and cross-generational
relationships a frequent situation where sex in exchange for commodities is
practised. 26 This was done through theatre and drama and through quiz and
poster contests organised during World AIDS Day.
However, SRH and HIV services at clinic level still need to be designed in a way
that is user-friendly for young people. In focus group discussions, for example,
young people talked about not wanting to go to the clinic for condoms, STI
treatment, or other SRH issues, out of fear that their confidentiality would not be
maintained or that they would be denied services. Furthermore, focus group
discussions with young people showed that sexual exploitation and abuse by
teachers is common in schools. Girls talked about a common practice of teachers
requesting sex in exchange for good grades. This highlights the need for more
sexual education both in and out of schools.
A recommended tool is the recently published International Guidelines on Sexuality

Education, by UNESCO, UNFPA, and other agencies. The guidelines address
common problems of STIs, HIV, unwanted pregnancies, and coercive and
abusive relationships in cultures where discussing sexual matters is often taboo
for adults including parents and teachers and young people enter adulthood
with conflicting messages about sexuality and gender. The guidelines promote
an evidence-informed approach to effective sex, relationships, and HIV/STI
education for children and young people. Different age groups are focused on,
from age five to 18+, and the guidelines are designed to be adapted to different
countries and contexts.
HIV and older people

Because most data available on HIV and AIDS relate to people aged between 15
and 49, it is often assumed that HIV does not affect people over the age of 50, or
that older people do not engage in sexual activity. On the contrary, in some cities
1525 per cent of PLHIV are over the age of 50. 27
Normally, safer sex messages target unmarried and younger populations. Post-
menopausal women and married couples, as discussed above, are often
erroneously considered to be at low risk of HIV infection. In fact, doctors at the
Radcliffe Hospitals Trust in Oxford, UK reported that older people are actually
more susceptible to STIs, including HIV. 28

There are a number of factors that are often overlooked when considering HIV
risk and vulnerability among older people. These include:
Routine health examinations often do not explore possibilities of HIV

infection in older adults. Health workers do not enquire about sexual activity
or other risk behaviours such as drug use or experience of violence. This
omission wastes the opportunity of screening that could help in prevention
and detection of HIV/STI cases.
The belief that condoms negatively affect sexual performance among older
men results in non-use of condoms in extra-marital sexual relations.
After menopause, people who may have used condoms to prevent pregnancy
or as a dual method stop using them once there is no longer a risk of
pregnancy.
Social attitudes about the sexual needs of older people create barriers to
discussing sexuality openly among this population.
Oestrogen deficiency in post-menopausal women causes the cervix and
vaginal tissue to become fragile. This can result in injuries that increase
susceptibility to HIV transmission.
The Manica project only gathered data on men and women between 1549 years of age.
Considering the increasing risks of older women, similar projects of this nature should
work with the Ministry of Health in gathering data on VAW, HIV, and SRH from
people over 49. Furthermore, programmes should train health workers in dealing with
age-specific SRH issues, and develop safer sex messages that target older people.

Recommended activities for HIV prevention programmes
to reduce womens and girls risk and vulnerabilities
Use community empowerment approaches to unpack social norms and identify

how they are harmful to both womens and mens health (e.g. STAR).
Use strategies that strengthen political will to reform and enforce policies and laws
that reduce womens vulnerability at both national and local levels.
Set up structures to oversee equity for women in property and inheritance laws.
Work with national and local judicial systems to enact and enforce laws against
gender-based violence, including domestic violence and marital rape.
Encourage governments and communities to commit to enrolling girls in school at
an early age, getting them to school on time, and to keeping them in school through
the secondary level.
Monitor school attendance and graduation rates as well as enrolment rates for girls
and provide incentives for girls and their families who complete secondary-level
education.
Promote health messages in communities that focus on completion of education for
girls, delaying marriage, knowledge of protection laws, and discouraging
transactional and inter-generational sex.
Design integrated HIV counselling and testing, family planning, maternal and child
health, and SRH services for couples.
Integrate HIV services with family planning and reproductive health services to
reach more married women with information and support (such programmes also
have a history of increasing male involvement in reproductive health decision-
making).
Address more than contraceptive use alone. Family planning services must highlight
the importance of educating girl children and giving women opportunities to earn an
income, make independent choices, and participate in decision-making at family
and community levels.
Develop programmes that promote condom use among couples.
Raise awareness of the extent of early marriage and the human rights abuse it
constitutes among community leaders, in- and out-of-school youth, parents,
teachers, elders and traditional leaders, religious leaders, protection officers, and
policy-makers.
Publicise and enforce protection laws, such as the Family Law in Mozambique,
which establish 18 as the legal age of marriage. Translate this law into local
languages and spread information among local traditional leaders. Use special
events such as the 16 Days of Activism to disseminate this information.
Create social and economic opportunities for out-of-school youth, particularly young
women.

Legal frameworks
Mozambique has ratified a number of policies and international instruments that
prohibit gender-based violence. These include:
The Gender Declaration of the Head of States of SADC in 1998;
The Convention on the Rights of the Child in 1994;
The Beijing Declaration and Platform for Action in 1995; and
The Convention on the Elimination of All Forms of Discrimination Against

Women (CEDAW) in 1997.
The African Protocol for Womens Rights was ratified in 2005. However, a recent
study in Mozambique showed that 54 per cent of women interviewed had
experienced physical or sexual violence at some point in their lives. 29 There has
been progress in some areas but, in general, application of these international
commitments has been weak and often does not reach local community levels. 30
Discriminatory legal frameworks often fail to uphold equal rights and protection.
Inequitable divorce and property laws make it difficult for a woman to leave an
abusive relationship. However, even when protection laws are written, they are
often not enforced due to insufficient resources, discriminatory practices by
police and courts, and weak institutional support. 31 For example, in
Mozambique, girls access to school is constitutionally guaranteed. However,
sexual exploitation and abuse in the schools is often not condemned, while
teenage pregnancy is. This leads to girls getting pregnant (often by teachers) and
dropping out of school early, reinforcing gender inequality and discrimination
and increasing HIV risk and vulnerability.
The Family Law of Mozambique

