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The Mekong
region STD/HIV/AIDS project in Cambodia, China, Lao PDR, Myanmar,
Thailand and Viet Nam.
Project
Name and Location:
The Mekong
region STD/HIV/AIDS project:
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Thailand: Nation-wide, focus in the north and northeast of
Thailand
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China:
Yunnan
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Viet
Nam: Six districts in five provinces; Khanh Hoa in the centre,
An Giang and Kien Giang in the south, and Quang Ninh and Lang
Son in the north
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Myanmar:
States and divisions bordering Lao PDR, Thailand, and China
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Cambodia:
Nation-wide
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Lao
PDR: Vientiane prefecture and 5 Provinces, in the North, South
and Centre of Lao.
Background/Rationale
for Project:
In the Mekong
region, the incidence of STD/HIV/AIDS is growing rapidly as
economic development and transportation links increase mobility
within and between countries and previously isolated rural people
and ethnic minorities become vulnerable to exploitation. All
six countries urgently need to expand community level efforts
in the areas of prevention, reproductive health education, and
care for people with and affected by HIV and AIDS. Government
officials also need to overcome the social and cultural barriers
at every level of society, which prevent frank discussions about
sexuality and sexually transmitted diseases. For women, children
and youth who suffer multiple disadvantages, tactical skills
need to be taught. These include skills to deal effectively
with peer pressure, skills to negotiate within sexual activity,
and skills to refuse demands from people who take unfair advantage
because of age, gender, and social status.
Since the
first AIDS case was detected in Thailand 1984, the epidemic
has spread rapidly and currently more than 900,000 people are
infected. In China there is no evidence of epidemic HIV
transmission anywhere except in one province, but HIV cases
are being diagnosed all over the country and STDs are spreading
rapidly which is a precondition for the spread of HIV. Although
reported cases of HIV infection in Viet Nam are few,
the World Health Organization (WHO) estimates that the epidemic
will expand dramatically unless preventive measures are taken
quickly. HIV/AIDS has recently emerged as a major public health
problem in Myanmar and the number of HIV-infected persons
is increasing rapidly. Widespread poverty and years of armed
conflict have created conditions in Cambodia that are
very favourable for HIV transmission. In Lao PDR the
identified HIV infections are low but cases of STDs are rapidly
increasing and recent studies of sexual behaviour strongly suggest
an imminent HIV epidemic unless immediate action is taken.
Project
Description
Time
frame: A three-year project, started in mid-1996
Implementor:
UNICEF
Lead
Partners: National governments, NGOs, Mass Organisations
and Community Based Organisations (APICT)
Partner(s)/alliances:
UNICEF has implemented the Mekong Project in the context of
UNAIDS as one of the original six co-sponsoring agencies of
UNAIDS. UNICEF has worked closely with the UNAIDS secretariat
in Geneva and the UNAIDS Asia-Pacific Intercountry Team.
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Thailand:
Communicable Disease Control Office, the Provincial Health
Office, Provincial social Welfare Office, Ministry of Education,
and NGOs such as the Phitsanulok AIDS Foundation, Thai Red
Cross and CBOs
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China:
All China Women's Federation, provincial, prefecture and county
HIV/AIDS leading groups, and INGOs
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Viet
Nam:
Various Ministries from the Government: Department of Health
and Physical Education of the Ministry of Education and Training
for in-school programmes, International NGOs and mass and
community organizations such as the Vietnamese Red Cross
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Myanmar:
Three NGOs and the Ministry of Health
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Cambodia:
National Aids Programme, the Ministry of Health, the Ministry
of Education, Youth and Sports, the Ministry of Social Affairs,
Labour and Veterans Affairs and the Secretary of State for
Women's Affairs and other relevant ministries and departments,
local and international NGOs: Save the Children; the Cambodian
Women's Development Organization; and Health Unlimited
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Lao
PDR: UNAIDS country programme advisor, government agencies,
National Committee for the Control of Aids (NCCA), mass organizations
such as the Lao Women's Union, Lao Youth Union, the Red Cross,
and the central, provincial, and district agencies concerned
with education and health
Funding
Source(s) and Overall Budget: The Netherlands government
and the Netherlands National Committee for UNICEF to promote
sharing of resources and strategies among the six Mekong countries.
