HIV Prevention and Behaviour Change

in the Uniformed Services

-- a training curriculum

Module 7

HIV Prevention

in Conflict and Crisis Settings

Produced by

The Civil-Military Alliance to Combat HIV and AIDS (CMA)

In collaboration with

The USAID/Tulane Complex Emergency Response and Transition Initiative

(CERTI)

March 2001

Revised March 2003

Authors

Donna Ruscavage, M.S.W.

Behavioural Scientist

Rodger Yeager, Ph.D.

Project Manager

Stuart Kingma, M.D.

CMA Director

Contents

Introduction 5

Information for Instructors 6

HIV Prevention in Crisis Settings: Purpose, Goals and Objectives 13

Part I: HIV Prevention and Behaviour Change Issues 15

Part II: HIV Prevention in Crisis Settings 31

Appendix A: Instructor’s Notes 49

Appendix B: Slides/Overheads to Accompany the Module 7 Curriculum 71

Introduction

There is a critical need to find effective ways to lower the risky behaviours that lead to infection with HIV and other sexually transmitted infections (STIs) in uniformed service populations (i.e., military, peacekeepers, police). Addressing behaviour change, based on acquiring knowledge and learning skills, along with individual risk assessment, is an effective method for reducing risky behaviours.

HIV poses a real threat to both uniformed services and civilian populations, especially during complex humanitarian emergencies, including the descent into and emergence from crises involving armed confrontations. However, HIV prevention is not always the first thing on a service person’s mind in a conflict or crisis situation because the “guns are going” and they are preparing to be deployed into difficult, dangerous and stressful situations. Nevertheless, learning about HIV/STIs and prevention strategies is critical for every uniformed service member before being sent into a conflict or crisis situation.

Throughout the world, uniformed service personnel, including military and civilian police, are especially at risk for infection with HIV and other STIs. Duty often puts individuals in stressful situations and can also take them away from home for extended periods of time. The need to relieve stress, loneliness, and boredom can lead to risky behaviour. Using alcohol and drugs to cope with stress or boredom can increase the incidence of risky behaviour even more. Many uniformed service personnel are young and think that “nothing will ever hurt me.” To add to this type of thinking, uniformed service institutions encourage and value risk-taking and aggressiveness.

Men and women engaged in uniformed service work carry out admirable and important work, particularly in conflict and crisis settings. It is imperative that these individuals learn effective HIV/STI prevention strategies so they can protect their health and the health of civilian populations amidst whom they work and maintain the integrity of their missions.

This training module was developed for integration within the larger training-of-trainers Curriculum that has been produced by the Civil-Military Alliance to Combat HIV & AIDS, in cooperation with the United Nations Department of Peacekeeping Operations (DPKO).

This Curriculum presently consists of six training modules under the overall title HIV Prevention and Behaviour Change in the Uniformed Services.

Information for Instructors

Within Module 7 in bolded text, appear special notes to instructors. These notes explain what the different sections of each module cover and their purpose, and provide instructions for specific exercises.

Training Trainers and Educators

To accompany the curriculum for Module 7, an overhead/slide set is included in Appendix B.

These overheads/slides are primarily intended to serve as teaching aides when training other trainers and educators on how to use this curriculum. However, some of the overheads/slides might be appropriate for use in teaching this course to the target audience. Instructors can modify these visual aides depending on the needs of their audience(s).

Detailed information about training is included in Appendix A, Instructor’s Notes, which provides technical assistance to trainers and educators in implementing the curriculum and discusses the behavioural theories the curriculum is based upon. These notes serve as a guide for conducting the course and provide information that will help instructors to maximize the effectiveness of the curriculum.

Cultural Considerations

The information and activities included in Module 7 are based on the premise that HIV infection is preventable. However, effective prevention may require people to change their behaviour, which is often deeply rooted in culture. Instructors for this course may have the opportunity to work with people from diverse cultural backgrounds and will be more effective in helping people to reduce their risk for HIV/STI infection if they are aware of the cultural dynamics that influence behaviour. Instructors need to pay particular attention to sexual and drug-use behaviour, including alcohol consumption, which can place individuals at risk for HIV/STI infection. It is also important to understand how participants choose to communicate about personal issues and their attitudes about seeking information and assistance.