Mozambique has one of the worst child marriage problems in the world. A study
by the Population Council in 2004 showed that, nationwide, 21 per cent of girls
were married by age 15, and 57 per cent were married by age 18. Nineteen per
cent of them were in polygynous marriages. Unmarried girls between 1519
years old were 13 times more likely to be in school than married girls. Close to
three out of four married girls could not read at all. Married girls were more than
six times as likely as unmarried girls to have had unprotected sex in the previous
week.
In December 2003, the Government of Mozambique passed the Family Law,

which was designed to prevent early marriage as well as other practices that fuel
gender inequality. The law moved the legal age of marriage from 14 and 16 (for

girls and boys respectively) to 18. Furthermore, the law now recognises
customary marriages, protecting women who were married under local laws but
not under legal contracts. Under the new law, women who have lived with their
partners for more than a year are entitled to inherit the property of their
husbands. The Family Law also asserts that both spouses have responsibility
over the family and that women no longer require their husbands consent before
taking a paid job.
Despite this important step in the direction of gender equality, most people still
do not know anything about the law or how it can protect their rights. As
pointed out through focus group discussions, household surveys, STAR circles,
and workshops in communities of Machaze and Mossurize Districts, customary
laws tend to prevail over constitutional laws when it comes to the rights of
women and girls in Mozambique. Members of the girls or womans family
traditionally decide whether or not a girl is to wed. Marriage brings money and
gifts to the brides family in the form of lobolo (bride price), so a family desperate
for money may often marry off a daughter despite her young age.
Knowledge about the protection of women under the Family Law is low,
suggesting that more efforts are needed to disseminate information and
aggressively promote such laws. Surprisingly, this lack of awareness is found not
only in rural communities, but also among change agents involved in
programmes aimed at tackling inequality and HIV.
In a workshop on gender and HIV, facilitated by Oxfam in Chimoio,

Mozambique in 2008, for instance, it emerged that none of the participants was
aware of the legal age for marriage. These included employees from the Ministry
of Health, international NGOs (including Oxfam GB), and the National AIDS
Council One participant knew that the Family Law had raised the legal age for
marriage to 18, but argued that a father could still override that law if he gave
consent for his daughter to marry at a younger age. In fact, the law states that the
legal age with parental consent is 18. Without parental consent, a man or woman
must be 21 to marry. 32
A survey conducted by the NGO Associaao Mulher, Lei e Desenvolvimento

(MULEIDE) found that nearly three years after the Family Law went into effect,
approximately 63 per cent of women in Mozambique were unaware of it.
Furthermore, when Save the Children conducted a study on inheritance practices
in June 2008, it found that 60 per cent of women were denied inheritance rights
for not being ritually purified (having sex with a member of their husbands
family) after the death of their husbands. 33

Violence against women
Violence against women (VAW) was consistently raised as a leading public
health concern and human rights issue during focus group discussions and
STAR circle groups in Machaze and Mossurize Districts. This is consistent with
other research that demonstrates the widespread problem of violence against
women in Mozambique. 34 In Machaze District in particular, almost all women
participating in focus group discussions said that they themselves had
experienced some form of physical, emotional, or sexual abuse from their
partners. Others had known women who had been killed by their husbands.
They reported this being a result of husbands leaving to work in South Africa for
months at a time, and later returning home and accusing their wives of having
extra-marital affairs. Women also reported increases in STIs and HIV infection as
a result of husbands travelling and engaging in extra-marital affairs while they
are away. The district authorities are aware of the problem and raised it during
initial consultations as a priority for this project.
VAW is a global human rights and public health problem. It increases HIV
vulnerability among females. There is evidence that women who have been
forced to have sex are at greater risk of HIV infection due to injuries to the
vaginal or anal tissue, 35 which creates viable entry points for HIV into the
bloodstream. Worldwide, up to one in three women and girls have experienced
domestic violence, sexual assault, or sexual abuse. Particularly in areas where
HIV-related stigma is high, fear of violence prevents women from being tested
for HIV, disclosing HIV status, accessing prevention services for infants, or
receiving counselling and treatment, even in cases where they know they have
been infected. When women and girls lack economic means, there is a higher
incidence of non-consensual sex, fear of abandonment or eviction from homes or
communities, and an inability to negotiate safer sex.
The cost implications of HIV prevention are much lower than the treatment costs
for HIV and AIDS. 36 However, interventions that focus solely on HIV prevention
are not effective in cases where women suffer from abuse and violence and are
unable to negotiate condom use. There is a recognised need to combine efforts
focusing on rights, empowerment, and education through a gender perspective
on eliminating VAW. The Manica project addressed the intersections of VAW
and HIV in a number of ways, including active participation in the 16 Days of
Activism, STAR circles addressing VAW, and lobbying the government for
stronger monitoring and enforcement of SRH- and HIV-related policies and
laws.

