REGIONAL TRAINING OF TRAINERS ON NURSING AND MIDWIFERY MANAGEMENT IN HIV/AIDS PREVENTION, CARE AND SUPPORT

Course 6: Issues and Trend in HIV/AIDS Prevention, Care and Support Title of seminar : Cultural and Other Social Sensitive Issues Related to HIV/AIDS : Mohamad Zaenal Abidin, From Indonesia : Jonni Hermanto, From Indonesia : Assist Prof. Dr Wantana Maneesriwongul Dr. Wanlaya Thamapanichawat : 13 October, 2006, at 13.00 16.00 : Room 505, Faculty of Nursing, Mahidol University, Bangkok Thailand : After this seminar, participant will able to: 1. Increase their knowledge about cultural and other social sensitive issues related to HIV/AIDS 2. Discuss about cultural and other social sensitive issues 3. Discuss about how to solve or to handle cultural and other social sensitive issues in HIV/AIDS related works Scope of the seminar: I. II. III. IV. Introduction Cultural related HIV/AIDS Sensitive Issues Conclusion

Leader of seminar Member of seminar Faculty Date & Time Venue

Objective

Cultural and other social sensitive issues related HIV/AIDS

1. Introduction

Almost 39 million people around the world are living with HIV slightly more than the population of Poland. Nearly two-thirds of them live in Sub-Saharan Africa. The global HIV/Aids epidemic killed 2.8 million people in 2005. But there was evidence that the number of new cases had stabilized for the first time in 25 years. Young people are at center of the global HIV/AIDS pandemic. More than half of those newly infected with HIV today are between 15 and 24 years old. An estimated 11, 8 million young people aged 15 and 24 are living with HIV/AIDS. Each day, nearly 6,000 young people between the ages of 15-24 become infected with HIV. Yet only a fraction of them know they are infected. Studies show that adolescents who begin sexual activity early are likely to have sex with more partners who have been at risk of HIV exposure. They are not likely to use condom. National HIV infection levels in Asia are low compared with some other continents, notably Africa. However, the populations of many Asian nations are so large that even low national HIV prevalence means large numbers of people are living with HIV. Latest estimates show some 8.3 million [5.4 million 12 million] people (2 million [1.3 million 3 million] adult women) were living with HIV in 2005, including the 1.1 million [600.000 2.5 million] people who became newly infected in the past year. AIDS claimed some 520 000 [330 000 780 000] lives in 2005.

Risky behavior often more than one form continues to sustain serious AIDS epidemics in Asia. At the heart of many of Asias epidemics lies the interplay between injecting drug use and unprotected sex, much of it commercial. Indonesia is classified as a country with a concentrated HIV epidemic, primarily among its injecting drug users population. By June 2006, the cumulative number of AIDS cases and deaths in Indonesia were and , respectively. The male-to-female ratio among reported cases in 2003 was 4.7:1. Prior to 1999, most of the cases acquired infection through heterosexual route, but since 2000, reported cases infected through injecting drug use have sharply increased. On the basis of the Mexico Declaration of 1982, culture is broadly understood within UNESCO to include: ways of life, traditions and beliefs, representations of health and disease, perceptions of life and death, sexual norms and practices, power and gender relations, family structures, languages and means of communication; as well as arts and creativity.

From this definition, it is clear that culture influences attitudes and behaviuors related to the HIV/AIDS epidemic: in taking or not taking risk of contracting HIV, in accessing treatment and care, in shaping gender relations and roles that put women and men at risk of infection, in being supportive towards or discriminating against people living with HIV/AIDS and their families, etc.

The difficulty in establishing effective HIV/AIDS programs comes from a lack of openness, in many societies, regarding sexuality, male-female relationships, illness and death, taboo subjects deeply rooted in the cultures.

Understanding what motivates peoples behaviours, knowing how to address these motivations appropriately, and taking into consideration peoples cultures when developing programs addressing HIV/AIDS are essential to changing

behaviors

and

attitudes

towards

HIV/AIDS.

