Regional Technical Meeting on Responding to the Feminization of AIDS: Gender Power Dynamics in Marriage and Sero-discordant Relationships Implications

for Practice

Workshop Report

18 20 February 2009 Dusit Thani Hotel, Bangkok, Thailand

 Report prepared for UNIFEM Jo Kaybryn Plurpol Consulting jo@plurpol.org

Contents
About this report........................................................................................................................................................5 Background ................................................................................................................................................................5 Context .......................................................................................................................................................................6 Objectives of the workshop .......................................................................................................................................6 Project strategy and objectives..................................................................................................................................7 Participants ................................................................................................................................................................7 Expected outcomes ....................................................................................................................................................8 Session 1: Opening address by Dr Jean DCunha, UNIFEM Regional Director, South East Asia ................................9 Session 2: Setting the scene .....................................................................................................................................10 Setting the scene and progress to date Karabi Baruah, Focal point- Gender and HIV Programme UNIFEMESEARO ................................................................................................................................................................10 Overview of Gender dynamics in the epidemiology of HIV in the Asia Pacific Region Caitlin WiesenAntin, UNDP Practice Leader .............................................................................................................................. 11 Session 3: Presentations from India and Cambodia followed by discussion ...........................................................14 Cambodia: Jenne Roberts, Consultant................................................................................................................14 India: Niranjan Saggurti, Population Council .....................................................................................................16 Session 4: Presentations from Thailand, Sri Lanka and Philippines followed by discussion....................................18 Thailand: Dr Pimpawun Boonmongkon, Mahidol University ............................................................................18 Sri Lanka: David Bridger, UNAIDS Sri Lanka .......................................................................................................21 Philippines: Malou Quintos, UNAIDS Philippines...............................................................................................22 Session 5: Presentations from Indonesia, Laos PDR, Malaysia and Pacific ..............................................................24 Indonesia: Ira Atmosukarto, National AIDS Commission ..................................................................................24 Laos PDR: Phokin Mouangchanh, Laos Womens Union ...................................................................................25 Malaysia: Azrul Khalib, UN Malaysia ..................................................................................................................28 Pacific: Stuart Watson, UNAIDS Pacific ..............................................................................................................29 Session 6: Positive womens perspectives and the greater involvement of men ................................................... 30

Culture of sexuality and gender in Thailand and women access to ANC clinics, Supeecha Baothip, Thai Positive Womens Organization ..........................................................................................................................30 Priorities, strategies and questions for regional networks: Anandi Yuvaraj (ICW), Frika Chia (WAPN+), Vince Crisostomo (Seven Sisters) ..................................................................................................................................33 Session 7: Research needs, programmatic entry points and advocacy messages ..................................................37 Researchers Group ..............................................................................................................................................37 Programme Group ...............................................................................................................................................39 Advocacy Group...................................................................................................................................................40 Session 8: Stakeholder perspectives on the process and outcomes including action steps in country ..................41 India, Pakistan, Bangladesh, Sri Lanka................................................................................................................41 Malaysia, Cambodia, Philippines, Vietnam ........................................................................................................42 Thailand, Myanmar, Cambodia, Lao PDR, Indonesia .........................................................................................44 The Pacific and Papua New Guinea ....................................................................................................................45 Session 9: Summary Comments UNAIDS/ UNIFEM .................................................................................................47 Jane Wilson, UNAIDS Regional Advisor Gender, GIPA and Human Rights ........................................................47 Caitlin Wiesen-Antin, UNDP Practice Leader .....................................................................................................47 Karabi Baruah, Focal point- Gender and HIV Programme UNIFEM-ESEARO ....................................................47 Vince Crisostomo, Coordinator Seven Sisters ....................................................................................................48 Agenda .....................................................................................................................................................................49 List of participants ....................................................................................................................................................51

About this report This report summaries the presentations and discussions that took place during the joint UNIFEM and UNAIDS Regional Technical Meeting on Responding to the Feminization of AIDS in Asia. Pertinent slides representative of the issues described are reproduced within the text and full presentations (in PowerPoint format) are available separately. Background The Feminization of AIDS and spousal/partner transmission of HIV are critical problems unfolding in the Asia Pacific Region. Despite evidence that prevention programs are beginning to have an impact in some countries (e.g. in Thailand and Cambodia), HIV infections among women, especially young women, continue to outpace those among men; a stark reminder that gender inequity and violence against women fuel the epidemic. Epidemiological evidence from most countries in the region indicates that the largest number of new infections is within stable or long-term relationships with married women accounting for most of the new HIV infections in the region and notes the rise of discordant couples1. In Thailand, for instance, approximately one third of new infections in 2005 were among married women who are believed to have acquired HIV from their husbands or partners2. Similarly in Cambodia, where a rapid feminization of the epidemic is also being observed, 43% of all new HIV infections are occurring in married women, most of whom are believed to have acquired the virus from their husbands.3 In Viet Nam as the epidemic evolves, increasing numbers of women are acquiring HIV from males who were infected during unsafe paid sex and injecting drug use: in 2006, an estimated one third of people living with HIV in Vietnam were women4. The HIV epidemic in Indonesia is among the fastest growing in Asia, and is currently seeing a gradual shift away from a concentrated epidemic among key populations at higher risk to a more generalized one. HIV is triggered mainly through heterosexual transmission and one of the main determinants of transmission in the region is the tendency towards multiple sex partners and the portent vulnerability of wives or regular partners. Feminization of the HIV epidemic does not refer solely to the increasing prevalence rate among women. Feminization of the epidemic is tacitly acknowledged to be the result of insufficient responses to the various interlinked, multi-layered, and deeply embedded gender issues, including: unequal power dynamics between men and women in society at large and within marriages; violence against women; feminized poverty; violence in the course of migration; gender disparity in education; and gender disparity in employment opportunities. Feminization of the epidemic requires prevention efforts that target specific gender related risk factors. Information provided by sound research and sex-disaggregated data pinpointing gender inequalities and gaps in prevention, treatment, care and support for women is urgently needed to develop gender and HIV programmes as an integral part of National AIDS Programmes.

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Discordant couple, where one partner is HIV positive and one who is HIV negative WHO (2007). HIV/AIDS in the South-East Asia region. March. New Delhi, WHO Regional Office for South-East Asia. http://www.searo.who.int/hiv-aids 3 UNAIDS, Scaling up Towards Universal Access to HIV Prevention, Treatment, Care and Support: Cambodia Country Report. Geneva. 2006 4 Viet Nam Commission for Population et al. (2006). HIV/AIDS in Viet Nam. Hanoi, Ministry of Health, Population Reference Bureau.

Context UNIFEM has a core role in gender analysis in the context of HIV and AIDS. In line with UNIFEMs interest in the feminization of AIDS and the Redefining AIDS in Asia report5, which highlighted the lack of focus on HIV transmission to spouses of men at high risk, UNFFEM commissioned a two phased study in 2008. The first study consisted of a Rapid Assessment in Indonesia, Lao PDR and Thailand to carry out a review and secondary analysis of existing data/resources, programs and policies, laws and legislation addressing (a) Feminization of AIDS with specific focus on spousal/partner transmission of HIV and sero-discordant relationships (b) current HIV post-test counseling program and prevention activities in response to national policies on HIV. The review provided an overview of the situation facing young women and girls in the context of spousal/partner transmission of HIV. The review resulted in a framework to ascertain: (i) the efforts undertaken so far by Government as well as NGOs and other stakeholders involved in HIV and AIDS activities in the region, to increase understanding of sexual and behavior patterns, practices and risks that expose women married or in long term relationship to the risk of contracting HIV through spousal/partner transmission and of serodiscordant couples; (ii) identify gaps/opportunities in areas that may require further information and data to streamline, strengthen policy formulation and guidelines on prevention of HIV among women and girls; and (iii) identify appropriate approaches/methodologies to carry out field research aimed at developing an evidence informed knowledge base on Feminization of AIDS and prevention strategies for spousal/partner transmission of HIV. Objectives of the workshop The regional technical workshop was designed to foster discussions and sharing of experiences among government agencies and concerned organizations in member countries in handling the issue of Feminization of AIDS with focus on spousal/partner transmission of HIV; while at the same time, using the information derived from the rapid assessments to identify appropriate approaches/ methodologies (country specific as well as a common regional framework) with a view to guiding the second phase of the study, an in-depth qualitative research with the following objectives: To develop an enhanced evidence-informed knowledge base on gender-power dynamics in marriage/relationships and sero-discordant couples; To contribute to evidence-informed strategic information and increased use of that evidence in programming and policies on primary prevention of HIV among and young men and women (of childbearing age) and on appropriate treatment, care and support to women living with and affected by HIV; To improve information on the post-test counseling programmes in the areas of: sexual practice; risks and implications of being HIV-positive; required treatment negotiated or ensured by clinicians; and health education and its effectiveness; To increase participation of women affected by and at risk of HIV through their active roles in the research and subsequent related advocacy. The participation of groups or networks of women, whose inputs and perspectives can keep the discussions grounded, were invited to make this technical workshop more meaningful.

Redefining AIDS in Asia: Crafting an Effective Response, Report of the Commission on AIDS in Asia, 2008

For countries like Cambodia, where sufficient information was generated through a rapid assessment in 2008, the focus will be on the operationalization of the research findings: that is, the required actions to implement the recommendations from the assessment reports. UNIFEMs Regional Meeting comprises a second technical meeting on spousal transmission on HIV as part of a strong focus by the United Nations and its partners in 2008-9. The first Regional Technical Meeting took place on 6-8 November 2008. The regional technical partners were UNAIDS, UNDP, UNIFEM, UNFPA, the Asia Pacific Network of People Living with HIV (APN+) and the International Community of Women living with HIV (ICW). Financial support was provided by UNAIDS, GTZ, GCWA and UNIFEM. Participating countries in South East Asia were: Cambodia, China, Lao PDR, Indonesia, Malaysia, Myanmar, Philippines, Thailand, and Viet Nam, and in South Asia: Bangladesh, India, Pakistan, Sri Lanka and Nepal. The first meeting aimed to assist countries in the Asia Region to develop evidence-informed HIV prevention strategies for married women, to form and maintain a network of national womens organizations and other civil society organizations to address prevention of spousal transmission of HIV and to facilitate provision of capacity building of organizations in the regional network. A regional policy meeting will take place in May 2009. Project strategy and objectives Keeping the goal of the overall project in perspective, namely improved evidence base on women and HIV and AIDS leading to increased use of that evidence in rights-based programming and in strengthened advocacy initiatives, the objectives of this second regional workshop were as follows: 1. To identify the topical and geographical focus and appropriate country approaches/methodologies for the follow up field survey to collect data as identified in the initial rapid assessment; 2. To prioritize recommendations (both short-term and long-term) and actions required for their implementation for countries, such as Cambodia, that may not need further operational research; 3. To initiate identification of entry points for regional cooperation through bilateral and multilateral relations that can contribute to improving gender responsiveness of policies and programmes for HIV transmission in marriage/among partners and sero-discordant couples, such as migration, to be continued at the May 2009 policy meeting; 4. To identify measures to strengthen the partnership with the positive womens networks in the region (APN+ & ICW) including increasing capacity for effective liaising and communication between the networks, UNIFEM and UNAIDS. 5. To identify networks of womens organizations focused human rights and CEDAW and networks of people living with HIV in each country to take the lead advocacy efforts in country. Participants Representatives from the National AIDS Commissions, networks of people living with HIV, researchers, UNIFEM staff and UNAIDS Gender Focal Points from Cambodia, Indonesia, Laos and Thailand; Members of the UN Joint AIDS Team from Thailand; Other researchers previously involved in the regional work on spousal transmission; Regional gender and HIV staff from UNIFEM, UNFPA, UNAIDS, UNDP. Representatives from the Asia Pacific Network of people living with HIV and the International Community of Women Living with HIV;

Expected outcomes The following are the specific outputs of the Workshop: The scope and methodology for data collection and prioritization of recommendations and actions required for their implementation including formats for regional reports about the country studies; Identified points of entries for advocacy on gender and HIV in country; Strategies for strengthening communication between the networks of people living with HIV and UN agencies at regional and country levels; The workshop report.