How can VAW and HIV be addressed comprehensively?
Promote human rights and disseminate existing laws to prevent VAW.
Systematically monitor the impacts and the dissemination of laws.
Empower civil society to demand that the state provides equitable resources,
services, and opportunities for women.
Provide continuing education to public servants on laws around VAW and monitor
and evaluate their performance accordingly.
Establish whistle-blowing systems and enforce zero tolerance policies against all
forms of SGBV by public servants, including sexual exploitation and abuse in
schools.
Carry out specific campaigns on HIV prevention illustrating how violence makes
women and girls vulnerable to the transmission of HIV (e.g. 16 Days of Activism).
Provide trainings for journalists, communication officers, and other media personnel
about avoiding communications that promote, reinforce, or reproduce violence
towards women.
Integrate messages on the prevention of gender-based violence into information,

education, and communication projects.
Establish treatment and rehabilitation services for perpetrators of violence.
Provide temporary and safe shelters for victims of VAW.
Strive for active involvement of people affected by HIV in decision-making and policy
design that address the causes and consequences of VAW.
Train police to counsel and refer victims of sexual violence to medical centres and
consider training on administering emergency contraceptives.
Ensure that emergency contraception and post-exposure prophylaxis (PEP) for HIV
prevention are available and accessible to victims of sexual violence.
Recruit more female police officers.
Vote for women representatives on legislative boards.
Strengthen advocacy on gender-based violence in all country programmes, in

conjunction with other United Nations partners and NGOs.
Conduct more research on GBV and its linkages to HIV.


Sexual and reproductive rights

Many people are simply unaware that certain practices are actually violations of
reproductive rights. For example, during a learning visit to a faith-based
organisation that supports children orphaned by HIV and AIDS in Chimoio,
Mozambique, it was learned that the church was performing virginity tests on
adolescent girls. If a girl was found to have a ruptured hymen, she was expelled
from the facility.
Virginity testing is a serious human rights violation in terms of HIV and

pregnancy prevention. It draws attention away from the role of men, who are
often perpetrators of sexual violence. Virginity testing is an attempt to control
female sexuality, and it completely lacks any protection element. Furthermore,
doctors have confirmed that checking for an intact hymen does not reliably
indicate sexual activity. 37 In fact, women and girls can lose their hymens in a
number of ways, including riding a bike or simply falling over.
Virginity testing can actually put young women and girls at higher risk of
pregnancy, STIs, and HIV when they are also denied the right to education and
information about SRH, including HIV and pregnancy prevention. Young
women in cultures where virginity testing takes place have been known to
practise more anal sex, in order to preserve their hymens, which increases the
risk of HIV even further. 38 This is why advocacy around traditionally accepted
practices such as virginity testing and other human rights violations related to
SRHR and HIV and AIDS must be a strong component of integrated SRH and
HIV programmes.
Reproductive rights 39
The right to life
The right to bodily integrity and security of the person (against sexual violence,
assault, forced sterilisation or abortion, denial of family planning services)
The right to privacy (in relation to sexuality)
The right to the benefits of scientific progress (e.g. control of reproduction)
The right to seek, receive, and impart information (informed choices)
The right to education (to allow full development of sexuality and self)
The right to health (occupational, environmental)
The right to equality in marriage and divorce
The right to non-discrimination (recognition of gender biases).

Multiple and concurrent partnerships
Focus group discussions in Manica Province revealed that most men felt it was
normal to have many girlfriends and wives. They even reported being shunned
by communities if they did not have many partners. Male NGO and government
workers reported pressures to have girlfriends when they travelled to different
communities for work.
Most of these same men also reported not using condoms with their partners for
a number of reasons, including:
Trust that their partners were clean;
Fears of the woman that the condom would get stuck inside her womb and
harm her;
Not being able to perform well sexually with a condom on.
Studies have shown that in the long term increased multiple partners reduce the
likelihood of condom use 40 and that the pattern of concurrent partnerships can
result in much higher rates of HIV transmission across communities. 41
Comparing the benefits and drawbacks of multiple and concurrent partnerships

to those of monogamous relationships is an effective topic for community
discussions when addressing multiple concurrent partnerships as a risk for HIV
infection. Focusing on changing these community attitudes and beliefs can be
used as a strategy for positive change through peer pressure. Addressing
multiple and concurrent partnerships in HIV prevention efforts requires
culturally sensitive approaches that deal not only with the behaviour itself, but
with circumstances that enable the behaviour, such as migration away from the
home to seek work in another town.
Sexual networks and bridging patterns should also be analysed to determine the
level of HIV risk in different contexts. For example, the number of persons in a
sexual network, number of persons with HIV, number of persons engaged in risk
behaviours, number of persons in monogamous relationships, and the number of
links each has to others are all factors in assessing how rapidly HIV can be
transmitted within and across sexual networks. 42
Stigma and discrimination

The WHO estimates that 80 per cent of the 33 million people living with HIV
(PLHIV) worldwide do not know their status, 43 and HIV and AIDS-related
stigma and discrimination are often listed as the reason. Stigma and
discrimination result from a number of factors. Thus, programmes must take the

time to unpack the concept of stigma and discrimination in each context to
understand where it stems from.
For example, it has been argued that:
Segregation of HIV and AIDS services from mainstream primary health care
services fuels stigma;
HIVs association with promiscuity, consequent to it being sexually

transmittable, causes stigma;
Those who stigmatise others are most likely to be those who are vulnerable to
HIV, are suspicious of being HIV-positive, and mostly likely want to deflect
attention from their own behaviour.
The Manica project worked to overcome stigmatisation associated with HIV and
AIDS by collaborating with local associations of PLHIV, such as local partner
organisation Rudo Kubatana, and local theatre groups to address HIV
stigmatisation during World AIDS Day. PLHIV said that community
sensitisation about HIV and AIDS had helped them feel less discriminated
against and more empowered as community change agents to encourage people
to get tested, know their status, practise positive living, and prevent new and
secondary infections. Training of health workers in treating and counselling
PLHIV based on their particular needs is also a step towards reducing
discrimination associated with the virus.
Overall, there is a call for increasing access to HIV and AIDS services as a way of
fighting stigma. At the same time, PLHIV can serve as champions to help
normalise HIV and AIDS and overcome the barrier of stigma and discrimination
in HIV prevention, care, and treatment.