The operating definition of “culture” used here is the shared values, norms, traditions, customs, arts, history, folklore and institutions of a group of people. These shared beliefs serve as guidelines for behaviour within cultural groups. Culture is complex and dynamic – it helps people adjust to an always- changing environment. While cultural commonalties can be observed among groups of people, considerable variation can also be identified within groups based on factors such as age, education, gender and exposure to other cultures. It is therefore of little value to attempt to identify cultural characteristics for broad groups such as Asians, Africans or Europeans. The best approach for instructors is to be sensitive to and aware of the cultural issues that may be influencing the behaviour of their participants. Instructors are also encouraged to explore these issues when conducting the training.

The following suggestions may be helpful to instructors when speaking about behaviour change issues, particularly when participants are from cultures different from their own.

Listen =

§ actively listen to participants;

§ respond to what is being said, not how it is said;

§ allow individuals to fully express themselves before responding to the situation;

§ avoid an ethnocentric reaction (i.e., anger, shock, laughter) that may convey disapproval of participant’s viewpoints, phraseology, facial expression and gestures;

§ stay confident, relaxed and open to all information;

Evaluate =

§ hold any reactions or judgments until you understand the message that the participant is conveying;

§ ask open-ended questions (i.e., ones that cannot be answered with a simple ”yes” or “no”), answers to these questions will give you valuable information.

Consult =

§ agree with the participant’s right to hold his or her opinion;

§ explain your perspective of the situation;

§ find out what the participant wants to accomplish;

§ acknowledge similarities and differences in your perspective (the instructor) and the participant’s perspective;

§ offer options – suggest to the participant what he or she can do given the situation;

§ allow participants to choose their own course of action;

§ commit to being available to provide support;

§ thank the participant for sharing his or her perspective with the group.

Keep in mind that some people and cultures focus more on individualism, while others focus more on being members of a group (which might influence interaction and participation in the course). Also, individuals and cultures vary in their comfort level with self-disclosure, especially around issues related to sexuality, personal relationships and health.

How Module 7 Was Developed

Parts of Module 7 were developed utilizing a number of training curricula for HIV/STI prevention and other sources including the: U.S. National Institute of Mental Health’s Project Light; U.S. Centers for Disease Control and Prevention’s Project Respect; Civil-Military Alliance to Combat HIV & AIDS’s Winning the War Planning Handbook; U.S. Naval Health Research Center’s STI/HIV Intervention Programme; U.S. Marine Corps HIV Prevention Training; American Red Cross’s HIV/AIDS Education Basic Fundamentals; U.S. Centers for Disease Control and Prevention’s and Georgetown University’s Simulated Patient Intervention Train-the-Trainer Manual; U.S. Department of Health and Human Service’s, Health Care Financing Administration’s Instructor’s Training Techniques; and United Nations Department of Peacekeeping Operation’s Protect Yourself, and Those You Care About, Against HIV and AIDS, Ten Rules: Code of Personal Conduct for Blue Helmets and We are United Nations Peacekeepers.

Course Summary and Rationale

This program will probably be like nothing you've done before. Throughout the program, we will be discussing sexual behaviour that all people engage in. However, our special focus will be on how to engage in sexual activity safely, so you do not get infected or infect someone else with HIV or another sexually transmitted disease (STI).

§ It is about reducing your risk of becoming infected with HIV, the virus that causes AIDS.

§ It is about learning how to protect yourself from HIV infection and making choices that may save your life.

§ It is about setting up a “buddy system” to look out for and take care of your friends, so everyone works together to reduce the risk for HIV/STIs.

§ It is designed to provide you with the information and skills you need to always make choices that will prevent you from ever placing yourself, your spouse or future sexual partners at risk for contracting an STI, including HIV infection.