The results of the workshop, especially the presentations and discussions of the rapid assessments on Feminization of AIDS will contribute to a planned publication for 9ICAAP6. UNIFEM funded the workshop and participants from Cambodia, Lao PDR, Indonesia and Thailand as well as other researchers. UNAIDS RST funded the participation of UNAIDS Gender Focal Points from other countries participating. UNIFEM/UNAIDS was responsible for the monitoring proceedings and UNIFEMs consultant/facilitator produced the workshop report.

9th International Congress on AIDS in Asia and the Pacific 9-13 August 2009, Bali

Session 1: Opening address by Dr Jean DCunha, UNIFEM Regional Director, South East Asia Date: February 18, 2009 Time: 17:00 hrs 19:00 hrs Moderator: Jane Wilson, UNAIDS Regional Advisor Gender, GIPA and Human Rights Dr DCunha opened the meeting by discussing the emerging themes related to the feminization of AIDS and spousal or partner transmission of HIV: Firstly that the feminization of AIDS is a significant issue; Secondly that there is an increase of HIV among young women, more than young men, with gender inequality being a major driver; Thirdly that the epidemiological data points to the fact that largest number of new infections are among women (AIDS Commission Report) including in countries where overall new infections are declining such as Thailand and Cambodia. Root causes: The power dynamics between adults and children, same sex relationships, men and women, boys and girls, are all affected by gender stereotypes. Gender stereotypes of men are constructed as breadwinners and public figures, while those of women are constructed as unpaid caregivers, religious celibates or vamps. Feminine qualities are promoted as passive, weak, docile and inert. Masculine qualities are promoted as potent, active and aggressive. The result of these gender stereotypes on women include their lower access to resources, lower access to information and little recognition of the link between HIV and gender. Women in the sex sector cannot negotiate safer sex. In marriage they cannot talk about sex or condom use. Stereotyping women leads to extreme stigmatization and doubles womens burden. Men have multiple relationships as appropriate outlets for their innate sexuality. Women are viewed as fitting options for release or seen as consenting adults, while mythology pervades around the desirability for sex with young girls for pleasure, to increase potency and to cure STIs, and condom use is seen to diminish pleasure. What is needed: We want links between groups of men living with HIV and different womens groups. The distinction between different womens groups perpetuates the madonna-whore divide and we must have more discussion. We must engage men and women to understand their feelings about rejection, loss of love, deception etc and convert the feelings of these groups into positive feelings to become guides and mentors. We need to interrogate the institution of prostitution, based on sex as a male right, and that sex and feminine bodies are to be sold to men. We must expand our partnerships to include not only the ministries of Health but ministries of Womens Affairs, Information, Education, Finance, Planning we want the entire government structure to address HIV. Among civil society, we must work with people living with HIV, migrant workers, injecting drug users, same sex rights, youth, and the media so the issues are mainstreamed. Actions 1. Systematic and rigorous research: we have the desk reviews and now we must identify gaps and research sexuality in nuanced dimensions. How do men and women cope in the context of migration? How do they cope in contexts facing alienation, fractured psyches and fractured sex, including children? Use research to inform policy and programmes Use research to develop advocacy messages to debunk the gender stereotypes. We must use the recommendations to create new perspectives in counseling programmes. Use the recommendations and data in development of informal and formal institutions, particularly the desperate need for work with high school students

2. 3. 4.

Session 2: Setting the scene Setting the scene and progress to date Karabi Baruah, Focal point- Gender and HIV Programme UNIFEMESEARO Overview of Gender dynamics in the epidemiology of HIV in the Asia Pacific Region Caitlin Wiesen-Antin, UNDP Practice Leader Date: February 19, 2009 Time: 08:50 hrs 09:30 hrs Moderator: Vandana Mahajan, UNIFEM South Asia Rapporteur: Dr Samia Hashim, UNAIDS Pakistan

The Session started with a welcome by Jane Wilson, UNAIDS, who thanked the participants for their participation. She then introduced the day, meeting logistics and the program. She requested Karabi Baruah, UNIFEM, to set the scene by briefing the participants on the progress to date. Setting the scene and progress to date Karabi Baruah, Focal point- Gender and HIV Programme UNIFEMESEARO Karabi once again thanked the participants and all the partners in working jointly on putting the meeting together. This workshop is the follow-up of the technical meeting on spousal transmission on HIV held in November 2008 and both meetings reflect a strong focus by the United Nations and its partners on the gender dynamics and spousal/partner transmission of HIV. She shared the overall project goal, which was to improve evidence-informed knowledge base on women, HIV and AIDS, which would facilitate the region and the countries in increased use of this evidence in rights-based programming and in strengthened advocacy initiatives in the region. She updated the participants regarding rapid assessments in Indonesia, Lao PDR, Thailand and Cambodia were commissioned by UNIFEM through which reviews and secondary analysis of existing data/resources, programs and policies, laws and legislation addressing Feminization of AIDS with specific focus on spousal/partner transmission of HIV and sero-discordant relationships were conducted to provide an overview of the situation facing young women and girls in the context of spousal/partner transmission of HIV. Karabi explained that the objectives of the Workshop were to try to finalize the scope and methodology for data collection and prioritization of recommendations and actions required for their implementation including formats for regional reports about the country studies; also to identify strategies for strengthening communication between the networks of people living with HIV, government and UN agencies at regional and country levels and points of entries for advocacy on Gender and HIV. She emphasized that this exercise has tremendously supported evolving partnerships. The technical partners in the first meeting in November 2008 Regional were: UNAIDS, UNDP, UNIFEM, UNFPA, the Asia Pacific Network of People Living with HIV (APN+) and the International Community of Women living with HIV (ICW). Financial support was provided by UNAIDS, GTZ, GCWA and UNIFEM. This current technical workshop was being financed by UNIFEM; co-organized with UNAIDS, while sharing experiences with UNDP and some national implementing partners. This was followed by an introduction session, facilitated by David Bridger, UNAIDS, which also served as an ice breaking session.

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Overview of Gender dynamics in the epidemiology of HIV in the Asia Pacific Region Caitlin Wiesen-Antin, UNDP Practice Leader Caitlin outlined the HIV pandemic in Asia and the gender aspects of transmission and impact. Several slides from the presentation are included below (the full presentation is available in the electronic annex). Caitlin spoke of what drives the epidemic in Asia; what is the impact of the epidemic; and the mounting costed national responses? An estimated 150 million people are living with HIV in Asia, 60 million of which are women. There is a core group of people at high risk of HIV infection and sex work is the main driver of transmission. HIV transmits from sex workers to male clients to their partners, and there is overlapping of sex work with injecting drug use and sex between males. There is an increase in new infections among women: 19% in 2000 to 24% in 2007 but these averages mask dramatic increases in numbers, for example in Papua New Guinea where girls are twice as susceptible to HIV infection as boys. Caitlin highlighted the 50 million married women whose spouses visit sex workers, added to that the female partners of injecting drug users and males who have sex with males and we have a very large number of women who are at high risk of HIV infection.

She shared the Commissions projection of an epidemic in a typical Asian country with about 100million population, based on an analysis of epidemic progression in a number of countries. It can be seen that majority of new infections are occurring among adult men visiting sex workers, second largest among the sexual partners and only a small percentage among low risk young men who engage in casual sex. So, contrary to popular belief, casual sex in the general population is not the main cause of the epidemic in Asia. Instead, it is paid sex which is the biggest risk factor in Asian epidemics. She shared the sobering data of the rise in the numbers of women living with HIV in Asia. She shared the critical gender issues that fuel the epidemic, on how impacts of HIV and AIDS on marriage and household is very direct and severe, transmission from men to women higher due to higher non-disclosure rates by men as large number of people living with HIV choose not to disclose their status to spouses immediately. She also shared the study from India where the evidence shows that HIV positive widows are most likely to have contracted HIV from their husbands, majority of whom did not know their status but those who did know their status had not disclosed it to their spouses. In terms of the impacts of the epidemic, as it epidemic expands and matures, it strikes at the heart of development. AIDS being the leading killer of Asians in their most productive years (15-44); it spreads and deepens poverty and additional poverty 5-6 million households (25-30 million people) is expected by 2015; it strains overstretched health systems ability to reach most at risk populations and vulnerable populations;

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deepens gender inequalities; unravels social cohesion; the $2 billion annual economic loss is mainly borne by poor households, though there is no perceptible impact on GDP growth there is severe impact at household level. Women bear the major brunt of these since they bear the burden of care, blame and shame. 75% caregivers in Vietnam are women; 90% positive women in South Asia infected by partners and 90% of HIV widows are thrown out of marital homes after husbands death in India. There are a number of critical gender issues: constructs of masculinity and femininity make womens negotiation difficult. Education is low for women, and access to quality reproductive health is lacking. Women have less economic opportunities which increase their dependency on others and increase their vulnerability to exploitation. Mobility impacts on HIV transmission through mens migration (internal and external) for work and the increased likelihood they will buy sex the longer they have been migrating. Among trafficked women, they younger the age of being trafficked, the higher the chance of being HIV infected. In addition to sex work, violence also plays a key role in both intimate relationships and in conflict and war. Non-disclosure of HIV status leads to increased transmission between partners. Most people dont know their status or their partners before (and during) marriage.