Part 3.
Integrating SRH and HIV and AIDS services

and programming
When designing a programme to integrate SRH and HIV services, it is important
to compare the cost-effectiveness of fully integrated programmes with that of
partially integrated programmes, which may vary by context. For example, in
Kenya, a study suggested that fully integrated services within family planning
service delivery points could be more efficient if family planning providers had
time to provide voluntary counselling and testing (VCT) to clients. If the
situation were such that family planning providers were too busy to offer VCT to
clients, partial integration could be more efficient if HIV testing centres were
nearby and under-utilised. 44 Another factor to consider 45 is that bi-directional
interventions (integrating SRH into HIV services as well as HIV into SHR
services) are likely to reach substantially more people than single-direction
interventions (SRH into HIV programmes).
A speaker at a regional conference on service integration in Addis Ababa,

Ethiopia in 2006 pointed to the need for policies and organisational structures to
support service integration. An example from Kenya showed that changes in
policy and guidelines to promote integrated services were achieved through
close collaboration between the Ministry of Health reproductive health division
and the National AIDS Programme.
Oxfams integrated SRH and HIV project in Mozambique aimed to increase

referrals between HIV and SRH service providers as a way of expanding access
to comprehensive care. This is a promising approach in areas where health
workers do not have the capacity, training, or time to offer more than one
service. On the other hand, reports have suggested that women in particular may
be more comfortable with VCT services that are camouflaged or integrated with
other reproductive services, 46 and that increasing the number of referral points
can reduce the likelihood that the patient will have all of her or his needs met.
As Dr. Joel Rakwar of AMKENI argues, 47 when dealing with human beings, it
does not make sense to separate their needs into different boxes, forcing them to
seek different types of care for their problems, which require a holistic approach
to individualised care. 48 However, each context must be considered when
deciding on which level of integration would be most cost-effective. For example,
prevention of mother-to-child transmission (PMTCT) is currently integrated into
MCH services in Mozambique, but problems exist with the capacity of health
personnel and limited resources. 49
One-stop-shop model
A holistic approach to responding to sexual violence is being tested in Kenya
through a one-stop-shop teaching hospital. After realising the obstacles that
vulnerable women and children face in accessing care, treatment, psychosocial
support, and legal aid for cases of SGBV, Kenyatta National Hospital established
a partnership with Liverpool VCT in 2006 to address the barriers to care and
treatment. The hospital was set up to respond to cases of sexual violence by
providing essential services, including medical surgery; emergency services such
as STI treatment, emergency contraception (EC), and post-exposure prophylaxis
(PEP); psychosocial support; legal aid; referral to shelters; and outreach. The
approach is still being evaluated, but results are showing that women are more
likely to receive comprehensive care for sexual violence due to a reduction in
referral points and with access to all of their needs at one location.
First points of contact

Police
An interesting study done in Zambia looked at addressing care and support for
survivors of sexual violence by training local police officers to administer
emergency contraceptives as well as increase referrals to health centres.
According to a Demographic and Health Survey, 53 per cent of women in
Zambia had experienced beatings or physical abuse since the age of 15 and close
to one in four had experienced violence in the previous year. Low reporting rates
suggested that GBV survivors did not seek medical care or legal redress due to
the poor quality of care available in public health facilities and police stations. In
2006, the Population Council developed a programme aimed at increasing access
to emergency contraceptives and appropriate referrals at first points of contact. It
found that almost all survivors first reported the assault to police, but very few
continued to seek medical care. The study indicated that police officers were in a
unique position to help survivors avoid unwanted pregnancy due to sexual
assault. 50
Overall conclusions of the Zambia study showed:

Police provision of emergency contraceptives is feasible;
Access to health facilities can be increased with simple training;
Systems need to be strengthened further;
Whoever is first point of contact for sexual violence can be trained;
Information about sexual and reproductive rights and how to access social
and legal protection services must be disseminated as part of the initiative.

Non-medical health workers
In Uganda, a working group of reproductive health and HIV experts laid the
foundation by developing guidelines and tools on how to implement and
monitor integration of HIV and family planning services. They developed
training materials and service delivery guidelines and trained central-level
trainers. Additionally, they trained non-medical health workers to provide
community-based services including HIV testing and counselling. 51 This is an
approach that could potentially be applied to traditional healers in Mozambique.
For example, expanding on the training already provided to AMETRAMO to
include counselling and rapid HIV testing could help reach most-at-risk
populations at an earlier stage of infection.
PMTCT Plus model

The PMTCT programme initially focused on three main areas: preventing HIV
infection among prospective parents; preventing unwanted pregnancy among
HIV-positive women; and preventing transmission from an HIV-positive
pregnant mother to her child during pregnancy, delivery, or breastfeeding. After
a number of years of evaluating the PMTCT programme, UNICEF started
campaigning for a PMTCT Plus initiative, which operates under the core belief
that HIV is a family disease, and that all members of the family should be
included in care and treatment. It is a promising intervention for integration with
maternal and child health programmes.
PMTCT Plus services include:
Initial provision of PMTCT interventions to pregnant and delivering women

and their newborns;
Delivery and post-partum care;
HIV treatment for women, infants, and their families, as appropriate;
SRH services, including family planning and dual protection advice for
women and their partners;
Counselling and support with regard to infant feeding options;
Treatment of other diseases such as malaria and TB;
Nutritional support.
The PMTCT Plus model is currently being implemented in a number of countries
in sub-Saharan Africa and Asia.

Key components for successful and sustainable integration 52
Enabling legislative and policy environment
Adequate resources and systems (financial, human, infrastructure, supplies)
Participatory processes involving stakeholders and key actors
Appropriate monitoring and evaluation systems.