§ Sexual behaviour is a private matter. Only you know what your choices are and whether or not these choices place you or others at risk for contracting HIV/STIs. Only you know if you are being honest about what risks you are taking for yourself and others.

§ In many ways this program is about choices. These kinds of choices are not always a simple or easy matter. For example, alcohol consumption can impair a person’s judgment and greatly increases the risk of making unsafe decisions about sex.

§ Sexual desire is very powerful. It can easily cause one to deny or ignore the risks involved with sexual activity. Also, there are many other reasons why people take risks. Even though a person has knowledge about HIV and STIs, they don't always choose to protect themselves against HIV or STIs.

§ This program will give you a chance to think about your choices and whether or not you choose to protect yourself and your sexual partners from getting infected HIV. HIV infection is life-long disease requiring life-long treatment. When HIV infection results in AIDS, AIDS has no known cure. In your jobs, you may be away from home for long periods of time and sent to areas where the HIV infection rate is high. You need to understand the risks and how to protect yourself, your present or future spouse, sexual partners, and children, your career, your peers and civilian communities where you are working.

§ Every time you engage in sexual activity you have to protect yourself. Every time. If you choose to make even one exception to this rule and have unsafe sex, you risk getting infected with HIV. The choice is yours and only yours. No one else can decide or choose to protect you from HIV/STIs. Only you can. That's what this program is about.

Participant Guidelines

In order to meet the objectives of this course, we will discuss and explore some sensitive and personal issues. It is important to establish some basic guidelines to make sure that everyone has an opportunity to participate in the program and is treated with dignity and respect. Our expectation is that you will honor the following guidelines:

Confidentiality. Confidentiality means that any discussion that takes place in the context of this program should not be discussed with those who are not participating in the program. We will also abide by this rule. All that you say to us will be held in the strictest of confidence.

Honesty. Honesty means that you should speak from your own feelings and not just what you think people expect you to say. The honesty rule also applies to questions, because if we ask honest questions we won't waste time.

“I Statements.” “I” statements are statements that you make when you speak for yourself. Be accountable for yourself and do not speak for anyone else. Even though you may be friends, it is important that each of you speak for yourself and not your friend.

One at a Time. We cannot all be heard at the same time. Allow others to speak without interrupting them. Listen while others are speaking and do not participate in side conversations.

Respect. Treat each participant with dignity and respect their feelings and opinions. We will not always agree, but everyone has a right to his or her beliefs and ideas. Do not ridicule or make fun of others. Any question or comment that is honest is valuable.

Take Care of Yourself. Take care of yourself by being aware of your feelings. If any of the issues we discuss are disturbing to you or make you curious, let the instructor know. If answering any question or taking part in any discussion or activity makes you feel uncomfortable, don't do it. Throughout the course, you can choose not to participate in any activity that makes you feel uncomfortable.

Getting to Know Each Other

Instructor Note: When a group is assembled for the purpose of acquiring skills related to HIV/STI prevention, individuals can at first be reserved or shy about discussing personal issues. “Getting to know each other” type of exercises can be useful exercises to warm up a group and get them better acquainted with each other. This type of activity often helps participants feel more comfortable, which ultimately enables them to get more out of the training.

When You Were 16 Years Old Exercise

When you were 16 years old:

1)                  Where were you living?

2)                  What was your family like?

3)                  What was your community like?

4)                  What did you do for fun?

5)                  What was your favorite song?

6)                  Were you in love? With whom?

7)                  What did you look like?

8)                  What did you want to be when you grew up?

9)                  What were the social taboos in your community?

10)              What were the pressing social issues for you or your community?

Directions for Exercise:

1) Distribute “When You Were 16 Years Old” exercise sheet to each participant.

2) Give participants three to four minutes to write answers. Emphasize they should not spend a lot of time thinking about the questions; first impressions are best.

3) Have participants talk in pairs for two to three minutes and switch partners two or three times.