US$ 6.1 million (Df. 10 million) for funding period 1996-1999
Objectives:
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To
reduce the rates of transmission of HIV/AIDS in Mekong countries
by focusing on vulnerable groups (women of reproductive age,
children and young people, with an emphasis on overlapping
populations of rural, ethnic and poor people). Of these, children
and young people, women, migrant workers, and commercial sex
workers will receive special attention
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To
assess and counteract the likely consequences of HIV/AIDS
on the health education and wellbeing of the most vulnerable
groups in the region
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To
build the capacity of government agencies, NGOs, mass organisations,
local communities and UNICEF country offices to design, test,
implement, monitor and evaluate activities which reduce HIV/AIDS
transmission and increase community acceptance and care for
women, children and families affected by the illness
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To
seek more vigorous promotion of the Convention on the Rights
of the child, particularly as it relates to the right to health,
and the protection of children and youth from exploitation
by prostitution
Beneficiaries/participants:
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Thailand:
the poorest 20 per cent of the population; children, young
people, women and hill tribe populations
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China:
Children and young people in and out of school
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Viet
Nam: Youth between 10 and 18
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Myanmar:
10.4 million people involved. 2 million young people and 2.6
million women of reproductive age
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Cambodia:
students in primary, secondary, and vocational schools; out-of-school
young people; women of reproductive age, and women and children
directly affected by HIV/AIDS
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Lao
PDR: Populations currently and potentially engaged in
high-risk activities
Description
of Activities:
The activities
listed below are a selection of Country Programme Activities
relating to Young People, not the totality of activities undertaken
by Country Programmes.
Thailand:
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Catalytic
work in formal education to create "Child Friendly Schools".
These schools focus on teaching life skills education and
other school subjects in a participatory and engaging way.
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Support
for Projects like Sangha Metta, which trains monks and novices
to be change agents in the communities they serve. Monks conduct
retreats for young people to address topics such as HIV /AIDS
and drugs in a reflective environment.
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Support
for projects that build the capacity of communities to support
and care for families affected by HIV/AIDS. Many such families
include young people orphaned by AIDS. Such children and young
people are often left with few financial resources, limited
care and attention from elderly relatives and the traumatic
legacy of death and illness, and are therefore in need of
special protection and are vulnerable to HIV infection in
turn.
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UNICEF
EAPRO supports an NGO, AIDSNET, which is active in northern
and north-eastern Thailand to produce a regular newsletter
on AIDS and children (including adolescents). This newsletter
contains the latest information from the field on Thai
projects for those children and young people most affected
by the epidemic.
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"The
Hope and Help" video and manuals showing Thai people with
HIV talking about their lives, has been developed as a
community education tool as well as a resource for people
living with HIV/AIDS. It is used with school children
and out-of-school young people to promote acceptance and
understanding of people living with HIV/AIDS.
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HIV/AIDS
Integrated into Multi-sectoral Development assists NGOs and
CBOs working with the hill tribes to integrate HIV/AIDS activities
into their long-standing development programmes. Health Project
for Tribal People has developed popular 'soap opera style'
videos in tribal languages on topics such as young women entering
the sex industry.
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The
Small Grant facility provides flexible funding (US$ 90,000
in 1996) to support NGOs/CBOs which are undertaking community-based
HIV/AIDS prevention and care
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Educating
youth about the disease; including Buddhist novices and students
from Ethnic High School, teachers college, vocational college
and university students,
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Use
of mass media to educate the public
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Community
level education
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In-school youth are being addressed through the development
of life skills health curriculum for grades 1-12. 500 Teachers
were trained in life skills. The introduction of life skills
health curriculum for grade five and a civics curriculum for
grade eight has been piloted in ten districts. The life skills
approach is being used nationally in health education and
applied in primary teacher training in sixty-one provinces.
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Provincial
and district chapters of the Vietnamese Red Cross have trained
teams of youth trainers (150 core trainers), who trained 7,500
young people in communes. A few young people with HIV were
invited to attend commune level training. Many of the youth
trained are now active in 'health clubs'.
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Developed
and introduced new school curriculum, SHAPE (School-based
Healthy Living and HIV/AIDS Prevention Education) in primary,
middle and high schools in 30 project townships (4,004 primary,
middle and secondary schools).