Overall recommendations for integrated SRH
and HIV and AIDS programmes
Below are a number of recommendations based on the Manica project findings,
as well as results from other SRH- and HIV-related research and programmes.
Approach
Remember that global strategies need to be adapted to local contexts.
Focus on combination prevention strategies i.e. multi-pronged prevention
programmes including behaviour change, biomedical strategies (e.g. PMTCT,
treatment of HIV and STIs), social justice, and human rights.
During the initial assessment, look for entry points for men, women, and
young people and identify most-at-risk populations (e.g. married women,
young and elderly people, sex workers, men who have sex with men).
Carry out a context analysis and identify first ports of call for SRH and HIV
services, and involve these service providers in the programme (in rural
areas of sub-Saharan Africa these are often family members, traditional
healers, traditional birth attendants, and others, rather than health centres).
Use participatory empowerment approaches such as Stepping Stones and
STAR that address issues such as healthy relationships, communication, and
unequal power relations, which can lead to increased safer sex behaviours
and reduced incidence of violence against women and girls.
Advocacy
Ensure that the linkages between SRH and HIV and AIDS are addressed in a
countrys national development plans and budgets, including in
decentralisation processes, poverty reduction strategy papers (PRSPs), and
sector-wide approaches.
Encourage ministries of health to amalgamate separate policy papers on
maternal, child, and infant health, PMTCT, family planning, VCT, and STIs
into one coherent policy paper.
Advocate for SGBV services to be exempt in cost-sharing or cost-recovery
systems.
Invest in building the capacity of civil society at local and national levels to
empower citizens to demand their rights to essential SRH and HIV services
from their governments.
Health services
Consider the needs of people of all ages, genders, sexualities, and
professions. Furthermore, ensure that health workers are trained to deal with
most-at-risk populations (men who have sex with men, injection drug users,
sex workers) in a sensitive, non-judgmental, non-discriminatory manner.
Train health workers to be aware of and to be able to respond to the specific
health needs of sex workers, providing e.g. regular counselling and testing,

access to MCH services, dual protection (protection against HIV/STIs and
unwanted pregnancy), family planning, and mental health services.
Promote dual protection (protection against HIV/STIs and unwanted
pregnancy), not just contraception alone, in family planning services.
Promote condoms as a family planning method, not solely for HIV and STI
prevention.
Encourage the provision of both clinical and outreach services for
progressive education on sexuality for young people and their parents and
guardians at school and community levels.
Gender
Engage boys and men from the outset in both community activities and
clinical services and outreach. Avoid integrating services into existing
female-friendly services only.
Develop strategies to provide essential SRH services for men and boys of all
sexual orientations, and not just in relation to women.
Pilot initiatives in conjunction with heath service providers and the ministry
of health to train first points of contact in responding to sexual and gender-
based violence, administering emergency contraceptives, post-exposure
prophylaxis, conducting rapid HIV testing and counselling, and referrals to
legal protection services
Conduct power and gender analyses with communities to identify and
address factors that fuel HIV and AIDS, including gender inequality and
violence against women and girls as both a cause and consequence of HIV.
Communications
Train and involve media in multi-sectoral collaboration efforts to promote
community-developed, gender-sensitive HIV prevention messages, and use
them for advocacy purposes around rights issues.

Summary checklist
An integrated SRH and HIV programme should include the following:
Rights-based approach 53
Services and programmes targeting most-at-risk and marginalised

populations
Community empowerment approaches and behaviour change strategies,

including interventions that address social as well as economic
empowerment of women
Strategies for male involvement
Work with traditional healers and traditional judicial systems
Multi-sectoral collaboration
Advocacy protocols for linking local issues to national and global policy
Support, advocacy, and lobbying of government to provide the

following:
o National policy frameworks for integrating SRH and HIV

services
o Strong co-ordination between all SRH and HIV services
o Age- and gender-sensitive services and programmes
o Promotion of male and female condoms as a dual method
o Interventions that address the intersections between sexual and

gender-based violence and HIV (both community and clinic)
Strong monitoring and evaluation unit
Clear exit strategy.

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Appendices
I. Manica change strategy

1.
1. District
District Steering
Steering
End-line
End-line Committee
Committee (DSC)
(DSC) Meeting:
Meeting:
survey
survey and Develop
and Develop ownership
ownership and
and
programme define
programme
evaluation define role
role
evaluation
Baseline Survey
Capacity analysis
8.
8. Try
Try out
out small
small experimental
experimental 2.
2. Select
Select Communities
Communities (DSC)
(DSC)
campaigns
campaigns that
that will
will lead
lead to
to
wider
wider national
national and
and regional
regional
campaigns
campaigns
7.
7. Systems
Systems analysis
analysis (DSC):
(DSC): 3.
3. Create
Create Awareness
Awareness about
about
How
How are the deeper-rooted
are the deeper-rooted project
project in Communities
in Communities
issues
issues entangled
entangled with
with each
each (OGB
(OGB and
and partners)
partners)
other
other and
and where
where is
is the
the
leverage? Focus group
leverage? discussions
Regular monitoring
IEC
World AIDS Day
& 16 Days of
6. Activism Against
6. Information
Information and
and key
key Gender Violence
4.
4. Recruit
Recruit peer
peer workers
workers from
from
messages
messages spread
spread into
into selected
selected communities
communities
communities
communities
Training
Training and
and refresher
refresher
Informing 5. Training of peer workers training
Informing training for
for health
health
communities
communitiesabout and implementation of STAR workers,
about workers,traditional
traditional
existence
existence of
of quality
quality in selected communities healers,
healers, and
and traditional
traditional
SRH
SRHand birth
and birth attendants
attendants to to
HIV&AIDS
HIV&AIDSservices improve
and
services improve quality
quality of
of SRH
SRH
and how
howto
to use
use and HIV and AIDS
and HIV and AIDS
them service
them service (MoH)
(MoH)