Culture should be taken into account at various levels: as context an environment in which HIV/AIDS communication and prevention education takes place; as content local cultural values and resources that can influence prevention education; culturally appropriate content of sensitization messages is mandatory for them to be well understood and received and as a method that enable peoples participation, which helps to ensure that HIV/AIDS prevention and care is embedded in local cultural contexts in a stimulating and accessible way. 2. Culture Poverty and behaviuors related epidemic Despite the misconception of some that behaviors associated with AIDS are the product of Western civilization in the second half of the 20th century, even the most cursory examination of the archeological and ethnographic record reveals art, literature, and ephemera that reflect the ubiquitous, pan-historic, and omni cultural nature of sexual behaviors, both procreative and no procreative, some of which have been implicated in the transmission of HIV. As we look at how expediently people have responded to AIDS, we must first look at AIDS in the context of other health treats. Bear in mind that the behavioral response to any other sexually transmitted disease. Behavior change in the AIDS epidemic has been quicker than any behavior change in response to any other illness-quicker than that to the illness caused by smoking, alcoholism, quicker than that to the treat of lethal heart disease (Coates, Stall & Hoff, 1987). AIDS has probably had the strongest singular impact upon sexual behavior (Kinsey, Pomeroy, Martin, 1948) In my opinion poverty also contributed to spread HIV/AIDS. Because, poverty societies they have lack of education, information and knowledge. It leads social problem such as unemployed, prostitution, trafficking etc. In Chiang Mai we

visited to community with PHA, and majority of them are poor. Some family they live in small house, family members ten or more. Gender relations and roles

Our culture is struggling with what it means to be male or female .Traditionally the label masculinity has connoted assertiveness, independence, lack of emotions, rationality, insensitivity, roughness. By contrast, femininity has connoted non assertiveness, dependence, emotionality, sensitivity, and gentleness. These distinctions are thought to follow us to bed, where men traditionally have been seen as aggressive initiators and women as passive receivers. To what extent are these perceived differences caused by biological differences between the sexes? To what extent are they the result of social learning? To what extent are they totally nonexistent? These questions are part of one of the hottest debates in the social sciences today. The answers are still evolving .Some say that its mostly biology ,,some say that its mostly social learning, and some say that its a combination of biology and social learning, males and females are similar and dissimilar in anatomy,physiologi,brain structure, hormones ,and so forth. These biological factors do not automatically translate into behavioral patterns .However; studies show that males tend to be more aggressive than females, in terms of willingness to hurt others (Maccoby and Jaclyn 1974. ) Gender as it relates to womens and mens different vulnerabilities to HIV infection, and their different abilities to access resources for care and support in order to cope with the impact of the epidemic. In most societies gender influences individual and societal risk of HIV/AIDS. Gender determines how and what men and women are expected to know about sexual matters and sexual behavior. As a result, girls and women are often poorly informed about reproduction and sex, while men are often expected to know much more. The following is known about the relationship between gender and individual risk of HIV/AIDS:

Gender attitudes and behaviors can increase individual risk. For example, women may be socialized to please men and defer to male authority Most efforts to understand individual risk of HIV from a gender perspective have focused on women. Fewer data are available on how gender roles and societal pressure put men at risk. For example, men generally have higher reported rates of partner change than women do, and the condoning of this often begins during adolescence Social and economic factors also foster conditions for risky behavior. These include:

The migration of men to find employment which may disrupt marital and family ties and lead to risky sexual behavior The increase in women entering manufacturing sectors of the economy without the protective features of their families and home communities. Young women are therefore often becoming sexually active at an earlier age and are often unaware of the risk of HIV and sexually transmitted diseases

Economic necessity is often linked to migration for the sex trade in southeast Asia Due to a lack of economic equality, many women choose to stay in a highrisk relationship rather than face the greater economic risk of leaving the partner upon whom they are dependent

Women are likely to be disproportionately affected by HIV/AIDS when a male head of household falls ill. The burden of caring for children orphaned as a result of the pandemic is borne chiefly by women. Loss of income from a male income-earner may compel women and children to seek other sources of income, putting them at risk of sexual exploitation

Gender-related discrimination is often supported by laws and policies that prevent women from owning land, property and other productive resources. This promotes womens economic vulnerability to HIV infection, limiting their ability to seek and receive care and support

Girls and young women are at greatest risk. As of December 2003, women accounted for nearly 50% of all people living with HIV worldwide, and for 57% in Sub Saharan Africa. Women and girls vulnerability is a reflection of gender inequalities. Gender refers to the social beliefs, customs and practices that define masculine and feminine attributes and behaviors. In most societies, the rules governing social relationship differ for women and men, with men holding most of the power. This means that for many women, including married women, their male partners, and sexual behaviors is the most important HIV-risk factor. Religious and HIV/AIDS prevention

Issues: Religious teachings, interpretations of religious texts and spiritual counseling can provide support and hope to people living with AIDS. However, they can also be a source of stigma and discrimination and can create barriers to care seeking and the use of condoms for the prevention of infection. Different religions have different codes of sexual morality, which regulate sexual activity or assign normative values to certain sexually-charged actions or thoughts. The views of religions and religious believers range widely, from holding that sex and the flesh are evil to the belief that sex is the highest expression of the divine. Views on sexuality may not even be shared among adherents of a particular sect. Some religions distinguish between sexual activities that are practiced for biological reproduction (sometimes allowed only when in formal marital status and at a certain age), and other activities practiced for sexual pleasure. a. Islam Birth control is permissible according to Islam, which recognizes that the sexual act is more than just a means of procreation. Condom use in legal marriage does not contradict Islamic teaching. Condom use outside marriage is bad, not acceptable in Islamic. In Indonesia ,even some

moderate Islamic groups are supported the condom use for family planning and STIs /AIDS prevention, but Islam fundamentalist not accept. Their opinion, condom associated with free sex, extra marital sex. b. Catholic Conservative Catholic opinion on condoms is not intended to be cruel. As traditional Catholics see it, using condoms is wrong, even as a prophylactic against disease, because they prevent conception. Life, from the moment of conception to death is, Catholics believe, sacred. Only God can terminate life. It is also worth noting that John Paul II spoke out against discrimination against people with HIV, and Catholic AIDS ministries around the world put his words into action. But pseudo-scientific arguments have also been deployed by some conservative Catholics against the use of condoms as a means of HIV prevention. A recent BBC Panorama documentary found that some senior Catholic clerics were maintaining that not only were condoms theologically unsound, but were also spreading false information about the reliability and safety of condoms. c. Budha One of the stars Buddhist monk is Ven Phra Tuangsit from Nong Khai in Thailand. He leads a project called Sanha Metta that many want to see duplicated in other parts of South Asia. Buddhist clerics involved in the project work with young people, sex workers and others to spread awareness of HIV/Aids, including demonstrating how to use condoms, if appropriate. "At first people were worried that it was inappropriate," says the saffron clad monk, "for a Buddhist cleric to work with condoms and things, but now people realize that I'm practicing Buddhist compassion and helping people avoid painful, humiliating illness." "They listen and respect us because we are monks. So much has changed."

3. Sensitive issues Stigma, discrimination and human rights The Microsoft Word Dictionary defines stigma as the shame or disgrace attached to something regarded as socially unacceptable. Sociologists have taken this a bit further. In a seminal study on stigma in 1963, stigma was defined as an attribute that is seen as deeply discrediting to a person or group (Goffmann). Those attributes could be an illness, physical deformity, aberrant behavior or social group (based upon religion or ethnicity, etc.). Stigma lets people or groups see differences or "others" in a negative light while confirming their own sense of normalcy and decency. Stigma refers to unfavorable attitudes and beliefs directed toward Someone or something. Discrimination is the treatment of an individual or group with partiality or prejudice. Stigmatization reflects attitude, discrimination is an act or behavior. Sexuality and sex education Sex education, which is sometimes called sexuality education or sex and relationships education, is the process of acquiring information and forming attitudes and beliefs about sex, sexual identity, relationships and intimacy. It is also about developing young people's skills so that they make informed choices about their behaviour, and feel confident and competent about acting on these choices. It is widely accepted that young people have a right to sex education, partly because it is a means by which they are helped to protect themselves against abuse, exploitation, unintended pregnancies, sexually transmitted diseases and HIV/AIDS. Sex education seeks both to reduce the risks of potentially negative outcomes from sexual behavior like unwanted or unplanned pregnancies and infection with STIs and HIV/AIDS, and to enhance the quality of relationships. It is also about developing young people's ability to make decisions over their entire lifetime. Sex education that works, by which we