4) Bring participants back into a large group and process the exercise with the following discussion questions. What was it like to go back? What differences do you see in yourself today? What differences are there among people in the group?

When You Were 16 Years Old Exercise Sheet

When you were 16 years old:

1) Where were you living?

2) What was your family like?

3) What was your community like?

4) What did you do for fun?

5) What was your favourite song?

6) Were you in love? With whom?

7) What did you look like?

8) What did you want to be when you grew up?

9) What were the social taboos (practices that are not allowed or acceptable) in your community?

10) What were the pressing social issues for you or your community?

Module 7: HIV Prevention in Crisis Settings

Purpose: To help men and women engaged in uniformed service work to learn about HIV and AIDS and how to promote good health.

Goals: To educate participants about the kind of changes in behaviour everyone needs to make in order to protect themselves and others from HIV/STI infection.

To educate participants about complex emergencies, or crisis and conflicts, and how the complex emergency can place uniformed service personnel and civilians at risk for HIV/STI infection.

Objectives: (1) To provide basic information on how HIV is transmitted, how it affects the immune system and about AIDS.

(2) To reinforce participant knowledge of risk factors for HIV/STI infection, awareness of personal risk factors and knowledge and skill in preventing the transmission of HIV and other STIs.

(3) To increase participant awareness of the efficacy of using condoms.

(4) To increase participant knowledge and skill regarding the use of condoms.

(5) To increase participant knowledge of the negative effects that alcohol and other drugs can have on decision-making, and how these substances can increase the likelihood of involvement in risky behaviours for HIV/STI transmission.

(6) To define the particular threat of HIV/AIDS in pre- and post-crisis situations for uniformed service personnel (i.e., military, peacekeepers, police) as well as local civilian populations.

(7) To explore the relationship between sexual activity, STIs and HIV in crisis situations and their immediate aftermath.

(8) To increase participant awareness of the duty to protect themselves and civilian populations, not just from immediate harm, but also the threat of HIV.

(9) To increase participant awareness of the elements of an effective HIV prevention message and to encourage sharing of effective HIV prevention messages with others. In particular, to encourage participants to serve as peer educators, both for fellow uniformed service personnel and to local civilian populations.

(10) To review guidelines for professional conduct for uniformed service personnel and their implications for the prevention of HIV/STIs, particularly in crisis situations and their immediate aftermath.

(11) To encourage participants to make a personal commitment to reduce their risk for HIV/STIs and to reduce the risk for civilian populations which is their duty to protect.

(12) To teach participants how to serve as early-warning sentinels in pre-crisis situations, to identify deteriorating public health, socio-economic and political conditions and communicate that information to their chain of command and others.

Time: 3 hours; Part I is 1 hour and Part II is 2 hours

Format: Information and skills building exercises, group discussions, and interactive slide presentations.

Materials: Items needed:

ü Newsprint or writing board

ü Tape

ü Slide or overhead projector and screen

ü Slide set for Module 7

ü “Strategies for HIV Prevention and Behaviour Change Exercise Instruction Sheet” for Exercise IV.A.

ü “Strategies for HIV Prevention and Behaviour Change Scenarios” for Exercise IV.A.

ü Male and female condoms

ü Handout on Guidelines for Effective HIV Prevention Messages

Instructor Note: All information in Module 7 is summarized on slides to assist with the presentation. Information to enhance the written curriculum (i.e., graphics) appears on slides/overheads and is indicated by a box next to the part of the curriculum it refers to.

This module is divided into two parts. Part I is a review of basic HIV/AIDS information and HIV/STI prevention strategies. Part II discusses HIV prevention in crisis settings.

Part I: HIV Prevention and Behaviour Change Issues

I. Introduction

Part I of this session will include:

§ information about risk factors for HIV transmission;

§ information about correct condom usage;

§ a skills building exercise on negotiating safer sex practices;

§ elements of effective HIV prevention messages.