II. Framework for priority linkages
WHO/UNFPA/UNAIDS/IPPF
SRH Key Linkages HIV/AIDS
Family planning Learn HIV status Prevention

Promote safer sex
Maternal and Treatment
infant care Optimise connection
between HIV/AIDS &
STI services Care
Management of
sexually transmitted
infections Integrate HIV/AIDS Support
with maternal & infant
health
Management of
other SRH problems

III. Key elements of STAR
From Pamoja Africa Reflect Network
Communication
Behavioural Decision
Choices Making
REFLECTION
Liter ion
pat
N
acy family i
D IA
ic
TIO
t
Par
LOG
ILIT A
t
HIV/AIDS
en
UE
c om
GENDER
FAC
rnm
RIGHTS
Solidarity &
m un
Demand for &

e
Access to Services gov Social Capital
ity
AC G
TI IN
ON ARN
LE
is
M for
s
ob A
aly
ili ct
An
za io
ti n
r
on
we
Po
Rights of Women, PLHIV

& Vulnerable groups

IV. U-Process
The five main steps of the U-Process
(1) People interested in facilitating profound change come together to discuss

and identify a common intention about a particular desired future or the kind of
change they would like to see.
(2) When common intention is discovered, group members go to places where

they have the best chances of learning the most about the situation for which
they desire change this will be achieved through observation, deep listening,
and purposeful dialogue.
(3) After the learning journey, the group retreats in silence in order to allow inner
knowing to emerge deliberate time for reflection and processing what was
learnt through observation, deep listening, and dialogue.
(4) The two or three most creative insights that emerge from the inner knowing
are then prototyped in order to learn by doing.
(5) Finally, the learning acquired from prototyping is scaled up as a push

towards the perceived new reality. This, however, is not a linear process: often
the process is iterative. 54
Diagram of the five main steps in the U process:
1. Co-initiating: uncover common intent 5 . Co-evolving: embody the new in

stop and listen to others and ecosystems that facilitate seeing and
to what life calls you to do acting from the whole
2 . Co-sensing: observe, observe, observe 4 . Co-creating: prototype the new

go to places of most potential and listen with your in living examples to explore the
mind and heart wide open future by doing
3. Presencing: connect to the source of inspiration and will:

go to the place of silence and allow
the inner knowing to emerge
2007 C.OScharmer

V. Resources
Sexual and Reproductive Health and HIV and AIDS:
A Framework for Priority Linkages WHO/UNFPA/IPPF/UNAIDS (October
2005)
A framework that suggests key policy and programme actions to strengthen
linkages between SRH and HIV programmes and services. It proposes two-way
linkages (SRH into HIV programmes and vice versa). It is intended to improve
sexual and reproductive health and to mitigate the impacts of HIV and AIDS.
The framework is based on experience and programming realities and sets four
priority areas where linkages are likely to result in public health benefits.
National contexts and local situations need to be considered when selecting
which action to support, including HIV prevalence, risk, and vulnerability, as
well as the utilisation of health services.
Linking Sexual and Reproductive Health and HIV/AIDS:

An Annotated Inventory WHO/UNFPA/UNAIDS/IPPF
This is an annotated inventory based on the framework for linking SRH and HIV
and AIDS. It contributes to strengthening linkages between HIV and SRH
programmes by providing information about tools for facilitating linkages and
integration of SRH and HIV programmes. It also points out gaps in areas that
require development of tools. http://www.unfpa.org/public/pid/1328
Global HIV M&E Information

Website: http://www.globalhivmeinfo.org/
Provides a one-stop-shop for information related to global HIV and AIDS
monitoring and evaluation. It posts links to resources, toolkits, digital libraries,
and trainings. It also provides mechanisms for corresponding with various M&E
professionals and communities of practice. Aimed at M&E specialists and people
interested in monitoring and evaluation of HIV initiatives, the website has been
put together through the collaboration of a number of international agencies.
MEASURE Evaluation
Website: http://www.cpc.unc.edu/measure
Provides technical support to build the sustainable capacity of individuals and
organisations to identify data needs, collect and analyse technically sound data,
and use those data for decision-making on health-related issues.
Resources for HIV/AIDS and Sexual and Reproductive Health Integration

Website: http://www.hivandsrh.org/
This website is designed to support efforts to integrate sexual and reproductive
health services with activities for preventing and treating HIV and AIDS. It
provides a selection of documents and other materials reflecting field experience
and the latest thinking by the health community on integration of HIV and
sexual and reproductive health services.
INFO Reports
Website: http://www.infoforhealth.org/inforeports/
Focuses on integrating family planning and HIV and AIDS services.
David Patient
Website: http://www.davidpatient.com
A free interactive resource for those living with or affected by HIV/AIDS,
written and hosted by David Patient, one of the longest-documented people
living with HIV/AIDS in the world.
Empowerment Concepts
Website: http://www.empow.co.za/
Resources around HIV, wellness programmes, articles, and downloadable
toolkits are available.
Sexual Violence Research Initiative

Website: http://www.svri.org/
Promotes research on sexual violence and generates data that ensure sexual
violence is recognised as a priority public health problem.
NGO Code of Good Practice:

Website: http://www.hivcode.org/
This site was developed by NGOs for NGOs. It provides a framework to which
NGOS can commit and be held accountable. The code sets out key principles,
practice, and an evidence base for successfully responding to HIV. The site
contains a number of checklists and tools by focus area, including the Self-
Assessment Check-list: Getting Closer Linking HIV and Sexual and Reproductive
Health.
International Guidelines on Sexuality Education: An Evidence Informed