The AIDS Commission reported that at present, there is no effective strategy to protect women within marriage or steady relationship in Asia on a large scale. There is a need for high quality research for designing prevention programs for these populations. Caitlin emphasized the need for impact mitigation projects/programs in Asia as they were lacking and were not part of national strategies in most Asian countries. These would cost only US$300 million per annum for region. These programs must provide income support for foster-parents; livelihood security for widows and affected families; secure property and inheritance rights for women and health insurance to protect against catastrophic health expenditures. Caitlin shared excerpts from the recently published Gender and HIV practitioners Guide developed by UNDP, ICRW, UNIFEM, UNAIDS, UNIFEM, UNODC and UNICEF (see full presentation in electronic annex). The Asian HIV and AIDS Resource Estimation and Costing Model developed by UNDP-UNAIDS-ADB is strongly aligned with directions and recommendations of the Commission on AIDS in Asia Report, and has the Universal Access targets for Asia and the Pacific embedded by default, with an addition of a new area of costing: Enabling Environment, addressing human rights, gender and governance dimensions of HIV responses. To ensure that women focused interventions are included and budgeted, the women-focused interventions were included in the Asian HIV and AIDS Resource Needs Estimation and Costing Model. The suggested interventions are womenfriendly income support programs for HIV-affected households; support for families caring for children

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orphaned by AIDS; Review/develop/amend laws and policies to guarantee inheritance rights especially for women; care for AIDS affected people incorporated into social security schemes and Prevention of Parent to Child Transmission including the involvement of family and partners. Costing the national response requires a re-focus on prevention. Impact mitigation is also included for the first time, as is the creation of an enabling environment. It is a difficult question to answer in terms of how much structural work the HIV response should take on, but we also must recognize that we cannot achieve our goals without ensuring rights. 30% coverage rate of key populations is not enough to stem HIV transmission, but if we reach 50% HIV transmission is modeled to level off. The Asia Commission pointed out there is no effective large scale prevention strategy for women in marriage. Impact mitigation can include foster grants, health insurance and property rights. The Asian HIV and AIDS resource estimation and costing model prompts us to ask questions about what should be included, especially in relation to womens rights based approaches. If these strategies are conducted at country level in a collaborative way, they are more likely to have meaning for the costers and therefore more likely to be implemented. We must avoid paralysis by analysis. It is important to move the response and define our advocacy messages. Discussion summary Cost efficacy for prevention programmes: whats the how? And how cost effective is it? There are little examples of costed models for Asian countries (i.e. in comparison to African countries) which tell us and policy makes the cost-effectiveness of various approaches at national level, and importantly the opportunity costs of not implementing certain strategies. The challenge here is that this is currently unknown. Do we launch an extremely large general campaign with high cost but potentially long term impact? The question is how do we be strategic?

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Session 3: Presentations from India and Cambodia followed by discussion Cambodia: Jenne Roberts, Consultant India: Niranjan Saggurti, Population Council Date: February 19, 2009 Time: 09:30 hrs 10:30 hrs Moderator: Alankar Malviya, UNAIDS Rapporteur: Jane Batte, UNAIDS Cambodia Cambodia: Jenne Roberts, Consultant Cambodia is an example of a country whose HIV epidemic has turned around over the last decade; currently national prevalence is 0.9%. The gender analysis shows that the percentage of women living with HIV has increased from 38% to 52% between 1997 and 2006, although this is more likely to reflect the fact that many men have died rather than an increase in new infections among women. Fifty per cent of Cambodias population is under 20 years of age which has implications for transmission and the response. There is a higher prevalence in urban over rural areas. Evidence also shows that there is increased prevalence among the most wealthy (although in percentage terms rather than in numbers). Much of Cambodias reduced prevalence is due to the introduction of the Continuum of Care and a strong commitment to universal access. Antiretroviral therapy coverage is 91%. 52% of both antiretroviral therapy and opportunistic infection patients are women. Yet still 20,000 people dont know their status and are without positive prevention messages.

In the 20-24 age range, women are three times more likely to be HIV positive than men. Projections show that there will be slightly more women than men living with HIV, and more women than men will need antiretroviral therapy. New infections are declining due to 100% condom promotion among sex workers, and the availability of treatment. In 2008, just over of infections were in children, just under were in women, and were in men. The sex industry is changing in Cambodia and men are using brothels much less but there is an increase is casual relationships and number of girlfriends. There is a small but growing number of injecting drug users, among whom prevalence is 25%, with the next highest groups are transgender and female sex workers. Vulnerability factors include: desensitization to violence, gender roles, migration, and womens low decision making power especially in relation to whether their husbands have relationships outside marriage. Outside of

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brothels condom use is very low. The situation within brothels is ambiguous: sex workers report high usage but the level of sexually transmitted infections has not changed since 2000. There are barriers to disclosure and 20-30% of people living with HIV at one clinic reported not knowing their partners status. In fact there is little known beyond anecdotal evidence what these barriers are. There are limited positive prevention approaches. 25% of HIV positive women have negative partners. There are few family planning, sexually transmitted infection and reproductive health services and in those that are operating, the staff often has discriminatory attitudes. The national HIV response includes a strategy for women and girls but there is limited capacity. Funds are directed mainly towards the Department of Health not the Ministry of Womens Affairs. A draft strategy for entertainment workers has been developed but no resources attached to it. Mandatory testing is not encouraged. Only 2 out of 50 services are providing integrated family planning and HIV services. Unmet information needs: Information is collected but not analyzed, interpreted and disseminated Incidence data for monitoring Anecdotal understanding of gender, violence, property rights but no evidence How discordance is managed Barriers to disclosure and testing (including lack of testing equipment, and denial of difficult issues such as child abuse) Pregnancy among people living with HIV on treatment Sexual behaviors of widows, divorced and separated women and men

Recommendations for action Focus on prevention efforts for married most at risk populations and their sexual partners Enable people living with HIV with positive prevention Enabling environment and human rights approaches

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India: Niranjan Saggurti, Population Council There are a high proportion of HIV discordant couples. Among couples affected by HIV, women are HIV positive in 39%. Many people who are at high risk have spouses and may be sero-discordant but we have no data. Vulnerability to HIV infection is increased due to the low status of women, different castes and violence. There are societal and cultural norms that affect disclosure. What are the best practice models for secondary and positive prevention? The contextual framework shows that the context affects variable (gender, behavior) which results in nondisclosure of status and low sexual health, both of which ultimately lead to HIV transmission.

Next steps: feedback will be given to the National AIDS Control Programme. There are currently no guidelines/toolkits to support the targeting of spouses so the development of an advocacy toolkit is proposed. This will seek the participation of civil society to build their capacity, especially among positive networks. In the long term, programmes should be developed to facilitate disclosure among discordant couples among those who know their status, and encourage those who dont know to go for testing. The approaches will use structural level coordination and not rely on vertical parallel programmes. All sectors must come together to work on how to maintain sero-discordance among couples.

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Summary of discussion Migration is also an issue for India, but evidence is lacking on testing of migrant workers (especially internal). There are other ways to support people in discordant couples, other than disclosure. For example, one Cambodian clinics support women to reduce their viral load to an undetectable rate to protect their husband. An epidemiological model could be developed with a gender analysis of prevention among women. 91% coverage of antiretroviral therapy but adherence is less known, but this is one way of analyzing discordance issues. Positive prevention: what does this mean in reality and does responsibility always lie on positive people, adding to their burden?

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Session 4: Presentations from Thailand, Sri Lanka and Philippines followed by discussion Thailand: Dr Pimpawun Boonmongkon, Mahidol University Sri Lanka: David Bridger, UNAIDS Sri Lanka Philippines: Malou Quintos, UNAIDS Philippines Date: February 19, 2009 Time: 11:00 hrs 13:00 hrs Moderator: Alankar Malviya, UNAIDS Rapporteur: Laura Tracy, UNIFEM Cambodia Thailand: Dr Pimpawun Boonmongkon, Mahidol University Dr Boonmonkon explained that the research undertaken by Mahidol University builds on the earlier rapid assessment by the UNIFEM consultant, Jo Kaybryn, and aimed to elicit the voices and experiences of women. Objectives: Examining the current policies, legislation and program implementation by government organizations and non-governmental organizations working with people living with HIV. The research examined the laws and legislation in regards to CEDAW7, abortion, sex workers, prostitution, prevention, and suppression of the domestic violence law and any other laws that involve HIV issues. The above examination provided an understanding of the sexual risk/behavior patterns and practices which expose women to HIV in Thailand. The methodology consisted of a rapid assessment over a three month period, including, a document review from research and other studies; and in depth interviews with three women living with HIV. An analysis of the legal framework in Thailand reveals many issues related to gender and rights from CEDAW to national harm reduction laws. However, it seems that most legislation is conceived from the paradigm of maternity which emphasizes womens roles as good wives and mothers. This detrimentally affects women perceived to be outside these categories i.e. those who want abortions, female sex workers and women living with HIV. The Thai government realizes there is a need to shift from health/medical approach to understanding the social dimensions. The findings included: the most at risk women were 20-40 years old; and the laws have encouraged young women to use marriage as a way to achieve conflict resolution in terms of male-female relationships, putting them at risk as opposed to being used as an empowering tool for them. In extreme cases marriage is used against women, for example in the case of sexual violence: a man is not prosecuted for rape if he marries the female complainant. Government policies on women living with HIV began in 1992. Various campaigns have focused on strengthening families, non-promiscuity and safer sex negotiation. Campaigns promoting non-promiscuity include: say no to sex; respect and acceptance of womens rights and roles; and love and warmth in the family. The aim has been to target married couples but the emphasis has been directed at women not men. The result was to encourage women to put aside their own sexuality, desires and encourage ignorance of their husbands/boyfriends infidelity. The campaigns were not really focused on men taking responsibility to be faithful and/or use condoms etc. Other examples of women-focused responses include prevention of mother to

Convention on the elimination of all forms of discrimination against women

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child transmission which is solely focused on drug delivery to women and is available at 800 hospitals, and the 100% condom use campaign which is targeted at women in brothels not their male clients.

In general, the analysis of policy on women shows that policy is based on an epidemiological approach, and excludes women of varied backgrounds. The gender bias includes the focus on women but policy does not empower women or address their rights. In fact violation of womens reproductive rights is the norm, such as sterilization imposed in exchange for abortion requested by women living with HIV. There are various leverages used for testing women but not men. There are also fewer entry points for targeting men. Most engagement with women takes place at mother and child health centers which largely exclude mens participation. Traditional values of womens sexuality prevail and women are polarized as good or bad, monogamous and non-monogamous. In addition to policy deficiencies, research is also lacking: only five studies discuss gender power dynamics and HIV in the last 10 years. Mahidol Universitys research looked at the reasons women have sex, female sexuality in discordant relationships, sexual relationships, sexual practices including verbal and nonverbal negotiation. For women who have regular sexual relations the meaning of sex include love, duty, own pleasure and desire, and male pleasure and desire. Most are monogamous and their sexual practice is characterized by no sexual communication and a lack of access to information and health care services. Condom use is viewed as a male responsibility and is also identified as a symbol of distrust (stigmatized due to the association of condoms with commercial sex and extra marital sexual activity). Women within HIV sero-discordant and HIV concordant relationships expressed their understanding of sex as love, to fulfill their own sexual desire, to fulfill their partners desire, reproduction, pregnancy and responsibility. Women also reported having extra marital sex for money transaction and in revenge for their partners masculine pride, betrayal, abandonment, and his extra-marital sex. Women within sero-discordant and concordant relationships are sexually active and have changed partners (total 2-7 partners). They find it difficult to disclose their HIV status but when they do they are more likely to stay with someone who accepts their HIV status. These men can be married or unmarried men, and HIV positive or negative. The women include both heterosexual and homosexual. Most women experience a lack of information with regards to positive prevention and avoiding re-infection. They also experience a lack of sexual communication and negotiation power with their partners, and very little