II. Facts about HIV Infection and AIDS, Global Impact of HIV and the Impact of HIV on Uniformed Service Personnel and Institutions

Instructor Note: This brief presentation will review facts about HIV infection and AIDS, present a global picture of HIV infection, and discuss the impact HIV has on uniformed services. Encourage participants to ask questions throughout this brief presentation.

A. Review of Facts about HIV Infection and AIDS

1) AIDS Is Caused By:

H = human

I = immunodeficiency

V = virus

which is also referred to as “the AIDS Virus”.

2) Definition of AIDS

A stands for acquired. It means that HIV is passed from one person who is infected to another person.

I is for immune and refers to the body's immune system. It's made up of cells that protect the body from disease. HIV is a problem because once it gets into a person's body, it attacks and kills cells of the immune system.

D is for deficiency, which means not having enough of something. In this case the body does not have enough of certain kinds of cells that it needs to protect against infections. They're called the immune cells or T-helper cells. Over time HIV kills these cells and the body's immune system becomes too weak to do its job.

S means that AIDS is a syndrome. A syndrome is a group of signs and symptoms associated with a particular disease or condition that occur together. AIDS is a syndrome because people with AIDS have symptoms and diseases that occur together only when someone has AIDS.

3) HIV is spread:

§ By having unprotected vaginal, anal, or oral sex with an HIV positive person.

§ By sharing needles or syringes with an HIV positive person.

§ During pregnancy, birth or breast feeding from an infected mother to her baby.

4) Body fluids of an infected person that spread HIV are:

§ Semen

§ Vaginal fluid

§ Blood

§ Breast milk

5) Other facts about HIV infection and AIDS:

§ AIDS is the late stage of infection caused by HIV.

§ We are all at risk; anyone can become infected with HIV from a single unsafe sexual act or from using drugs by injection even just once.

§ The vast majority of all HIV infections are caused by having unprotected intercourse with a woman or man who is already infected with HIV (70-80% of infections). HIV infection can also be transmitted through infected blood during blood transfusions (except in countries that test all blood donations for HIV); sharing of needles contaminated with the blood of an infected person; and from the blood of an infected woman to her baby before birth, during delivery or through breast feeding.

§ HIV infection is not spread through casual (non-sexual) social contact.

§ Once infected with HIV, a person can look and feel healthy for up to ten years or more before signs of AIDS appear. However, during this time of apparent health, a blood test can reveal the presence of HIV. This is what is referred to as being “HIV positive.” An HIV positive person, in spite of looking and feeling healthy, can pass it on to someone else.

§ Most HIV positive persons require life-long treatment. HIV positive individuals can eventually develop AIDS, because the body’s immune system (which fights off everyday infections and diseases) is steadily weakened by the HIV infection. After a while, the body’s immune system becomes weakened, affecting its ability to fight off infections like pneumonia, as well as diarrhoea, tumours and other illnesses, all of which can be part of AIDS. There is no cure for AIDS.

§ There is no vaccine to protect people against getting infected with HIV. There is no cure for AIDS. This means that the only certain way to avoid AIDS is to prevent getting infected in the first place.

§ Both men and women are vulnerable to infection from HIV and other sexually transmitted diseases, many of which have serious long-term consequences, especially for women e.g., pelvic inflammatory disease, tubal pregnancy, sterility.

§ The presence of an untreated sexually transmitted disease (STI) like syphilis or gonorrhoea facilitates the transmission of infection with HIV from one person to another. Open sores and blisters provide an easy entrance into the body for STIs, including HIV. Having an STI is already a sign of risky behaviour. Prevention and treatment of STIs is another way to protect yourself against HIV infection.

§ Drinking alcohol or using illegal drugs will reduce your judgment and your ability to act within the bounds of safe behaviour. When you are under the influence of alcohol and/or drugs, you are more likely to indulge in risky sexual contacts.

§ Being tattooed or body pierced with unsterile needles can result in infection with HIV and other STIs e.g., Hepatitis B. Make sure needles are sterilized in an autoclave or try to use your own needles.

§ Sexual transmission of HIV can be prevented by practicing safer sex. Safer sex includes not having sex, fidelity between uninfected partners, using a latex condom every time engaging in vaginal, anal, or oral sex, non-penetrative sex and engaging in activities such as hugging, kissing, masturbation, mutual masturbation.

B. Global Impact of HIV

This slide/overhead shows a map of different areas of the world with rates of HIV infection. As you can see, there is no area of the world without HIV, the virus that causes AIDS.

C. Impact of HIV on Uniformed Service Personnel and Institutions

§ Military, peacekeeping and police duty may take individuals away from home for long periods of time. The lack of the normal supports of family plus peer pressure from other soldiers leads to risky HIV behaviours, such as casual sex and commercial sex (paying prostitutes), not using condoms when having sex and injecting drugs like heroin.

§ The need to relieve stress, loneliness and boredom can lead to risky behaviour. The use of alcohol and other drugs to combat stress, loneliness and boredom can contribute to excessive risk taking. “R and R” (rest and relaxation), or leave, post-training and post-deployment periods are especially dangerous for individuals getting infected with STIs, including HIV, because of the need to relieve stress.

§ The uniformed services employ large numbers of young men and women who are in the most sexually active age bracket. Also, young people typically feel that nothing will ever hurt them and do not think they are at risk for things like STIs and HIV. This way of thinking (i.e., “nothing will ever hurt me”) can be very dangerous because worldwide, the majority of new HIV infections are in young people between the ages of 15 and 24.

§ Character traits that are highly valued in uniformed services such as risk-taking and aggressiveness, can lead to greater dangers of getting infected with STIs or HIV when carried over into sexual situations.

§ Soldiers have cash, or are perceived to have it; military installations attract commercial sex workers, or prostitutes.

§ War and other social upheavals dislocate populations, increasing the number of persons who use sex as a means of survival. Since soldiers are deployed in periods of distress like this, there can be increased opportunities for sexual encounters.

§ Uniformed service personnel need to take care of each other to prevent infection with HIV/STIs. Units or organizations can set up “buddy” programs where individuals look out for each other, avoid risky situations and try to promote safer behaviours.

§ HIV and STIs affects individual lives, as well as uniformed service organizations (i.e., careers, personal life, ability to have a family).

Instructor Note: Close this discussion by summarizing the following facts:

§ HIV is the virus that causes AIDS.

§ AIDS is the result of HIV infection.

§ HIV infection can be prevented.

§ HIV is not spread through casual social contact.

III. Demonstration to Review Correct Condom Use

Instructor Note: This demonstration teaches participants correct condom use. Emphasize that male condoms, if used consistently and correctly, can decrease the risk of transmission of pregnancy and all sexually transmitted diseases (including HIV infection) to less than two percent (2%). Ask for volunteers from the audience to demonstrate how to use a male and female condom, and how to use a condom to protect during oral sex, after you present the following information.

Directions for Demonstration of Male Condom

Demonstrate how to use male condoms correctly, according to the following 10 steps:

1. Choose a latex condom. Latex condoms give protection against HIV. Emphasize that lambskin (also known as sheepskin or “natural”) condoms do not give protection against HIV/STIs or pregnancy.

2. Check the expiration or manufacture date on the condom package. If the condom has expired, don’t use it. Condoms can become dry and subject to breakage with time. Never keep a condom anywhere it may become hot or under pressure because that may make it dry out. If there is only a manufacture date on the package, it should expire about two years from the manufacture date.

3. Open the package without tearing the condom. With the package still intact, push the condom to one side and it will be out of the way when you tear open the package. Do not open the condom package with things like your teeth, scissors, knife.

4. Place the condom on the head of the penis prior to any contact with a partner’s mucous membranes. Make sure that the reservoir tip sticks out. Putting a drop of lubricant inside the tip of the condom may give extra feeling.