Approach to Effective Sex, Relationships and HIV/STI Education (June 2009)
These guidelines were produced by UNESCO in partnership with UNFPA and
other agencies to support sexuality education programmes for young people in
order to reduce their risk of HIV and other STIs, unintended pregnancy, and
abusive and coercive sexual relationships. Available at:
http://www.unaids.org/en/KnowledgeCentre/Resources/FeatureStories/archi
ve/2009/20090731_unesco_Sex_edu.asp
Advancing the Sexual and Reproductive Health and Human Rights of People
Living with HIV. UNAIDS (2009)
A tool for policy-makers, programme managers, health professionals, donors,
and advocates to better support the sexual and reproductive health and rights of
people living with HIV. See:
http://www.aegis.org/news/unaids/2009/UN090812.html

The Sasa! Activist Kit for Preventing Violence Against Women and HIV.
Raising Voices (2008)
Offers tools, guidance, and encouragement for individual activists and activist
organisations ready to start a process of change by examining the concept of
power, and how understanding power dynamics between women and men can
help prevent violence against women and HIV infection. Available at:
http://www.raisingvoices.org/sasa/
Suggested training materials
A Handbook for Measuring and Assessing the Integration of Family Planning

and Other Reproductive Health Services
Available at: http://www.comminit.com/en/node/288951/cchangepicks/
Toolkit for Increasing Access to Contraception for Clients with HIV

Training Guide for HIV Counselling and Testing for Youth

Sexual and Reproductive Health for HIV-Positive Women and Adolescent

Girls: A manual for trainers and programme managers
Designed by EngenderHealth and the International Community of Women
Living with HIV (ICW), this manual enables programme managers and health
workers to provide non-judgmental, comprehensive, and high-quality SRH care
and support to HIV-positive women and adolescent girls. The manual
emphasises linkages between SRH and HIV services in limited-resource settings.
Available in English, French, Portuguese, Spanish, and Russian at:
http://www.engenderhealth.org/pubs/hiv-aids-sti/srh-hiv-positive-women-
girls.php
Comprehensive Counselling for Reproductive Health:

An Integrated Curriculum
Designed by EngenderHealth, this manual uses client profiles developed by the
participants to focus on the individual. It tailors training to local needs and aids
participants in adapting counselling frameworks to help providers assess and
address the patients comprehensive SRH needs. Available at:
http://www.engenderhealth.org/pubs/counseling-informed-
choice/comprehensive-counseling-for-rh.php
HIV Prevention in Maternal Health Services:

Programming Guide and Training Guide
Designed by EngenderHealth to help policy-makers, programme managers, and
trainers address the gaps in HIV and other STI prevention in maternal health

services and increase providers capacity to provide HIV and STI prevention
services and referrals to pregnant and post-partum women. Available at:
http://www.engenderhealth.org/pubs/hiv-aids-sti/hiv-prevention-in-
maternal-health.php
COPE Self Assessment Process: Client-Oriented, Provider-Efficient

A process developed by EngenderHealth to help health-care workers improve
the quality and efficiency of SRH services provided at health facilities, and to
make services more responsive to the needs of clients. Useful guidelines for
assessments, interviews, and action plans are available in handbooks and
accompanying toolkits. Available at:
http://www.engenderhealth.org/pubs/quality/cope.php
Reducing Stigma and Discrimination Related to HIV and AIDS:

Training for Healthcare Workers
Designed by EngenderHealth, this manual encourages health workers to identify
the root causes of stigma and discrimination and their own attitudes and beliefs
about HIV and AIDS, and how these attitudes might affect the care they provide
to PLHIV. It also addresses client rights issues and prevention of HIV through
occupational exposure. Available at:
http://www.engenderhealth.org/pubs/hiv-aids-sti/reducing-stigma.php
Integration of HIV and STI Prevention, Sexuality and Dual Protection in

Family Planning Counselling: A Training Manual
Designed by EngenderHealth, this manual recognises the importance of an
integrated approach to counselling as a key component of integrated
programmes and services. Its intention is to increase health workers comfort
levels in addressing sensitive issues of sexuality, gender, and HIV and AIDS.
Addresses the inextricable links between family planning and HIV and AIDS.
Available at: http://www.engenderhealth.org/pubs/hiv-aids-sti/integration-of-
hiv-fp.php
Empowering Messages What You Should Know:

Strategic Communication and Gender-based Violence
This document, published by Media Monitoring Africa, is designed to be a
comprehensive resource to address the development and implementation of
communication for issues related to gender-based violence. It includes guidelines
on how to develop a communication strategy and on understanding and
targeting the intended audience, and suggests appropriate monitoring and
evaluation techniques. Available at:
http://www.comminit.com/en/node/293197/38