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or no condom use. Women in relationships with men have varied approaches and ability to negotiate or refuse sex. Non verbal tactics include going to bed later than their spouse and participating passively in sex act. Verbal tactics include making excuses for health reasons or citing tiredness or the unavailability of condoms. Sexual negotiation power depends on a range of factors. Womens lack of ability to negotiate depends on the time, the context and the type of partner. Other factors include their own inexperience, especially at the beginning of marriage, their views of sex as shameful and a duty, and their partners sobriety and chauvinism. Women who can negotiate are economically more independent, have more life experience, influenced by their residence (e.g. a couple living with the wifes parents) and their own physical capital. Womens attitudes towards masturbation correlate with ability to negotiate. Those that do masturbate have been able to cross the perceived lines of morality and sexual perversion. They have more sexual agency and they have experience in touching and feeling themselves. Women who do not masturbate displace their interest to other activities because they feel it is shameful. As a result they have no experience of touching and feeling themselves. Another issue that affects womens ability to negotiate is their self-perception. Women with greater agency have increased self-perception of their physical power and beauty, which links closely to their confidence. This is reflected in condom use within commercial sex: subjective perceptions of physical beauty and desirability by providers and clients of sex workers play a significant part in setting the price for services and also dictate the conditions, i.e. condom use. Future research should look at gender, power and sexuality within couples, and especially within discordant couples, for women growing up with HIV, for injecting drug users (positive and negative). We need to understand the health providers perspectives of gender, women and rights and how these impact on the HIV and the quality of care. The methodology should include both qualitative (focus group discussions, in-depth interviews) and quantitative (survey questionnaires) research. Population samples should focus on: Young people living with HIV (14-18 years old), Female injecting drug users (18-25 years old) Women living within sero-discordant/concordant relationship (20-55 years old) Men living within regular relation and concordant relationship (20-55 years old)

Suggested study sites include Bangkok, North, South, Northeast, East, and hospitals which have PM prevention of mother to child transmission programs (836), villages, and communities. Data analysis should include both social science software (e.g. SPSS) and content analysis.

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Sri Lanka: David Bridger, UNAIDS Sri Lanka Sri Lanka has a low overall HIV prevalence and there are 100-120 new infections each year. It is a truncated epidemic: HIV is entering the country but does not appear to be spreading. 108 women are on treatment, 36% reporting infection via spousal transmission, 94% of which reported their partner acquired HIV while working overseas. The vulnerabilities of HIV transmission are predominantly due to separation (i.e. partner is a migratory worker); gender-based violence; low knowledge and low condom use (women use hormone treatments for birth control, which offers no protection against sexually transmitted infections or HIV); and consensual and non-consensual sex. Vulnerability also stems from risk-taking behavior from the bridging populations (sex workers, males who have sex with males, prison population and uniformed services). Migrant workers were found to be over-represented in HIV research and results as they are subject to mandatory testing. The Bureau of Foreign Employment pre-departure program for female migrant workers responded by providing some information/education before departure. However, this response captures about 60% of women who work abroad. 30% of women and most young men do not get any support or input. Overall the quality of both data and reporting is very weak.

The next step for UNAIDS Sri Lanka includes using the UNDP report on HIV vulnerabilities to develop advocacy messages and strategies. Programming must include women and men and strategies to reach partners of the most at risk populations. Organizing our Messaging- sexual and gender-based violence are huge issues in all conflict zones Sri Lanka is no exception, although, there is no data from the North. There is a strong possibility that when they receive the data from the conflicted North that the HIV statistics will rise.

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Philippines: Malou Quintos, UNAIDS Philippines

Objective: Undertake an assessment on spousal transmission of HIV in the Philippines as inputs to country and regional strategic plan to address this issue. Methodologies: Desk reviews - epidemiology of spousal transmission in the Philippines, mapping of policies that facilitate or impede prevention of spousal transmission. Key informant interviews of AIDS programmers programmes that address directly or indirectly spousal transmission, resource mapping (budget for addressing spousal transmission), organizations/sectors and their capacities to do work on spousal transmission, opportunities for addressing spousal transmission in the Philippines. Focus group discussions with: discordant and concordant couples. The discussions centred on; the psycho-social, emotional and economic impact of spousal transmission on families. A Validation workshop was utilized. Key findings: Passive data collection shows that: 6% of HIV infections are among people registered as housewives; 10% are among people who claim to be married; 20% of transmission is through bisexual transmission. The research on spousal transmission reviewed the available data and policies and determined the key influential players through a desk review and interviews with key informants including men and women who are in relationships where one or both are HIV positive. Spouse in the Philippine context, not only means the legal husband/wife, but also live-in/common law partners, mistresses and other forms of relationships considered long-term and stable. The 4th AIDS Medium Term Plan is gender blind. For instance, ongoing prevention strategies and activities target most at risk populations (sex workers, males who have sex with males and injecting drug users) and vulnerable populations (e.g. migrant workers). But it is only among the migrant workers where there are ongoing efforts to target their partners. There is a dearth of information on the issue of spousal transmission in the country. We are not even sure who these positive women/spouses are who are reported in the AIDS registry. Some of them are wives of migrant workers, but we are not sure of the others. We do not know whether they are wives of bisexual men or wives of clients of sex workers, or from a different scenario. Some good practices on work with migrant workers: (1) UNDPs pilot impact mitigation project livelihood support for migrant workers living with HIV. (2) Integration of AIDS education in both the Pre-Employment Orientation Seminars and Pre-Departure Orientation Seminars. Although on a small scale, efforts focused on preventing HIV transmission to women including in relationships has targeted overseas workers. This usually occurs in pre-departure orientation sessions but in terms of an intervention this is probably a bit late. Preemployment seminars prior to appointment would give people more time to think about their risks. It is also important to look at the large segment of domestic workers (women) rather than only the male dominated industries such as maritime and sea faring. The wives of maritime workers have begun demanding that HIV information is included for both their husbands and themselves on exit and return of workers as part of reintegration. One large company (30,000-40,000) has expanded its orientation and re-integration sessions to include wives and families of the workers. The study has generated some useful insights as inputs to ongoing strategy development and implementation of intervention programmes. At the same time, the study raised the need for further related researches given the dearth of information on the issue. The analysis of the Spousal Transmission Study will be enhanced and understanding deepened by the Integrated HIV Behavioural and Serological Surveillance to be conducted

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starting June 2009 and the planned Country Assessment on Gender and HIV. Findings and analysis, including issues around spousal transmission, will inform the development of the 5th AIDS Medium Term Plan (20112015), the next Common Country Assessment and UN Development Assistance Framework (CCA/UNDAF) for 2011-2016 and future GFATM proposals. Next Steps: Findings to be presented to the Philippine National AIDS Council (PNAC) Recommendations around data collection and reporting to be integrated in the revised manual of operations for the AIDS Registry (Dept. of Health)

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Session 5: Presentations from Indonesia, Laos PDR, Malaysia and Pacific Indonesia: Ira Atmosukarto, National AIDS Commission Laos PDR: Phokin Mouangchanh, Laos Womens Union Malaysia: Azrul Khalib, UN Malaysia Pacific: Stuart Watson, UNAIDS Pacific Date: February 19, 2009 Time: 14:00 hrs 15:30 hrs Moderator: Dr Khamlay, UNAIDS Laos PDR Rapporteur: Ashley Heslop, UNAIDS Indonesia Indonesia: Ira Atmosukarto, National AIDS Commission Indonesia consists of 17,500 islands. The patriarchal culture is still very strong and affecting the AIDS epidemic. Cultural attitudes are also affecting the AIDS epidemic. Discriminating laws particularly affect women and transgender. The HIV epidemic was largely concentrated among injecting drug users, but a second wave impacts on womens vulnerability through both their own sexual patterns with multiple partners (e.g. there are more women living with HIV than men in Papua), and impacts mens vulnerability, especially those that are married and have high mobility and/or multiple partners. Key areas of progress include the formation of a positive womens network (IPPI) and groups of female injecting drug users. Two national research workshops saw the creation of a national HIV strategy for women. The national AIDS commission has undertaken a gender audit (November 2008) and created a working group on Gender and Human Rights to review gender and rights mainstreaming. Gaps in response continue, especially in reaching migrant workers, women prisoners, sex workers (women, transgender and males who have sex with males). The national AIDS commission recognizes the need to connect with the region to cement the fragmented responses. Challenges to achieving holistic coverage include low gender awareness among government, divided civil society, clinical vs. non clinical approach, no integrated efforts from all players, problematic geography, and a virtually non-existent social security system vs. community based security system. The research on spousal transmission of HIV will take place in Jakarta, Bali and Papua. It is challenging to get women involved in the studies and there are also different views between the researchers.

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Laos PDR: Phokin Mouangchanh, Laos Womens Union Overall Laos HIV prevalence is low 0.2%. Of those people living with HIV, 57% are male and 43 are %female. The highest affected age group is 20-29. 900 people are on antiretroviral therapy. The main vulnerability factors are economic and the migration needs of men and women. There are also social and cultural elements such as gender inequity within relationships, and mens increased likelihood of having several partners. The response includes: voluntary counseling and testing, prevention of mother to child transmission, condom distribution, TV and radio campaigns, drop in centers, and programme to involve men (e.g. maternal health care). Background: By June 2008, the official cumulative total number of people living with HIV was 2,858. 1,837 AIDS cases were recorded and 873 had already died. 57% of people living with HIV are male and 43% female. More than 77% are between the age of 20 and 29 years. 85% reported as a result of heterosexual sex. 900 people are on antiretroviral therapy. Estimates: HIV prevalence among population 15 49 years (0.2%). HIV seroprevalence among female sex worker: 0.4%. HIV seroprevalence amongst males who have sex with males (in Vientiane capital) 5.6%. Total number of PLHIV: 8,000. Number of women over 15 years living with HIV: 1,500. Number of children with HIV: 65 Key findings Existing data, policies and programmes related spousal and partner transmission Data limited to national HIV estimates and studies of populations most at risk which have implications for spousal transmission Gaps: Data on sex workers excludes information and services directed at clients of sex workers Qualitative and quantitative data on female migrant workers and their male counterparts for policies and programmes Vulnerabilities Womens seasonal external migration for work (illegally) Sex work much more indirect than other countries Lack of openness about sexual health High HIV prevalence among men who have sex with men in Vientiane (males who have sex with males are often married to women) Sexual patterns of men (concurrent partners) Sexual patterns of women (serial monogamous relationships) Unmet information needs Gender and decision making at household level Sexual patterns and decision making Internal and external migration decisions of and impacts on women Vulnerability factors for HIV infection Discordant couples (men and women) Low condom use Migration for work internal and external (men and women) Selling and buying sex Men who have sex with men their male and female partners Gender power imbalance: womens negotiation in sexual relationships/barriers to access information and treatment Mens reluctance to attend clinics or seek treatment

