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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:

  • Thailand: Nation-wide, focus in the north and northeast of Thailand
  • China: Yunnan
  • 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
  • Myanmar: States and divisions bordering Lao PDR, Thailand, and China
  • Cambodia: Nation-wide
  • 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.

  • 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
  • China: All China Women's Federation, provincial, prefecture and county HIV/AIDS leading groups, and INGOs
  • 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
  • Myanmar: Three NGOs and the Ministry of Health
  • 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
  • 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:

  • 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
  • To assess and counteract the likely consequences of HIV/AIDS on the health education and wellbeing of the most vulnerable groups in the region
  • 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
  • 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:

  • Thailand: the poorest 20 per cent of the population; children, young people, women and hill tribe populations
  • China: Children and young people in and out of school
  • Viet Nam: Youth between 10 and 18
  • Myanmar: 10.4 million people involved. 2 million young people and 2.6 million women of reproductive age
  • 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
  • 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:

  • 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.
  • 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.
  • 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.
    • 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.
    • "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.
  • 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.
  • 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

China:

  • Educating youth about the disease; including Buddhist novices and students from Ethnic High School, teachers college, vocational college and university students,
  • Use of mass media to educate the public
  • Community level education

Viet Nam:

  • 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.
  • 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'.

Myanmar:

  • 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).
  • 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.
  • 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.

Cambodia:

  • 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)
  • 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"

Lao PDR:

  • HIV education for in-school youth
  • 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:

  • Thailand:
    • 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.
    • 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.
    • 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.
  • 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.
  • 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.
  • 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.
  • 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).
  • 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?

  • 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:
    • a range of young people are consulted and involved (not just the 'good citizen' kids);
    • they meet young people's social needs as well as educational ones; and
    • there is scope to discuss sexual activity and drug use in a non-judgemental way.
  • 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:
  • 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.
  • Thailand:
    • 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.
    • 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?

  • 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.
  • In Cambodia, IEC materials for young people have been very popular and effective with the target group.
  • 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.
  • 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?

  • The Review of the Mekong Subregion STD/HIV/AIDS Project, March 1999
  • 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?

  • 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?

  • 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.
  • The nexus between education for young people on HIV/AIDS, safe sexual behaviour, safe drug use and "Social Evils" campaigns requires careful attention.
  • The location of HIV/AIDS in the context of reproductive health may allow for a more practical approach.
  • 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.
  • 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?

  • Many of the life skills training materials, curricula and IEC materials can be exchanged and adapted for use in other countries.
  • 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.
  • 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.
  • "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