Notes
1 Essential services are services required to protect the life, personal safety, or health of
the whole or any part of a population. These include, but are not limited to, services for
health care, HIV and AIDS, education, and safe water.
2 The Millennium Development Goals are eight international development goals, agreed
by UN member states and various international organisations, to achieve by 2015. They
include reducing extreme poverty, achieving universal primary education, ensuring
environmental sustainability, promoting gender equality, reducing maternal and child
mortality, combating HIV and AIDS, TB, malaria, and other diseases, and developing a
global partnership for development. http://www.un.org/millenniumgoals/bkgd.shtml
3 UNICEF (2009).
4 CIA Factbook (2009).
5 UNICEF (2009).
6 Ibid.
7 UNAIDS (2008).
8 An international campaign started by the Centre for Womens Global Leadership
(CWGL) in 1991, running from 25 November (International Day Against Violence
Against Women) to 10 December (International Human Rights Day) to symbolically link
VAW and human rights. For more information on the 16 Days of Activism Against
Gender Violence, visit: http://www.cwgl.rutgers.edu/16days/about.html.
9 A tradition whereby the wife of a deceased man is inherited by a male relative
10 Welbourn (1995).
11 Jewkes et al. (2007).
12 For more information on Reflect, see:
http://www.actionaid.org/main.aspx?PageID=128.
13 Pamoja Africa Reflect Network is an Africa-wide, non-profit, participatory and
educational development initiative established in 2002 to facilitate learning, sharing, and
continuing evolution of Reflect practices in Africa.
14 Bukali (2002).
15 Oxfam (2006) p.32.
16 Smart (2005).
17 Nanjakululu (2008).
18 Ibid.
19 Ibid.
20 Interact Worldwide et al. (2008).
21 A practice where newly widowed women are made to have sex with one of her
husbands relatives in order to purify his spirit.
22 UNAIDS, 2008 Report on the Global AIDS Epidemic, August 2008.
23 Remenyi (2008).
24 Boonstra (2004).
25 Global Coalition on Women and AIDS (2005).
26 PSI (2005).
27 Bilevich de Gastrn (2008).
28 Ibid.
29 Romao et al. (2007).
30 IPPF (2006).
31 Global Coalition on Women and AIDS (2005).
32 IPPF (2006).
33 US Department of State (2008).
34 Oxfam (2006); US Department of State (2008); UNIFEM (2008).
35 Remenyi (2008).
36 Ibid.
37 SIECUS (no date).
38 Ibid.
39 Sundari Ravindran (2001), cited by Allanson et al. (2009).
40 Medical Research Council (2003).
41 UNAIDS.
42 UCSF (2003).
43 2008 estimate.
44 FHI (2007) p.5.
45 As suggested by Safreed-Harmon and Daly (2008).
46 Tullock (2008).
47 AMKENI is a consortium led by EngenderHealth and composed of the following
partners: Family Health International, IntraHealth International, the Carolina Population
Centre, and the Program for Appropriate Technology in Health (PATH).
48 Fischer (2006).
49 Safreed-Harmon and Daly (2008).
50 Zama and Keesbury (2008).
51 FHI (2007).
52 Caucus for Evidence-Based Prevention.
53 Based on human rights principles of equality, non-discrimination, accountability, and
participation. For more information on the human rights-based approach, see:
http://www.unicef.org/sowc04/files/AnnexB.pdf.

54 Kalungu-Banda (2008).


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Leveraging Opportunities to

Integrate Reproductive Health

Integrated HIV and AIDS

Project Lessons Learned and Models of

2 Integrated HIV and AIDS Response in Manica Province, Mozambique

3 Integrated HIV and AIDS Response in Manica Province, Mozambique

AIDS Acquired Immune Deficiency Syndrome

4 Integrated HIV and AIDS Response in Manica Province, Mozambique

5 Integrated HIV and AIDS Response in Manica Province, Mozambique

Oxfam would also like to thank the following:

Communities of Machaze and Mossurize Districts, Manica Province,

The Ministry of Health in Mozambique for collaboration on this project;

The CNCS (National AIDS Council) of Mozambique especially for its

District Administrators of both Machaze and Mossurize Districts for their

Rudo Kubatana, a local partner organisation, for support in trainings and

District Steering Committees in Machaze and Mossurize for their active

6 Integrated HIV and AIDS Response in Manica Province, Mozambique

Appreciation also goes to Kristen Uhler-McKeown, the projects Funding

7 Integrated HIV and AIDS Response in Manica Province, Mozambique

The project: Leveraging Opportunities to

8 Integrated HIV and AIDS Response in Manica Province, Mozambique

There are no HIV surveillance data for key at-risk populations.

Oxfams Integrated HIV and AIDS Response in Manica Province (IHARM)

9 Integrated HIV and AIDS Response in Manica Province, Mozambique

B) Building spaces for behavioural change and strengthening the capacity of

C) Consistently elevate the project quality and adjust it to circumstances

10 Integrated HIV and AIDS Response in Manica Province, Mozambique

A multi-sectoral District Steering Committee (DSC) was set up to oversee the

3. Conducting a needs assessment is an important first step in being able to

11 Integrated HIV and AIDS Response in Manica Province, Mozambique

District Steering Committees (DSCs)

1. DSCs were successful in bringing a number of actors from various sectors

12 Integrated HIV and AIDS Response in Manica Province, Mozambique

ActionAid also uses an innovative approach to adult literacy known as Reflect

ActionAid recently started piloting an evolution of Stepping Stones and Reflect

Equip vulnerable populations with skills to negotiate and participate in

Promote processes to enhance access to integrated SRHR and HIV services;

Facilitate processes that foster community involvement in design and

STAR was implemented in 10 communities, five in Machaze and five in

13 Integrated HIV and AIDS Response in Manica Province, Mozambique

Peer workers were selected based on a set of criteria including:

Resident in the community or Open-minded; unafraid of change;

Able to read, write, and speak Non-discriminatory attitude towards

Able to commit to a full 10-day Completed at least primary school

Gender training: Peer workers participated in a number of gender trainings by

1. Follow-up trainings on various skill and subject areas are essential to

2. It is important to counter-check selection criteria when recruiting peer

15 Integrated HIV and AIDS Response in Manica Province, Mozambique

4. Orientation should be designed in a way that enables facilitators to look for

5. Time management became problematic during trainings due to the

Gender analysis and mainstreaming

Gender analysis framework: A gender analysis framework, which looks at control

16 Integrated HIV and AIDS Response in Manica Province, Mozambique

2. Gender trainings using gender analysis frameworks for all stakeholders,

3. Adapting the gender analysis framework to explore access to and control of

Working with traditional healers

In Oxfams Situational Analysis of Mozambique in 2006, a report by UNESCO is

Traditional doctors curandeiros have been reluctant to participate in government

A study conducted by Concern Worldwide in Machaze District in 2006 showed

Traditional healers are important participants in all aspects of integrated SRH

Considering the important role that traditional healers play in treating

18 Integrated HIV and AIDS Response in Manica Province, Mozambique

Theory-U forms the philosophical and practical underpinning of the U-Process: