The main themes discussed during the first day of the conference
in Track D were thematically diverse: youth vulnerability, male sexuality, obstacles for
policy implementation, the role of evaluation in national programs, and the right to
access appropriate care and treatment.
Youth and vulnerability
Some of the strongest obstacles to behavioural change in youth are contextual:
- Parent notification is common in many countries;
- Lack of access to explicit information on sex and drugs;
- Norms on appropriate behaviour. Compliance with certain social norms are a risk
factor;
- Lack of power;
- Religious norms.
In order to change individual and group behaviour and
behavioural scripts, it is important to target children’s role-models as well as to
critically assess the moral and social values that need to be changed.
Male sexuality
The session devoted to male sexuality began with a historical overview of how sexuality
has been understood in the western civilisation. An emphasis was put on the shift of
paradigm which took over a century to change from conceiving sexuality as biologically
determined to a sociological framework that sees it as socially constructed and culturally
divers.
Examples were given of the diversity of sexual practices and the
diversity of the meaning of the same sexual practices for different people in different
environments. The social, economic and cultural contexts also affect the way people see
themselves and how they are perceived by others.
In the academic world there is a great array of gender studies.
However it is only recently that men have started to be analysed from this perspective. It
is surprising how researchers working in the field of gender studies, have not analysed
more systematically the links between masculinity construction and the risk of AIDS.
Politics Behind AIDS Policies
There is considerable knowledge and understanding about the prevention and control
of HIV/AIDS, which was defined as the AIDS rationality model. However, the epidemic is
still out of control in many parts of the world. Why hasn’t knowledge been translated
into policy?
- One factor is that HIV/AIDS is associated to behaviours that governments
don’t want to acknowledge or accept such as certain types of sexual behaviour and use
of illicit drugs. This has meant that silence and/or prohibition has been prominent in the
response of many societies and states.
- While in the North there has been a process of (1) sexual revolution, starting
with the contraceptive drugs, feminism, gay and lesbian activism, (2) increasing drug use
in the 1970s, and (3) health promotion, which facilitated a response to HIV/AIDS, in the
South this process has not taken place. As a result, societies and states have denied
reality.
- A number of fundamental key persons who participate in the development of
politics and the adoption of policies were enumerated; for example, governments, health
and public-health care systems, the judicial system, the armed forces and police and the
religious institutions. These actors need to be involved to create effective AIDS policies
but each one has agendas, priorities which can lead to contradictions that need to be
addressed. Politics behind policies in India, South Africa and Russia were presented as
case examples.
- Government can change under different circumstances for example: change of
regime; recognition of risk due to overwhelming epidemiological evidence; pressure from
multilateral institutions.
States need to act as enabling leaders in the prevention and
control of the epidemic. Ideally, the states need to co-ordinate action while taking into
account participatory dialogue and collaboration with community-based initiatives for a
more effective response to the epidemic.
Five countries (Venezuela, Israel, Brazil, Uganda and France
with migrant population) reported on the obstacles they had overcome or were trying to
overcome to adopt comprehensive prevention education and access to treatment:
Stigmatisation, discrimination, misconceptions, fear, shame and, as a result,
people suffering in silence;
Important discrepancies between the real number of aids cases and the official
statistics;
Lack of leadership for taking responsibility; lack of national programmes; and
lack of support of the private initiative.
In the different countries, all modes of communication were used
to convey HIV awareness (TV, newspapers, radio, cultural events, peer counselling, polling
for needs assessment, meeting with religious and business leaders in the community). It
was important to destigmatise AIDS in order to create awareness for prevention as well as
funding for treatment.
Policy and Programme Evaluation : Does it matter?
Evaluation is understood as a process of assessment, validation, improvement and
adjustment of strategies. The process also involves political accountability and
legitimisation, scientific responsibility, and should lead to new development. Evaluation
allows to :
- Observe and compare changes;
- Address discrepancies;
- Set standards and indicators;
- Use effective information and data for guidance and decision-making;
- Strengthen advocacy and reinforce the involvement of political leaders.
Treatment and Care
Quality of Life
There is reason for therapeutic optimism, but all problems are
not solved :
- Combination therapy (duo or triple) have a moderate effect on quality of life;
- Attendance of day treatment centres, high perceived social support, high self
esteem and self realisation have a greater effect;
- However, levels of anxiety and depression remain high (59 and 39%).
End of life issues
Although the new therapies provide hope, they will not work for
everybody even if they can afford it. An unknown number of PWAs do not profit from the new
therapies. For these patients, questions with respect to end of life are acute ones.
Euthanasia (EU) and physician assisted suicide (PAS) were addressed:
- The majority of persons (73%) with HIV infection in Europe are in favour of
allowing euthanasia by law; 16% had already discussed the possibility of euthanasia with a
physician.
- Increasingly, physicians are willing to grant a patient’s request for
euthanasia (EU) or physician assisted suicide (PAS) : 35% in 1991, 51% in 1995. The
figures on EU/PAS indicate a prevalence of 13 to 26% of all deaths due to AIDS.
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