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 Low service provision in rural areas Mens concurrent multiple partners Vulnerability factors Understanding economic and sexual power dynamics between women and men Addressing barriers to womens access to information and services Understanding the sexual health needs of women who migrate (internally and externally) for work Strategies to reach men who have multiple partners (male and female) with sexually transmitted infection and HIV information Current responses Population priorities Female migrant workers (internal and external) Geographical priorities Northern and Southern provinces that border Thailand, Vietnam and China Social and cultural factors related to HIV/AIDS Increased trade routes and construction projects Increased commercial sex workers Varying levels of knowledge Increased sexual activity amongst youth Low condom use Stigma and discrimination Traditional practices Negotiation skills (particularly for women) Alcohol and drug abuse Men who have sex with men Gender inequality (including violence against women) Responses voluntary testing and counseling screening: antenatal care, pregnant women, gynecology patients, postabortion, ectopic pregnancy, migrant returnees, men Counseling Prevention of mother to child transmission (nevirapine, formula meal, caesarean) Free condoms Drop in centre for women who sell sex Information campaigns on radio and TV Workplace approaches with trade unions Involvement of men in sexual and reproductive health Sexual and reproductive health education in schools National Response to the HIV epidemic Voluntary counseling and testing networks cover 17 provinces and 20 districts Expansion of antiretroviral therapy services in 3 provinces National strategy and action plan on HIV/AIDS/STI 2006-2010 Strategy and action plan for women 2007-2010 100% Condom use programmes STI treatment services Training activities for people living with HIV The Ministry of Education is promoting HIV/AIDS and sex education

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Sites for Voluntary Counseling and Testing 40 sites for provincial level 50 for districts level and 1 health center level Results of focus group discussions Stigma and discrimination Some participants identified feelings of isolation arising from the social stigma and talked about this as a factor in their mental health. People who are HIV positive are afraid People living with HIV suffered stigma from their co-workers and employers Some officer who has HIV positive said I have to stop my work because I am afraid that they will know my HIV situation and I have to avoid to face in order to keep this secret Gender and HIV Gender inequalities Some women reported that they are totally dependent on men and have no decisions to make in matters of sex. In the female group discussion, some women reported that they cannot refuse their husbands sex. My husband is a play boy. He goes away and commits adultery with other women and prostitutes. When he comes back, I have sex with him. Even when I am annoyed, I cannot deny him sex. Barrier to get HIV treatment Limited number of health care professionals and places Long wait times to see specialists. In rural areas, there are fewer services for people living with HIV/AIDS. Fewer health care providers who are knowledgeable about HIV/AIDS and want to treat people living with HIV/AIDS. Travel a long distances to get services. Data Gaps The Healthcare Experiences of Married Couples with HIV/AIDS Factors contributing to spousal transmission Barriers to receiving care Interactions and relationships with the healthcare providers Knowledge level about their illness Information needs for their health care HIV and Stigma The root causes of stigma: knowledge and morality Expressions and forms of stigma Consequences and impact of stigma The relationship between reducing HIV-stigma and uptake of HIV services, treatment and prevention

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Malaysia: Azrul Khalib, UN Malaysia The epidemic has been concentrated in male injecting drug users. There are 5,640 new HIV cases each year but quality data is not available. A shift in the transmission patterns are occurring from injecting drug use to heterosexual, and therefore from men to women. Compulsory HIV testing is prevalent, and within pre-marital testing confidentiality is often violated. The testing is largely due to the influence of the religious department which is involved in all public health matters. However, a newly formed task force on HIV will include the participation of civil society. Incidentally, government public health settings provide all HIV treatment and testing.

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Pacific: Stuart Watson, UNAIDS Pacific There are three major regions: Melanesia, Polynesia and Micronesia, and all three contain enormous diversity in terms of language, culture, political, social, history. Overall in the pacific HIV knowledge is low. There is an increasing rate of HIV and it is likely to be under reported. While the number of infections might be small, the impact can be significant among small island populations.

The impacts of gender interplay with high mobility of people. There is a high level of sexually transmitted infections. There are culturally based gender relationships, some of which are very fluid. At the same time there are ongoing changes in traditional male, female and other roles in society. Recommendations include: Mainstream gender into national and regional policies and programmes Gender equality in strengthen laws and enforcement Address violence against women Promote positive masculinity

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Session 6: Positive womens perspectives and the greater involvement of men Culture of sexuality and gender in Thailand and womens access to ANC clinics, Supeecha Baothip, TPWN Priorities, strategies and questions for regional networks: Anandi Yuvaraj, ICW - Frika Chia, WAPN+ - Vince Crisostomo, Seven Sisters Date: February 19, 2009 Time: 15:30 hrs 17:30 hrs Moderator: Aleta Miller, UNAIDS Myanmar Rapporteur: Malou Quintos, UNAIDS Philippines This session bridges the country presentations with the later sessions in which the workshop will identify strategies to address issues around the feminization of AIDS. This session focuses on the perspectives and realities of people who are directly affected by HIV. Culture of sexuality and gender in Thailand and women access to antenatal care clinics, Supeecha Baothip, Thai Positive Womens Organization This presentation highlighted societal gender expectations which act as barriers to womens and mens access to information, prevention and treatment services. Gender expectations are also reflected in the formal healthcare response which: lacks gender sensitivity; does not uphold womens rights; excludes men in reproductive health and HIV testing; remains unprepared for positive womens pregnancies.

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Gaps in testing and counseling for women: staying negative, male involvement and disclosure With 99% of pregnant women getting tested for HIV the procedure is unlikely to be voluntary. Group pre-test counseling is followed by further group counseling if the results are negative, with little support or information on how to stay negative. For those who test positive, one-to-one counseling does not support women to involve their male partners or to disclose their status to them. Unprepared pregnancy of positive women Factors contributing to pregnancy Cannot negotiate safer sex The decision in having a baby is not womens choice Condoms are for positive persons and sex workers only No choice of contraception or counseling about suitable options

UNPREPARED PREGNANCY

Health System is not ready Unsafe abortion service Positive women leaders cannot be good counselors as they are also expected to be good leaders who dont have a baby or sexual relationships Rejection from healthcare worker Conditioned services (abortion provided in exchange for sterilization)

RESULT Positive women less likely to go to hospital when they are pregnant

Disclosure and male involvement Positive men Might use violence to solve problems. Expectations of male behavior may blocks men from discussing problems, feeling guilty that they cannot earn enough to feed the family. When learning about wifes status, Husband started to feel less confidence. Might not know that women are Positive women Not ready to disclose their status For the women who had sex before marriage, women tend to blame themselves that they might have given virus to men and babies Afraid to be looked at as a bad women Women who never had sex before marriage might be afraid that they will lose family life, afraid of violence, afraid that men will leave Healthcare system Tend to pressure on Women to disclose their status, even by drafting the law for this. Thought that disclosure will helps in prevention.

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positive at all (even when they are also positive) Did not receive the needed information on aids. Didnt get to prepare about HIV status. No involvement in HIV test

and they will have no family leaders. Fail to assess risk in pre-test Counseling Thought that mens sexual relationship before marriage is normal men behavior

Recommendations 1) Reproductive Health care services for women should be to empower woman to help them make choices and offer all available services For women Pre-post test Counseling should be strictly on Voluntary and be effective in helping women to access their risk (even with their husband) properly Informed choices of drugs in prevention of mother to child transmission Choices for contraception and getting pregnant Help women to understand the cultural factors of their attitude and that they have right in express their opinions and needs which is the base where rejection of unsafe sex comes from. For men More program to encourage men to understand their attitude that blocks them from - performing participatory parenthood - Be able to express their feelings and needs - Be able to communicate in sexual relationship Direct program to advertise for male involvement in - Birth control - Prevent unwanted pregnancy - Pregnancy preparation and testing For health care workers Be prepared for discussion on sexuality and gender Be able to practice effective counseling especially - Deep listening - Watch out for ones attitude in sexuality and gender - Respecting in womens choices and rights than controlling and deciding for the best choices for women Provide choices of contraceptive and tools includes female condoms and lubrication

2) The participation of positive women as part of the counseling system and in planning process of the program for prevention and care for women 3) VCT and prevention programmes need to be scaled up to include those who currently fall through the gaps such as migrants and injecting drug users/drug using woman Woman (injecting drug users)/(drug user)prevention programme need to include Needles and Syringe exchange programme /implementation of harm reduction Methadone-pregnancy woman

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Priorities, strategies and questions for regional networks: Anandi Yuvaraj (ICW), Frika Chia (WAPN+), Vince Crisostomo (Seven Sisters) Interactive group work The participants formed small groups to identify the following: 1 priority issue 1 strategy who 1 burning question for regional networks

Priorities Enabling environment to reach women in marriage from prevention to impact mitigation Paradigm shift in the way we do business moving the burden of interventions/ response away from the victims to what? Enabling environment which will lead people to disclose, seek testing, access services, reduce stigma Advocate for safe sex in marriage

Strategies Empowering women to access prevention, treatment, care and support services No business as usual with regards prevention programmes More gender friendly interventions Involvement of men, government, CSO, PLHIV network, local service providers, media practitioners, political champions How to advocate/negotiate safe sex among married couples Working with men and partners of MARPs

Burning Question for Regional Networks How can regional networks help communities on the ground in our communities? Can we do it?

Do you feel there is real space and involvement of communities in all levels of the response, including decisionmaking? How do you get different government agencies to involve positive networks in the response? Within the rights framework, what duties do PLHIV networks have in promoting safer sex and changing power dynamic within in the community? Working at the inclusion concept, why do positive networks feel insecure about the diversion of resources and focus away from them to their partners with regards the discourse on spousal transmission? What is holding us back from expressing how we feel?

Changing power dynamics between genders in society to prevent new infections

Raise awareness of sincerity in relationships

Open discussion about sex and sexuality within relationships Start talking within the community about sincerity in relationships Stop dividing of groups (MARPS) Gather information but work with positive networks in defining good practice

Documenting and disseminating information on good and promising practices

What are your criteria for good and promising practices in reducing spousal transmission?

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Summary of discussion (responses of Frika, Anandi and Vince) Enabling environment We need to look at enabling environment within the larger context of the countrys legal framework criminalization, discriminatory policies, freedoms and liberties (e.g., right to speech)

Representation The expectation on us is very high. The priorities are increasing and your expectations growing along with these priorities. The pace at which you want us to respond is not the same pace as we receive resources and support, including capacity building. There is goodwill among partners to involve us. People assume we have all the tools and capacity in place. This is not true, but we have the potential. You need to invest in us to capacitate us to participate effectively and meaningfully. What does involvement mean? Even some of our partners dont understand. You invite us to meetings to provide our perspectives but we are not involved in the planning. We are also challenged that everything has to be done fast. Deadlines here, new initiatives there. When do we have the time to do all these and still be able to consult with our partners on the ground, noting that the Asia Pacific region is huge? But we know that communicating with national networks is fundamental. Every time we speak out is a risk. While we know our voices need to be heard, we also dont want to embarrass our governments or our non-governmental organization partners. So we need to do some balancing act. Regional networks role is advocacy. We need to strengthen communication within our network as we do not have a common language. For example, the 7 Sisters to push APNSW to work with womens networks. We also have to be honest that we (7 Sisters) are not truly representing the MARPs. And even among ourselves we are fighting for inclusion.