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Members
of Myanmar Red Cross Society (MRCS) and the Myanmar Maternal
and Child Welfare Association (MMCWA) are trained as facilitators/trainers
for peer education to carry out community education activities
among women and youth through life skills training promoting
healthy sexual behaviours and reproductive health. MRCS had
conducted life skills training to youth in 47 townships by
the end of 1998.
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A
pilot project for social marketing of condoms is being implemented
in 12 towns with the involvement of Population Services International,
a social marketing agency.
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Training
in life skills for the School Health Department, Teacher Training
Department, Literacy Program of Non-Formal Education Department
and NGOs working with Out-Of -School-Youth (Cambodian Red
Cross, Save the Children UK, Centre for Hope)
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Introduction
of HIV/AIDS curriculum and teaching methods into the teacher
upgrading project and the national primary and secondary school
curriculum · IEC materials for Youth with Risk behaviour,
for example the videos "Snooker" and "A Quiet Place" and a
radio serial aimed at youth, "Red Light, Green Light"
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HIV
education for in-school youth
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HIV
education for out -of-school youth, especially ethnic minorities
How
have adolescent boys and girls been involved in the project?
In what stages have they been involved - situation assessment,
situation analysis, planning, implementation, monitoring, and/or
evaluation?
Most of
the projects involving youth use a peer education approach and
have involved youth at the implementation stage. However, as
more youth are trained as peer educators and acquire experience
in implementation, they may be involved in planning as well.
In addition, many projects used a participatory analysis approach
that involved youth from the outset. The following examples
clarify some of the different ways and stages at which young
people have been involved:
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Thailand:
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School students have been involved in implementing initiatives
like the "Teenage Modern Club" in Phitsanulok, which trains
peer educators to develop media campaigns and empowers
them to conduct outreach to peers.
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Young people affected by HIV, from the NGO projects and
self-help groups for people with HIV in the North of Thailand,
have participated in specially tailored camps and other
activities to encourage sharing of experiences and to
address their specific needs. Camp Leaders are generally
young NGO staff members who build a 'big brother/sister"
relationship with young participants.
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The
Sangha Metta Project uses a participatory analysis approach
in which the large numbers of novice monks at a temple
(aged around 9 or 10 to 16 years of age, numbering from
a handful up to a hundred, depending on the temple) are
always included. They participate in situational analysis
and designing solutions to assist in supporting PLWHA
in their communities and in educating communities about
HIV/AIDS. Novices, along with other (usually poor) village
boys receive their education at the temple school. Young
women ordained as Buddhist nuns are also involved in the
Sangha Metta Project.
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Myanmar:
Young people and women are trained as reproductive health
and HIV/AIDS community educators to implement education programs.
As a result of this training, youth were able to discuss positive
behaviours with family and friends. Most of the trained youth
disseminated messages to friends not involved in training.
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Cambodia:
Young people were closely involved in planning and producing
the IEC material, through focus group discussions and testing.
Youth are also involved in the Cambodian Red Cross implementation
of a Youth Peer Education Program, which UNICEF assisted by
providing lifeskills training.
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Vietnam:Youth
trainers are now active in 'health clubs'. Activities in health
clubs vary; some organise sporting activities and then conduct
HIV/AIDS awareness activities and condom demonstrations. One
mobile group from Ninh Hoa Youth Union goes to communes to
present an hour of slides on STDs, and games and condom demonstrations.
(Constraints for such clubs are that in some locations HIV/Activities
are linked with the "Social Evils" Campaigns that make it
difficult to acknowledge risk behaviours without penalty and
mitigate against condom promotion). In Lang Son, a group of
young men with HIV have been trained as peer educators.
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Lao:
Lao Youth Union built capacity in the training of young volunteers
to work with young people in villages of ethnic minorities,
generally out-of-school-youth, using "Friends tell Friends"
methodology, which promotes dialogue, skills acquisition and
problem-solving, (not just delivery of one-way messages).
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China:
Youth have been involved in designing IEC materials, song,
dance and story performances, blackboard notices, posters
and magazines and in peer education.
What
influence has their involvement had on the project?
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Despite
the difficulty of generalising over such a range of countries
and projects, it is safe to say that, generally, peer education
projects have seemed to be more successful when:
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a
range of young people are consulted and involved (not
just the 'good citizen' kids);
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they
meet young people's social needs as well as educational
ones; and
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there
is scope to discuss sexual activity and drug use in a
non-judgemental way.