mean that it is effective is sex education that contributes to this overall aim. Young people get information about sex and sexuality from a wide range of sources including each other, through the media including advertising, television and magazines, as well as leaflets, books and websites (such as www.avert.org) which are intended to be sources of information about sex and sexuality. Some of this will be accurate and some inaccurate. Providing information through sex education is therefore about finding out what young people already know and adding to their existing knowledge and correcting any misinformation they may have. For example, young people may have heard that condoms are not effective against HIV/AIDS or that there is a cure for AIDS. It is important to provide information which corrects mistaken beliefs. Without correct information young people can put themselves at greater risk. Information is also important as the basis on young people can developed wellinformed attitudes and views about sex and sexuality. Young people need to have information on all the following topics:

Sexual development Reproduction Contraception Relationships

They need to have information about the physical and emotional changes associated with puberty and sexual reproduction, including fertilization and conception and about sexually transmitted diseases, including HIV/AIDS. They also need to know about contraception and birth control including what contraceptives there are, how they work, how people use them, how they decide what to use or not, and how they can be obtained. In terms of information about relationships they need to know about what kinds of relationships there are, about love and commitment, marriage and partnership and the law relating to sexual behaviour and relationships as well as the range of religious and cultural

views on sex and sexuality and sexual diversity. In addition, young people should be provided with information about abortion, sexuality, and confidentiality, as well as about the range of sources of advice and support that is available in the community and nationally. Dr Warunee is a success leader to develop sexual education for youth in Chiang Mai. She created sex and health reproductive education very easy to accept, just not education but also entertainment, they called edutainment. Chanpratanphataek school is a good sample for successfully Sexual and Reproductive Health program. The youth leader looked very expert and also as a role model for peer group. They just not learn and increase their knowledge about sexuality but also learn about leadership which very useful for their live at this time and future. Harm reduction Abstinence from drug is not only goal of drug work. It is equally legitimate to help make a persons continued drug use safer for them or to offer treatment options where stabilization of drug use is the goal. When someone has had a drug problem for a number of years, it should be taken that progress is obviously going to be slow and erratic in nature. Harm reduction is defined as any change which, on an individual and at social level, minimizes the harm associated with drug use. Risk reduction is encompassed by this and is defined as any measure designed to reduce the risk of transmission of HIV through both drug use and sexual behaviour. As a result of successful risk reduction, drug services are then free to develop strategies to enable them to work with drug users at a wider range of stages in the IDUs career. Some risk reduction strategies are listed below: Abstinence Using but not injecting Using but injecting with sterile equipment

Using but not sharing Using and still sharing

Condom, sex pre-marital and AIDS prevention

Many inter-related topics concerning youth sexuality are being hotly debated. The positions that people take are often influenced by their religious beliefs and lead conflict related to youth sexuality. Some "hot" topics are: Where should information about human sexuality be taught to youth: at home, at school, at religious institutions, or at some combination of the above. Whether methods of prevention of pregnancy and/or STDs (sexually transmitted diseases) should be included in sex-ed classes . Whether abstinence should be taught alone or in addition to disease and pregnancy prevention. Whether condoms should be supplied to students in schools. Whether information about sexual orientation (particularly

about

homosexuality and bisexuality) should be taught in class. What beliefs about minority sexual orientations should be taught? Almost all gays, lesbians and human sexuality researchers believe that a person's sexual orientation is fixed, not inherently sinful, and not chosen. Most religious conservatives believe that homosexual behavior it is changeable, sinful, and chosen. Conflicts mostly occur at the local school board level, where more heat is often generated than light. There is no magic solution that everyone will find acceptable. There is probably not even a compromise on the above items that will satisfy the majority of parents and other adults.