Positive prevention We have to admit that sex without a condom is nice. Yet we ask people to use condoms. We need time and space to do our own paradigm shift. Deep inside, no positive person wants to spread the virus because we know the pain of stigma. Many times, initiatives are handed down from Geneva or New York without taking into consideration the reality on the ground (example PITC translates into mandatory testing on the ground)

Terminology HIV in marriage what defines marriage? Spousal transmission - use the term to help us increase coverage of services for sex workers

Criteria for good and promising practices ICW is willing to assist in defining the criteria

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Frika presented the perspective of the networks (sex workers, lesbian gay bisexual transgender, injecting drug users) on the issue of spousal transmission:

MARPs IDUs Sex workers Migrant workers MSMs

Bridge?

Spouses

General population

Bad

Good Innocent

Stigma: Criminals Illegal Immoral Sinner Not socially accepted Discussion: o Not valid work o Guilty o o o o o

Prevention vs. treatment

Prevention and treatment

Networks recognize that more spouses are being infected but we are being undermined by the good/bad divide. Allocation of resources may later be a problem as government will prioritize the good over the bad. We should not over-amplify the good vs. bad concept and create artificial fear such as allocation of resources. We have to recognize that women get infected through no fault of their own, and we need to deal with this issue with more prominence. The issue of spousal transmission is no longer academic, its already happening. Do we wait/remain passive for X million women to be infected before we take action? Is this a gap that can be addressed? Where do we start - sex work and their clients? Is that sufficient? , We need to empower women to act as their own agents of change. This is not about shifting responses from one to another. The Commission is clear about focus on most at risk populations but also need to address the issue of spousal transmission as a gap. Approach to women has been piecemeal. Some of these groups are not in water-tight compartments. Spouse has no face; we are giving them a face. Look at strategies and entry points most at risk populations will definitely be an entry point, then spouses of most at risk populations. We are making progress. No matter which angle each of us is coming from, we are beginning to talk. THINK OF INCLUSION ENOUGH OF CONSULTATION.

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What is needed? Broad consultation with groups Develop understanding, communication Capacity on how to approach the issues Empower sex workers and clients Empower women as active agents Multiple entry points Multi-pronged strategy

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Session 7: Research needs, programmatic entry points and advocacy messages Researchers group Programme group Advocacy group Date: February 20, 2009 Time: 09:00 hrs 12:30 hrs Moderator: Jay Silverman, Harvard University Rapporteur: Stuart Wilson, UNAIDS Pacific Researchers Group The researchers were asked to identify: Standardized structure for country studies Themes emerging from the studies Framework for regional synthesis Gaps needing further studies Standardized structure for country studies As the research and report writing are in various stages with some completed and others still in progress, it was agreed that a common framework should be used for a summary of each study. All country profiles for completed research should be submitted to UNIFEM/UNAIDS by 3rd March 2009 Country profiles: 2-4 pages max 1. 2. State of the epidemic Factors influencing spousal transmission (modes of transmission, disclosure, GBV, concordant/discordant couples etc) Key research findings Gaps in research Promising responses

3. 4. 5.

Framework for regional synthesis Needs to be a synthesis of reports which has clear country and regional recommendations for actions, research and which identifies evidence for programmatic response Need to review common themes, gaps, issues, epidemiology, risk contexts, etc which are common across the region and which are country specific Need to strategically focus on interventions testing, prevention

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 Prevention oriented research must identify vulnerabilities, areas which could put people at risk Continues to be hard to reach most at risk populations in research context Research needs to focus on: most at risk populations and their spouses, as well as sero-discordant couples Themes emerging from the studies o testing and disclosure seem to be common issues in the region o active case finding o need to promote voluntary and confidential counseling and testing as opposed to mandatory testing o making use of research outcomes for policy development especially around testing o positive prevention o gender-based interpersonal dynamics o sexual coercion, o lack of sexual negotiation power o condom use o female dependence on males in marriage o service provision denial for certain vulnerable groups o enabling environments that lead to transmission in marriage including injecting drug users research is inadequate at the moment to explain dynamic of commercial sex related to injecting drug use and transmission risk inside marriage males who have sex with males should not be excluded Gaps needing further studies Need regional as well as country applicability Need to look at secondary transmission Need to develop capacity to undertake research and to make use of research findings Need to know the barriers to testing disclosure men, women, spouses Need to know norms and practices that increase risk of spousal transmission and within sero-discordant couples Need to look at the bio-medical determinants which can reduce transmission: sexually transmitted infections, antiretroviral therapy (i.e. not only disclosure but lowering viral load etc) Mechanisms of spousal transmission has there been research? Need to know what communication systems work when targeting what is essentially a private relationship Needs to know modes of transmission and what prevention modalities work How do we work with men? Men are often left out particularly when it is the spouse being talked about. Reactions to the report back from the research group: Overwhelming thought we would learn more out of the mapping and research exercises Where are the connections to gender-based violence? Are we going to only focus on transmission or also on the impact?

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Programme Group The programme group was asked to identify Programmatic entry points Key partners Programmatic entry points Have to acknowledge the perspective of good/bad divide but leaving it is a risk from a programmatic perspective. We need to move forward with the discussion at country level. Diagram does now acknowledge that populations are not boxed in but interact with each other, sexual and other forms of networking, therefore need to see most at risk populations as part of general population Be careful of how to package messages maybe we need advocacy now rather than modeling and projections Entry point through service delivery to most at risk populations strategies to reach families Mobility and Migration Target migrant workers and spouses Need to give a space to spouses/partners to become more comprehensive in our approach Capture migrant workers when they come back. RISK: mandatory testing. Involve partners when migrant workers return home Multi-sectoral approach targeted, integrated; HIV feeding into other programmes Review testing guidelines, look at sero-discordancy Work with migration/labor ministries/agencies Include female migrants analyze migration patterns for entry points; include men and women + spouses Develop comprehensive package for migrants What about International Organization on Migration? Above strategies are for documented migrants; what about internal migrants? Need to be inclusive and analyze trends Sustainable entry point: cross-border programmes. When we speak of systems, whose system? Include border authorities. Reproductive Health Capacity development for basic health staff, traditional birth attendants Analyze factors defining married women who are more vulnerable and at risk to HIV - who are they? Where are they? Making health staff aware of who these women are and what to include in their SRH counseling Engaging with womens organizations Sexual and reproductive health is also entry point for gender-based violence, family health Most at risk populations as entry points Training for sex workers on negotiating condom use Discussing relationships with partners with most at risk populations Looking at who are the spouses

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Private health care providers (example Philippines medical associations), targeting those who are not reached by the public health system Look at size of most at risk populations in each country who, where, are they married? We need these size estimations to every country to begin to respond

Other partners Private migration agencies Ministry of welfare Ministry of law/human rights Ministry related to police border Advocacy To policy makers Involve mass organizations/womens unions they know well who are these spouses Need tools to support programming Tenderize AEM to include analysis on spousal transmission Actions How do we begin measuring impact? (Of prevention programmes for most at risk populations and spouses) Unanswered questions: Define at country level who are the partners/spouses at risk o Quantify extent of problem build the evidence: who are they, how many are there, what are the demographic markers vs. gen pop o Extrapolate from size estimation the population of spouses/partners of most at risk populations (incl. Most at risk populations) How can we cost these programmes with some evidence What are the advocacy gaps Advocacy Group The advocacy group was asked to identify Possible messages Key partners Mechanisms needed Feedback: Must find ways to package messages around having pleasurable but safe sex Have mechanisms in country which can be exploited Increase involvement of men as well as working with women Have existing champions in each country who can be made use of Use the partners - parliaments, government, the media

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Session 8: Stakeholder perspectives on the process and outcomes including action steps in country India, Pakistan, Bangladesh, Sri Lanka Malaysia, Philippines, Cambodia, Myanmar, Vietnam Laos PDR, Thailand, Indonesia Pacific and PNG Date: February 20, 2009 Time: 13:30 hrs 15:30 hrs Moderator: Niranjan Saggurti, Population Council Rapporteur: Azrul Khalib, UN Malaysia India, Pakistan, Bangladesh, Sri Lanka What kind of commitment is needed by different stakeholders in order to take initiative forward? Commitments from governments, policy and decision makers to ensure that there is national priority for addressing spousal transmission and HIV is part of a national response (i.e. National Strategic Plan on HIV) National AIDS Commission is on board The UN Joint Team is able to be mobilized according to the respective strengths of the UN agencies UN agencies expertise and resources committed to programmes related to spousal transmission Donors are on board and provide funding and prioritization for ST related interventions. Building partnerships with community-based organizations, non-governmental organizations and people living with HIV.

What are the key challenges and how to address these challenges?
Strengthening national and sub-national capacity to mainstream gender and HIV utilizing a multi-sectoral approach response. Limitations of pre-existing structures and institutional boundaries The need to quickly demonstrate results, and impact of interventions Bringing different stakeholders together with the help of National AIDS Commission Mapping of potential partners beyond usual stakeholders and partners Conducting a pilot intervention research (operations/ action research).

What can make an informed action on spousal transmission? Development of advocacy tools. Presentation of evidence gathered by countries as part of proving that most at risk populations and spousal transmission are joined and not treated separately.

What resources currently exist and what are needed? Resources exist within other ministries and Ministry of Health. Accessing those resources is still a challenge and catalytic support needed to begin pilot programmes. Sexual reproductive health services at community level Identification and utilization of practical entry points for convergence and interventions The need to identify mobilize additional funding to upscale the programmes of community based organizations/ non-governmental organizations Capacity building of existing human resource to ensure sustainability and continuity of programmes. Mobilization of Global Fund grants

41

How to promote national programmes buy-in (government)? Ensure that SAARC ministers commit to a Declaration to respond to spousal transmission of HIV in upcoming May meeting. Organizing a forum to discuss spousal transmission at the upcoming 9ICAAP in Bali A letter of commitment highlighting spousal transmission jointly signed by UNAIDS, UNDP, Global Fund, UNIFEM, Global Coalition of Women on AIDS

Malaysia, Cambodia, Philippines, Vietnam What kind of commitment is needed by different stakeholders in order to take initiative forward? Financial resources Technical resources Political will Leadership political leaders, civil society

What are the key challenges and how to address these challenges?
Key challenges Absorptive capacity of health systems and health staff Staff capacity at community/government level Government with top-down approaches Hard to find most at risk populations, even harder to find their partners Problem of engaging the right partners and giving people a voice in the right forum Housewives not sexy to work with/on (yes and no) Competing priorities with limited resources Not clearly defined interventions for spousal transmission Conversations about gender/social issues arent welcome in the HIV industry Men in decision-making positions (doctors) not open to discussing gender and HIV Challenge of discussing gender in UN JTA Internal advocacy Simple, well-defined, regional best practices; Information sharing Use their language, their framework; appeal to what matters to them; make them look good How to address Staff focusing on what works, stop working on whats not working Pooling funding, support/ capacity building of government staff

42

What can make an informed action on spousal transmission? Regional Forums for discussion/sharing o 9ICAAP presentation of reports Advocacy statement/factsheets Use regional/global bodies to make statements/policy to mainstream action into core AIDS work Regional advisor can advocate to UN Heads of Agencies to integrate gender aspect in their work plans Include interventions in regional costing model (but first we need to know which interventions)

In-Country Disseminate country reports National workshop to share, develop action plan Analyze data on modes of transmission to inform response and for advocacy Explore data that exist (e.g., non-governmental organizations) and do analysis, interpretation and utilization Review international commitments of country (e.g., CEDAW) and integrate spousal transmission in programming and advocacy around these commitments Explore with partners expanding programmes already targeting most at risk populations to include their partners