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IEC
materials have been more effective when they incorporate local
youth cultural and experience. Some specific examples of the
way youth involvement has benefited projects are as follows:
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Cambodia:
Cambodian
videos, "Snooker" and "A Quiet Place" are notable for their
accurate depiction of youth slang, dress and attitudes, this
would not have been possible without the participation of
young people in planning, testing and providing feedback on
the videos.
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Thailand:
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Teenage
Modern Club and many other similar clubs, have become
a focus in the participating schools for both social and
educational activities of the teenagers involved, giving
them both communication skills and a supportive social
setting which militates against risky behaviour.
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Young
People affected by AIDS: Through young people's sharing
of their experiences and participation in camps, NGOs
have learnt much more about the needs of young people
affected or orphaned by AIDS. Increasingly, these young
people are writing, drawing and speaking of their experiences.
How have
the adolescent girls and boys involved in the project been affected
personally?
Thailand:
Camps for
Young People affected by HIV/AIDS have formed a new friendship
network for affected young people. Many of them have spoken
of their participation in the camps with enthusiasm, and some
have been described as changing from anti-social to social behaviour
during the period of the camp.
Vietnam:
Young men
who were HIV positive and received some training, wished to
have more training to become peer educators.
Lao:
Young people
have said they feel able to acknowledge and speak publicly about
young people engaging in risk behaviour, which was not the case
before. They have said that they now understood that they have
options with regard to sexual behaviour, one of which is condoms.
China:
Young people
in schools have information on HIV but some are still shy about
discussing this with friends.
Myanmar:
Young people
who received life skills training believe that they had become
more thoughtful, careful and considerate and had reduced their
risk behaviours. In one town participants stated that visits
to commercial sex workers dropped by 50% after training. For
some, training was an entry point for further volunteer activity.
One young man joined the Red Cross after doing the training.
What
have been the achievements of this project to date?
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Young
people have been provided with life skills training and HIV/AIDS
through schools and programs for out-of-school young people
throughout the region.
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In
Cambodia, IEC materials for young people have been
very popular and effective with the target group.
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In
Lao, hilltribe youth have been reached through training
and Lao Radio. · UNICEF has supported projects promoting community
acceptance and support of families with HIV/AIDS affected
members. These projects directly benefit young people and
children whose parents and relatives have HIV/AIDS, through
educational scholarships for them and income generation schemes
for their carers, as well as through reduction in stigmatisation
by communities. The Sangha Metta Buddhist monks and nuns project,
'Hope and Help' video kit and 'Women Against AIDS' project
working with children affected by AIDS, in Thailand,
are examples of projects supported by UNICEF, the lessons
from which are being disseminated through the region.
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A
1999 review of the project concluded that the sub-regional
approach of the project has been instrumental in strengthening
the response to HIV/AIDS/STD prevention and care needs at
both country and inter-country levels. The project has helped
to build high-level political commitment, contributed to improving
service delivery, was able to reach vulnerable groups such
as migrant workers and ethnic minorities, and responded to
the local situations and needs.
Has a
formal evaluation been performed?
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The
Review of the Mekong Subregion STD/HIV/AIDS Project, March
1999
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Participatory
Evaluation of Lifeskills and HIV/AIDS Training for Youth and
Women, Myanmar Red Cross Society, Myanmar Maternal and Child
Welfare Association, UNICEF, June 1998
What
were the main constraints in meeting the project objectives?
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In
many countries there is a level of concern by government that
acknowledging sexual activity among youth will encourage immorality
and promiscuity. In Vietnam, the Government has run campaigns
condemning "Social Evils", including immorality and promiscuity
and drug use etc. This is also a concern for Governments in
China, Lao, and Myanmar.
-
In
Thailand, conversely, young people's sexual practice is may
now be discussed openly. However, the Government is currently
pursuing an zero tolerance abstinence policy in regard to
drug use, which creates a level of denial about young people
who use drugs.
Lessons
Learned/Recommendations/What would you do differently if you
could do it over?
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Following
the 1999 review, a regional HIV/AIDS strategy was formulated
in collaboration with key partners. The strategy focuses on
behavioural change and development, reproductive health, care
and support for people living with HIV/AIDS and capacity building.
Based on the strategy, phase two of the Mekong HIV/AIDS partnership
was formulated for which funding is being negotiated.