Consensus does exist in some areas:

There are a number of factors which are provable or which most people agree with: Human sexuality is an important part of life. Under optimal conditions, sexual activity is an overwhelmingly positive experience. The best way for a child to learn about sexuality is in the home, from knowledgeable parents who are able to teach it in a relaxed manner. Most parents give little information to their children; those who do often lack sufficient knowledge and/or feel awkward when talking about this subject. Young people often go through a "superman/superwoman" phase when they feel immune from pregnancy, cancer and STDs. Youth pregnancy rates, STD rates and abortion rates vary greatly among different countries. The U.S. rates tend to be higher than those of western European nations. A woman who engages in penile-vaginal intercourse without a condom with a variety of partners is at greatly increased risk for cervical cancer. The risk is higher for women who became sexually active earlier in life. Individuals who engage in anal, vaginal or oral sexual intercourse without a condom run a high risk of contracting HIV (which leads to AIDS), Chlamydia, gonorrhea, hepatitis B, herpes, human papillomavirus [genital warts], syphilis, trichomonas, and other STD's if their partner is infected with one of these viruses or bacteria. Some STDs are not curable. Condoms (if used) greatly reduce the chance of disease and pregnancy. (Some religious conservatives teach that condoms are almost totally useless) A heterosexual couple engaged in penile-vaginal intercourse without contraception once per week will typically be pregnant within a few months. The chance of transmission of HIV from an infected partner during a single sexual encounter ranges from perhaps 1 in 10 (for anal sex) to possibly 1 in many hundreds of thousands of encounters (for oral sex). The transmission rate depends upon the exact sexual act, the way in which it is performed, whether a latex barrier was used, and whether the individuals have genital scarring from previous STDs. Anal intercourse without a condom is the highest risk sexual activity. Sexual activity is most enjoyable if it is done between an enthusiastically

consenting, committed couple. Many people feel that it should be restricted to married couples. Many young people are manipulated or pressured into sexual activity before they are ready. This often causes a great deal of emotional pain. In excess of 95% of heterosexual young people become sexually active before marriage. Most heterosexual couples live together for an interval before marriage

Condom use in legal marriage does not contradict Islamic teaching. Condom use outside marriage is bad is not acceptable in Islam and Indonesia. So, promoting condom in Indonesia is very difficult, because some people think condom promotion is mean free sex promotion.

4. Conclusion HIV/AIDS is not only related about the disease. Also talk about ways of life, traditions and beliefs, representations of health and disease, perceptions of life

and death, sexual norms and practices, power and gender relations, family structures, languages and means of communication; as well as art and creativity. HIV/AIDS is a major public problem in all over the world. It has major health, social, economic, political impact which effect all most all aspect of human of life included cultural and sensitive issues such as: stigma, discrimination, sexuality and sex education, harm reduction, condom and pre marital sex etc. Effective collaborating between government, expert, health care facilities, NGOs, PHA, and civil society is recommended to successfully against handicap related culture and to solve other social sensitive issues related to HIV/AIDS.

References Social Problems and The Family, edited by Rudy Dallos and Eugene McLaughlin, Published in association with The Open University

Sexuality Today, Gilbert D. Nass and Mary Pat Fisher, University of Connecticut, Storrs, John and Bartlett Publishers, Boston Counseling Drug Users About HIV/AIDS, Geraldine Mulleady, Blacwell Scientific Publication, Boston The Kinsey Institute Series Volume IV, AIDS and Sex, An Integrated Biomedical and Biobehavioral Approach, Edited by Bruce Voeller, June Machover Reinisch and Michael Gottlieb Home and Community Based Care, Module 3, TOT Guidelines, The Faculty of Nursing Chiang Mai University, Chiang Mai, Thailand, 2006 Religious Tolerance Org, Human Sexuality Conflicts and Consensus on Youth Sexuality, Wikipedia. Condom and religious, www.unaids.org/en/religions _countries/region/Asia.