What resources currently exist and what are needed? Existing International resources Country studies Technically competent consultants but not enough Womens machinery; sexual and reproductive health workers, mass organizations as entry points need capacity

Needed Personal risk assessment tools (e.g., in counseling and testing) appropriate for the region Regional consultants need development Tool/checklist for defining markers of sub-population of women with elevated risk that can be applied in each country, migration, sexually transmitted infections (RISK: could lead to mandatory testing)

How to promote national programmes buy-in (government)? Buy-in comes with funding Data management improving data collection, reporting o Input at operational policy level (e.g., national AIDS registry) Placing spousal transmission in national strategic plans (e.g., during mid-term review or roll-over) Will be affected by community buy-in getting communities on-board so they can input on what works and contribute to planning process (theory to reality)

43

Identify our spheres of influence Countries adapting spousal transmission response to Millennium Development Goal indicators or Universal Access targets (localize targets) Influence how the data is analyzed

Thailand, Myanmar, Cambodia, Lao PDR, Indonesia What kind of commitment is needed by different stakeholders in order to take initiative forward? Non-governmental organizations, government partners, researchers High level political commitment Commitment of financial resource Commitment from multisectoral stakeholders: government, researchers, human rights activists

What are the key challenges and how to address these challenges?
How to get commitment and responses utilizing evidence based advocacy Obtaining equal participation from all stakeholders due to different levels of involvement. Development of a coherent policy framework of action Sustainable resource mobilization Lack of gender empowerment. Improving common awareness and understanding of spousal transmission in the country contexts (e.g. development of common terminologies, and descriptions of the epidemic) Indicators of involvement Organizing a consultative process/ forum where issues can be included, agreed upon and responsibility taken. Gender movement must include others such as human rights activists and lesbian bisexual gay and transgender groups

What can make an informed action on spousal transmission? Knowing your rights training Provision of training for service providers especially healthcare service providers such as doctors. Testimony from community members to strengthen evidence based interventions, particularly in policy development. Equal participation of non-governmental organizations in decision making and policy development relating to spousal transmission.

What resources currently exist and what are needed? Financial (existing and continue to be needed) Global Fund International donors Government Business communities/ private donors Community

Non-Financial (existing and continue to be needed) Technical support

44

Capacity building Human resources Peer educators Faith groups Life experience/ skills Community knowledge (local wisdom) Academic/ research institutions Media (mainstream/alternative)

How to promote national programmes buy-in (government)? Utilizing research to push for evidence based interventions Sharing of testimonies from community representatives Creating environment to ensure participation and engagement of high level officials related to the national AIDS programmes Mutual ownership from all stakeholders Recruitment of political leadership Policy formulation utilizing a bottom up approach whereupon civil society is involved and actively participates in the process. Taking a positive approach and thinking, emphasizing on the need for harmonious and complimentary relationship between government and non-government programmes.

The Pacific and Papua New Guinea 1. What kinds of commitments are needed in order to take forward initiatives to address spousal transmission in the Pacific? First, acceptance by all players that there is an issue around spousal transmission / HIV transmission in intimate relationships in the Pacific Commitment to conduct research to better understand what information already exists, and around identified evidence gaps Commitment from all stakeholders including the faith community and the private sector to participate realistically in responses to spousal transmission / transmission in intimate relationships, and in issues around sexuality and sexual behavior in the Pacific Commitment to ensure good school-based / out of school education around gender-based violence, gender and HIV, relationships Commitment to incorporating gender-based violence and related issues in teacher education and health worker prep training Commitment to ensuring that programmatic and research initiatives are culturally appropriate and sensitive (without sacrificing reality and an ambitious approach) Commitment from governments and policy makers with commitment to fund interventions / prevention Commitment from governments, policy makers, regional bodies to deal with migration and reintegration issues especially for those living with the virus noting the significant issues around the maritime, peacekeeping and resource industries Commitment to better understand the potential nexus between HIV transmission, gender-based violence and conflict, disaster, and civil / political upheaval

2. What are the challenges that we would face?

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Difficulty in negotiating with various stakeholders (government, civil society, private sector) in developing consistent and realistic messages and response approaches Prioritizing the resources both at national and at the Pacific regional levels Poor evidence base at country and regional levels in the Pacific around HIV, modes of transmission and gender Not enough hours in the day i.e. time The generally low capacity levels amongst all stakeholders Poor resourcing (human, financial) and high turnover levels with personnel Poor infrastructure to support responses throughout the Pacific region Geography, isolation, challenges of confidentiality in small island communities, poor transport systems, political instability, diversity of language, culture and sexual identity / diversity, and government systems (American, French, New Zealand or Australia affiliated states, colonial governance, military regimes, failed states, monarchies, parliamentary democracy, etc) Disproportionate epidemics and responses across the region The 4+ Pacifics Papua New Guinea, Melanesia, Micronesia, Polynesia, American territories, French territories Burnout migration of trained personnel

3. What can make an informed action or response? Better and stronger monitoring and evaluation systems - Tracking progress, better coordination, communication and networking between various responders throughout the Asia-Pacific region Better evidence, more research, better involvement of all Improved consultation processes between stakeholders both at national and at regional levels

4. What resources currently exist for us and our stakeholders? Some very committed and vocal champions from a range of sectors and levels UN system, SPC and the other CROP agencies, good committed donors (Australia and NZ), GFATM funding, Clinton Foundation / Gates generally good government commitment if not always good or realistic responses All countries have at least some sort of national strategic plan, NCM, though most do not have monitoring and evaluation systems Good funding sources (e.g. the regional response fund, Global Fund, bilateral) Strong communities, cultures and acceptance (in some countries / contexts) of diversity

5. What resources are needed? Just need more and better More and better trained human resources

6. What do we need to do to increase / improve national government engagement? Better and more evidence for better advocacy Ensuring that the Pacific is on the international and Asia-Pacific regional agenda and not lost to Asia Even more money the cost of doing business in the Pacific is considerably higher than other parts of the Asia-Pacific region Improved coordination around training and capacity development which helps to value and recognize the experience of training beyond the opportunity to come to Fiji on a shopping trip. Need to foster a culture of social involvement, of activism, of community research and involvement there is a very small and weak civil society sector across the Pacific And yes, we did talk about social capital.

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Session 9: Summary Comments UNAIDS/ UNIFEM Jane Wilson, UNAIDS Regional Advisor Gender, GIPA and Human Rights Caitlin Wiesen-Antin, UNDP Practice Leader Karabi Baruah, Focal point- Gender and HIV Programme UNIFEM-ESEARO Vince Crisostomo, Coordinator Seven Sisters

Jane Wilson, UNAIDS Regional Advisor Gender, GIPA and Human Rights So many things have happened in the past decade improving the HIV response (e.g. better healthcare services available, not just doctors anymore involved in HIV prevention, care and support, implementation of GIPA - greater involvement of people living with AIDS) Challenges continue to exist, particularly on the need to sustain and upscale progress and achievements. Constantly need to retrain and build capacity, raising awareness with more and more stakeholders. HIV in marriage enormous and constructive opportunity to address issues relating to testing and disclosure So much data available but not able to effectively assist National AIDS Commission colleagues to utilize data well for evidence based interventions. Emerging economic challenges which will affect the HIV response. Food imports, food security, changes in the economy resulting in increased migration related issues. Mass repatriation of migrant workers back to their home countries may have impact on spousal transmission in the Asia Pacific region.

Next Steps - Regional Continue to support civil society organizations in addressing this issue. Commit to assisting ICW and APN+ in regional consultations Dialogue with Asia Pacific Business Coalition on HIV workplace efforts to reach spouses (utilizing UNGASS data) Conducting regional analysis through country studies to understand, analyze implications for the region. Production of synthesis by end of March 2009. Regional Head of UNIFEM, Dr. Jean D'Cunha committed communications person to draft communications strategy on this issue. Organizing of regional meeting on spousal transmission: 20 -22 May 2009 Regional support for in-country networking, capacity building

Caitlin Wiesen-Antin, UNDP Practice Leader Need to identify key indicators to take action at country level identification of best practices around the region to support much needed actions. We need to strengthen advocacy utilizing civil society as the main driver civil society knows how best to develop campaigns, develop effective core advocacy messages. Need to recognize that we continue to not have an effective prevention programme to address spousal transmission know how to engage with sex workers but no idea with 50 million women of spouses at risk (AIDS Commission)

Karabi Baruah, Focal point- Gender and HIV Programme UNIFEM-ESEARO Strength in responding to spousal transmission is in partnership with UN family as well as different project partners in different countries.

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Still need to identify and discern the responses needed but the workshop has brought about many issues often addressed on assumed understanding of the issues that need evidenced-informed responses. Acknowledgement of communities concerned of shifting priorities and resources, namely addressing spousal transmission will deprive support for marginalized groups such as sex workers, males who have sex with males, etc. Need to address 50 million women who may contract HIV from spouses/partners. Give a face to 50 million while addressing all women's issues in general We should be careful to not give conflicting messages. Exchange ideas and information between stakeholders. Expectations for the workshop have been met. Blueprint to all solutions not expected and was not intended to solve all problems. But there are actions we can start with now.

Vince Crisostomo, Coordinator Seven Sisters Input from community not usually reflected into the outcome of such workshops. This workshop has involved community input from the very beginning and has been able to ensure that community views are taken into serious consideration in the development of programmes responding to spousal transmission. This is progress and acknowledgement of the partnership necessary to ensure the success of programmes, country or regional level.

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Agenda

17 February 9:00 5:00 One day gender and HIV training for UNAIDS Gender Focal Points

18 February 9:00 13:00 Meeting of UNAIDS Gender Focal Points Review recommendations from Gender Exchange Meeting in November 2009 Sharing of plans and strategies for 2009 Finalize regional support plan for 2009

18 February 17:00 19:00 Session 1: Registration and opening address at the Library by Dr Jean DCunha, UNIFEM Regional Director, South East Asia.

Day 2, 19 February 08:30 08:40 08:50 09.30 Introduction to the day, logistics and the programme UNAIDS Session 2 Setting the scene and progress to date Karabi Baruah, UNIFEM Introduction of participants David Bridget, UNAIDS Overview of Gender dynamics in the epidemiology of HIV in the Asia Pacific Region, Caitlin Weisen-Antin, UNDP Practice Leader

09:30-10:30 10:30 11:00 11:00 13:00 13:00 14:00 14:00 15:30 15:30 17:30

Session 3: Presentations from India and Cambodia followed by discussion (researcher or nominee) and including planning with advocacy/ consultation with stakeholders. Coffee break Session 4: Presentations from Thailand, Sri Lanka and update from the Philippines followed by discussion Lunch break Session 5: Presentation by Indonesia (Ira and I Gusti Wahyunda), Lao PDR (Researcher), Malaysia (Azrul Khalib) and Pacific (Stuart Watson) on progress to date Session 6: Positive womens perspective and the greater involvement of men. This session will be led by Anandi Yuvaraj, Frika Chia Iskandar and members of the Thai Positive Womens Network and will include group work. (The coffee break will be incorporated). Dinner

18:00 19:00

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Day 3, 20 February 09:00 11:00 Session 7: Group work session Researchers Group to focus on Standardized structure for country studies Themes emerging from the studies Framework for regional synthesis Gaps needing further studies 2. Programme Group Programmatic entry points Key partners 3. Advocacy Group Possible messages Key partners Mechanisms needed? Coffee break Plenary session: Jay Silverman, Harvard University Lunch Session 8: Stakeholder perspectives on the process and outcomes including action steps in country (who/how/where/when) Moderator: Niranjan Saggurti, Population Council Coffee break Session 9: Wrap up and way forward Feedback from four groups Summary comments UNAIDS/UNIFEM Participants Review 1.