5. Pinch the tip to let the air out.

6. Slowly unroll the condom down to the base of the penis. Make sure that the condom covers the entire penis.

7. If lubrication is desired, choose water-based (e.g., KY jelly or spermicidal jelly). Oil based lubricants such as Vaseline can damage the latex and cause tearing.

Immediately after ejaculation:

8. Hold the condom at the base of the penis and carefully withdraw (pull out). Do this while the penis is still erect to avoid having the contents of the condom spill out.

9. Roll the condom down and remove it from the penis, making sure that the contents of the reservoir tip do not spill.

10. Dispose of the condom. Condoms should never be used more than one time. It is not okay to wash them out and use them again.

Directions for Demonstration of Female Condom

Demonstrate how to use female condoms correctly, according to the following nine steps:

1. Check the expiration date on the condom package. If the condom has expired, don’t use it. Condoms can become dry and subject to breakage with time. Never keep a condom anywhere it may become hot or under pressure because that may make it dry out.

2. Open the package without tearing the condom. With the package still intact, push the condom to one side and it will be out of the way when you tear open the package. Do not open the condom package with things like your teeth, scissors, knife.

3. Open the end of the condom (at the outer ring). The outer ring will cover the area around the vagina. The inner ring will go inside the vagina and is used to guide insertion and hold the condom in place.

4. Hold the inner ring between the thumb and middle finger. Place your index finger on the pouch between the other two fingers or just squeeze the inner ring.

5. Squeeze the inner ring to insert the condom into the vagina. Insert the sheath into the vagina as far as it will go. It is in the right place when the woman can’t feel it. It is not possible to insert the condom too far up into the vagina.

6. Make sure placement is correct by making sure the sheath is not twisted. The outer ring should be outside the vagina.

7. If lubrication is needed, choose water-based (e.g., KY jelly or spermicidal jelly).

Immediately after ejaculation:

8. Remove the condom before standing up. Squeeze and twist the outer ring and pull out gently.

9. Dispose of the condom. Condoms should never be used more than one time. It is not okay to wash them out and use them again.

Directions for Demonstration of Condoms for Oral Sex

Condoms help make oral sex safer. For fellatio, place a male condom (using the same instructions as already outlined) over the erect penis before beginning.

For cunnilingus, take a rolled male condom and cut it from any edge to the centre. Carefully unroll into a rectangular piece of latex and place over the opening to the women’s vagina before beginning cunnilingus.

IV. Review of Universal Precautions

Skills and simple measures against the transmission of HIV and other blood-borne diseases can be important when accidents or battlefield injuries result in active bleeding, and in the case where personnel are required to handle dead bodies. The following Standard Operating Procedures (SOP) should be learned by all uniformed service personnel – and consistently practiced – in the care of the wounded and the handling of the dead to minimize the risk of blood-borne disease transmission.

These procedures are referred to as Universal Precautions:

§ Safe handling of sharps (needles, knives, and other cutting instruments) to avoid getting the skin cut or punctured.

§ Hand-washing with soap and water after all exposure to blood or other body fluids or

exposed bodily tissue.

§ Wearing of gloves and protective clothing when blood and other body fluids are being contacted - this is especially important in the handling of dead bodies.

§ Safe disposal of medical waste (drapes, sponges and wipes that contain blood or other fluids – and body tissues and fluids themselves).

§ Decontamination of all instruments and equipment that have been in contact with blood and body tissues.

V. Strategies for HIV Prevention and Behaviour Change

Instructor Note: This exercise gives participants an opportunity to put the knowledge and skills they’ve acquired in the course to potential real-life situations. Participants will be presented with scenarios where they will make choices and develop strategies with the ultimate goal of preventing getting infected with STIs, including HIV. Encourage participants to draw on their experiences as uniformed service personnel. This exercise may be challenging to participants because it may be very different from the type of training they are accustomed to. Let the group know before you do the exercise that this may be difficult for them, but emphasize they will learn important skills and ideas from this discussion. Be sure to tailor the discussion regarding “Guidelines for Negotiating Safer Sex” to best meet your audience’s needs, taking into account cultural issues. Tailor the small group discussion scenarios to your audience as well.