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The
nexus between education for young people on HIV/AIDS, safe
sexual behaviour, safe drug use and "Social Evils" campaigns
requires careful attention.
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The
location of HIV/AIDS in the context of reproductive health
may allow for a more practical approach.
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The
next phase of the Mekong project will continue to promote
training in life skills for young people, on as wide a scale
as possible, but also the integration of HIV/AIDS in Reproductive
Health and Sexually Transmitted Infections, and making such
services appealing and accessible to youth.
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Care
and support for children and young people affected by AIDS
will be a greater priority for the future, as Thailand
is now estimating that numbers of orphans will increase to
225,000 by the year 2005. Other countries may see similar
trends emerging. The social and emotional problems for children
orphaned by AIDS could emerge as major problems for them in
adolescence, (when the generation gap between them and their
elderly carers may be most apparent and when they may not
be able to continue studies due to fall in family income).
These problems may make this group of adolescents more prone
to risk-taking, more vulnerable to HIV and could pose a social
problem for their communities, unless the needs of this 'army
of orphans' are anticipated and met.
What
program support tools/resources were developed that can be used/adapted
by other country offices?
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Many
of the life skills training materials, curricula and IEC materials
can be exchanged and adapted for use in other countries.
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The
Sangha Metta Buddhist monks and nuns project, 'Hope and Help'
video kit and 'Women Against AIDS' project working with children
affected by AIDS, in Thailand are examples of projects
supported by UNICEF, the lessons from which are being disseminated
through the region.
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Sangha
Metta has visited and trained monks in Yunnan, in Lao,
in Cambodia and Myanmar. Further networking
and training is envisaged for the region. "Sangha Metta" has
an impact on entire communities, but retreats and workshops
run for young people are an important part of their work.
In addition, "Sangha Metta" involves the many adolescents
who have been ordained as novices within temples in situation
analysis, and support for PLWHA.
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"Hope
and Help" videos have now been produced in Thailand, Lao
and Vietnam. One is in production in China.
All show people with HIV, of different ages, talking about
life with HIV. Accompanying manuals have been produced in
Thai and English and are being prepared for Lao, Vietnam
and China. The manuals contain games and activities
suitable for youth groups and school students.
Youth
Perspective:
"We
can help our friends by talking about preventative measures
and proper use of condoms"
"Talking
about sex is widely accepted by the younger generation but most
of the parents do not like it. They think it can promote promiscuous
behaviour among us."
- Trained Youth, Myanmar
"I've
drawn a picture about the conservation of nature. The trees
are in the forest at the foothills behind my house. I don't
know what kind of trees they are but all their leaves are yellow.
I like to look at them. I'm not sure if it is because when I
noticed the trees they were dying or whether they were just
changing their leaves. I wonder why the tree leaves become yellow
when they are going to die? It is the same colour as the yellow
rose which people with AIDS use as their symbol. I haven't got
an answer to the question of why they are yellow. I live with
my mum, stepfather and younger brother. My dad died a long time
from a gas explosion in the factory where he worked. My mum
got infected with AIDS from my dad. She got married again and
my stepfather doesn't mind about her illness. He hasn't got
AIDS. Mum teaches me not to be bad. I went to see the movie
"Bad Kids" (Dek Sephle). It was good fun and tells you not to
do like they do in the movie."
- 'Korn'
12 years, boy, participant in 'Children's Picture Project',
Northern Thailand
"AIDS
is an evil demon killing great numbers of people; both those
who go to prostitutes and drug addicts. It's like they're immersed
in darkness being blown along by a terrible storm attempting
to spin them into the vortex of death. AIDS is the hand of a
demon dragging people off to hell. Everyone is being harmed
by this demon without even realising what is happening. I don't
want AIDS. My father and little brother died of AIDS. Now I
live with my mum and grandfather. My mother's health is good.
She sells dok mai jan funeral offerings. … Up to now our neighbours
have been understanding. When I go to school, I don't face any
problems. I intend to do well at school. I'd like to be a doctor."
- "Rin"
13, boy, participant in 'Children's Picture Project', Northern
Thailand
Source
of Information: Robert Benoun
HIV/AIDS
Officer Prue Borthwick
Assistant
Project Officer, HIV/AIDS
UNICEF
EAPRO
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