10:30 11:15 11:15 12:30 12:30 13:30 13:30 15:30

15:30 15:50 15:50 17:00

Moderator: UNIFEM/ UNAIDS

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List of participants

No. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Country Cambodia Cambodia Cambodia Fiji India India India Indonesia Indonesia (Researcher) Indonesia Indonesia Lao PDR

Name and Ms Jane Batte Ms Jennifer Clare Roberts Ms Laura Tracy Mr. Stuart Watson Mr. Alankar Malviya Mr. Niranjan Saggurti Ms Vandana Mahajan Mr. Ashley Heslop Ms Geni Floribunda Achnas Ms Ingrid Irawati Atmosukarto Mr. I Gusti Ngurah Wahyunda Mr. Khamlay Manivong

13. 14.

Lao PDR Lao PDR

Mrs. Kaysamy Latvilayvong Mr. Phokin Mouangchanh

Position and Organization Social Mobilization Advisor UNAIDS Cambodia Tel: +855 23 219 340 / Fax: +855 23 721 153 Researcher and Consultant on A Rapid Assessment on Spousal/Partner Transmission of AIDS and Sero-Discordant Couples in Cambodia Tel: +855 12 409 132 Gender and HIV/AIDS UNIFEM Cambodia Tel: +855 23 216217 UNAIDS Coordinator (UCC) - Pacific region Tel: +679 331-0480 or 331-0481 Fax: +679 331-0425 National Programme Officer, Advisor - State Support UNAIDS India Tel: +91 11 4135 4545 Fax: +91 11 4135 4534 Senior Program Officer Population Council, India Tel:+91 98 71211195 Programme Officer, Gender and HIV/AIDS UNIFEM - South Asia Office Operations Officer UNAIDS Indonesia / UNIFEM Tel: +62 21 3141308 ext 213 Country Director Uplift International Tel: +62 21 7197476, 912 67729 Mobile: +62 816 1613 561 Research coordinator and regional coordinator for eastern Indonesia Tel: + 62 21 390175 Mobile: + 62 8158957124 IKON Bali Tel: 62 0361-724699. Partner and Social Mobilization Officer UNAIDS Lao Tel: : +856 21 267 795 Fax: +856 21 267 799, +856 21 264 939 Mobile: +856 21 267 796 Chief of Development Division Lao Women's Union Tel: +856 21 223543 Fax: +856 21 214300 Member of research team Lao Women's Union Fax: +856 21 214300

E-mail address battej@unaids.org jroberts@online.com.kh laura.tracy@unifem-eseasia.org watsons@unaids.org malviyaa@unaids.org nsaggurti@popcouncil.org vandana.mahajan@unifem.org HeslopA@unaids.org gachnas@upliftinternational.org irawati@aidsindonesia.or.id ikon@ikonbali.org khamlay.manivong@undp.org

kaysamy_2005@hotmail.com

No. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25.

Country Malaysia Myanmar Pakistan Papua New Guinea Philippines Philippines Sri Lanka Thailand Thailand Thailand Thailand (Researcher)

Name and Mr. Azrul Mohd Khalib Ms Aleta Miller Dr Samia Hashim Ms Maria Nepel Ms Teresita P. Bagasao Ms Ma. Lourdes (Malou) Quintos Mr. David Bridger Ms Orawan S. Bettenhausen Ms Yupin Chinsa-nguankiet Ms Lisa Kuntamala Dr Pimpawun Boonmongkon

26. 27. 28. 29.

Thailand Thailand Thailand Thailand

Ms Sulaiporn Chaowilai Mr. Ronnapoom Samakekarom Ms Supeecha Baothip Ms Prairat Kaewwansa

Position and Organization HIV/AIDS Coordinator Resource Mobilization and Technical Assistance Coordination Officer UNAIDS Myanmar Tel: +95 1 252361, +95 1 252362 Senior National Programme Officer UNAIDS Pakistan Tel: +92 51 825 5781 Fax: +92 51 265 5051 Social Mobilization Adviser UNAIDS Papua New Guinea Tel: +675 321 2877 Ext 242 Fax: +675 321 3968, 321 1224 UNAIDS Country Coordinator Tel: +632 901-0411, 632-889-7414 (Direct) Fax: +632 901-0415 Programme Assistant UNAIDS Philippines Tel: (632) 901-0414 UNAIDS Country Coordinator Tel: + 94 115 764 666 / Tel: +94 112 580 691 Ext: 361 Fax: +94 112 581 116 Programme Assistant UNAIDS Thailand Tel: +662 288 1203 / Fax: +662 280 2701 Bureau of AIDS TB and STIs Department of Disease Control, Ministry of Public Health (MOPH) Tel: +66 2 2759903 Bureau of AIDS TB and STIs Department of Disease Control, Ministry of Public Health (MOPH) Tel: +66 2 2759903 Deputy Dean of Academics and Research, Director of Center for Health Policy Studies, and Advisory Board Member of Southeast Asian Consortium on Gender, Health and Sexuality, Faculty of social Sciences and Humanities, Mahidol University Tel: 662-441-9184 ext 0 / Fax: 662-441-9184 ext 112 Researcher Center for Health Policy Studies, Mahidol University Tel: 662-441-9184 Researcher Center for Health Policy Studies, Mahidol University Tel: 662-441-9184 Raks Thai Foundation Thai Positive Women Network Ozone Home, assistant to Network coordinator Thai Positive Women Network Tel: +662 9136994 / Fax: +662 9136993 Mobile: +66 89 2147935 52

E-mail address azferul@gmail.com milleral@unaids.org samia.hashim@un.org.pk nepelm@unaids.org bagasaob@unaids.org quintosm@unaids.org bridgerd@unaids.org BettenhausenO@unaids.org yupin_kyn@yahoo.com lisa@aidsthai.org shpbm@mahidol.ac.th

schonwilai@yahoo.com sronnapoom@hotmail.com

too_pk@yahoo.com

No. 30. 31. 32. 33. 34.

Country Thailand USA USA USA Viet Nam

Name and Mr Apichai Mai-Uggree Dr Jay G. Silverman Ms Michele Decker, ScD Ms Heather McCauley, MPH Ms Phan Thi Thu Hien

35.

Viet Nam

Mr Le Xuan Tho

36.

Viet Nam

Ms Nisha Prichard

37.

ICW, Thailand WAPN+, Thailand Thailand UNIFEM UNIFEM UNIFEM Consultant / Coordinator UNDP

Ms Anandi Yuvaraj

38. 39. 40. 41. 42. 43.

Ms Frika Chia Iskandar Mr Vincent Crisostomo Dr Jean DCunha Dr Karabi Baruah Ms Jo Kaybryn Ms Caitlin Wiesen

Position and Organization Thai Positive Women Network Associate Professor of Society, Human Development and Health Harvard School of Public Health ph 617-432-0081 fax 617-432-3123 Instructor and Research Associate Harvard School of Public Health ph 617-432-0081 fax 617-432-3123 Research Coordinator Harvard School of Public Health ph 617-432-0081 fax 617-432-3123 Gender & Rights Based Approaches Officer UNAIDS Viet Nam Tel: +84 4 734 2824 ext. 117 Mobile: 0914127084 Fax: +84 4 734 2825 Programme Officer United Nations Development Fund for Women UNIFEM VIETNAM Mobile: (844)- (0) 94-522-8072 Tel: 844- 3 942-1495 (extra 208) Fax: 844-3 8223579 UNIFEM Vietnam Campaigns Officer UNIFEM Vietnam Tel (84-4) 9421495 - Ext 138 Mobile: 0936115746 Fax (84-4) 8223579 Asia Pacific Regional Coordinator International Community of Women Living with HIV/AIDS (ICW) Tel: +662 255 7477-78 Mobile:+66 876818060 Fax:+662 255 7479 WAPN+ Coordinator Women working group of APN+ (WAPN+) Tel: +662 255 7477-78 Fax: +662 255 7479 Coordinator The Coalition of Asia Pacific Regional Network on HIV/AIDS (7 Sisters) Tel: +662 255 7477-78 Fax: +662 255 7479 Mobile: +668 969 8 2432 Regional Programme Director UNIFEM East and Southeast Asia Regional Office, Tel: +662 288 2225 / Fax: 662 280 6030 Focal point- Gender and HIV Programme UNIFEM-ESEARO UNIFEM East and Southeast Asia Regional Office Tel: +66-2-288-2453, Fax: +66-2-288-6030 Director of Policy Plurpol Consulting, New Zealand Tel : +44 794 222 734 Fax : +44 808 280 1257 HIV/AIDS Practice Team Leader and Regional Coordinator Asia & Pacific Asia & Pacific Regional Centre, UNDP Regional Centre in Colombo 53

E-mail address chaitharae@yahoo.com jsilverm@hsph.harvard.edu

PhanH@unaids.org

tho.le-xuan@unifem.org

nisha.prichard@unifem.org

anandi@icw.org

frika@apnplus.org coordinator@7sisters.org jean.dcunha@unifem.org karabi.b@unifem-eseasia.org jo@plurpol.org caitlin.wiesen@undp.org

No. 44. 45.

Country UNAIDS RSTAP WHO

Name and Ms Jane Wilson Ms Suwanna Sangsuwan

46. 47. 48. 49.

UNESCO UNFPA Bangladesh UNIFEM

Ms Xia Chen

Mr Dan Odallo Ms Sara Brinkberg

Position and Organization Tel: +94 (11) 4526400 ext. 150 / Fax: +94(11)4526410 Regional Advisor Gender, GIPA and Human Rights UNAIDS RSTAP Tel: +662 288 2869 / Fax: 662 288 1092 Programme Assistant (HIV/AIDS) WHO Country Office for Thailand Office of the WHO Representative, Permanent Secretary Building 3, Tel +662 590 1526 / Fax +662 591 8199, GPN Tel 24819 Researcher, UNESCO Mom Luang Pin Malakul Centennial Building Tel +66 2 391 0577 Ext. 172 Dr. Taweesap Siraprapasiri HIV/AIDS Programme Officer, United Nations Population Fund Tel: +662 687 0130 Fax: +662 280 1871 Line Director, National AIDS/STI Progamme and UNAIDS Country Coordinator Intern UNIFEM East and Southeast Asia Regional Office Fax: +66-2-288-6030

E-mail address wilsonj@unaids.org suwanna@searo.who.int

x.chen@unescobkk.org siraprapasiri@unfpa.org odallod@unaids.org sara.brinkberg@unifemeseasia.org

54