A. Dyad or Small Group Practice

Instructor Note: Begin this exercise with a brief presentation on negotiating safer sex.

Guidelines for Negotiating Safer Sex

1) Practice TALK:

T = Tell your partner “I am listening to what you are saying.” Acknowledge

them. Use “I” statements (speak for yourself).

A = Assert what you want in a positive way. State your goal or need. Be

positive. Use “I” statements (speak for yourself).

L = List your reasons for wanting to be safe (use condoms). Be brief. Use a

reason that is about you. Do not mention disease.

K = Know the alternatives (for safer sex) and your personal bottom line

(exactly what you are comfortable doing).

TALK is a set of tools that a person can use to be assertive and persuasive. Use TALK to tell a partner you want to have safe sex, you won’t have unsafe sex, or in any situation where you want to be assertive.

2) Be assertive, but not aggressive:

§ make sure you say what you want;

§ use “I” statements (speak for yourself);

§ listen to what your partner is saying;

§ respect and acknowledge your partners’ feelings and options;

§ be positive;

§ use reasons for safe sex that are about you, not your partner.

3) If your partner is being negative (not wanting to practice safer sex):

§ Find something positive in what they’re saying and turn their negative objection into a positive thing. For example, if your partner is very controlling, you can say to them that you appreciate that and are glad they care so much about you (rather than accusing them of being too controlling).

§ Never blame the other person for not wanting to be safe, blame the environment or something else, but never the other person.

4) Remember, HIV is not all you can contract from not practicing safer sex. You can contract another STI or cause an unwanted pregnancy.

Directions for Exercise

1) Have participants work in small groups or have them form pairs of two (dyads).

2) If dyads are formed, one person will need to volunteer as a notetaker. If small groups are formed, the group will need both a facilitator and a notetaker. Give each dyad or small group newsprint and writing materials. Give each dyad or facilitator in the small group a “Strategies for HIV Prevention and Behaviour Change Exercise Instruction Sheet.”

3) Give each dyad or small group a scenario (described below) from the “Strategies for HIV Prevention and Behaviour Change Scenarios.” There are two scenarios; be sure to distribute them evenly. Ask participants to review and discuss their scenario and develop responses/strategies to it. Each dyad or small group notetaker should write down the responses/strategies developed on paper or on newsprint (which they can use for their presentation to the larger group).

Small Group Discussion Scenarios

Scenario #1: Peter and Sarah

This is Peter’s first mission outside of his country and it’s also the first time he has ever been in another country. Peter is surprised and overwhelmed with the amount of diversity in his new home environment (cultural, religious), not just in the local population, but within his mission. It has been very stressful for Peter trying to adjust to so many different types of people and this new environment. He has formed a friendship with Hector, another soldier, and they have both been given their first two and a half days of “R and R” (rest and relaxation) and they are ready for it! They’re going to a nearby beach and are very much looking forward to it. Peter and Hector are in a social club drinking, after spending a great day on the beach. Peter meets Sarah at the club. They dance and talk and Peter can tell just by the way Sarah smiles and touches him that she’s sexually interested in him. Sarah invites Peter back to her place. Peter is worried about HIV and other STIs and wants to use a condom. After they get to Sarah’s apartment, they begin to move towards intimacy.

Peter: I should tell you now that it’s very important to me to use condoms. I have some with me.

Sarah: Why do you want to use one of those things? I’ve never met a man who wanted to use a condom!

Peter: Well, I think it might be a good idea…

Sarah: But Peter, it feels so much better without a condom.

What should Peter do? What should Peter say to Sarah? Develop possible responses and

strategies for Peter to effectively negotiate safer sex with Sarah.

Scenario #2: Carmen and John

Carmen suspects her boyfriend John has been sleeping with someone while she was away from home on a special six-month assignment. She’s getting ready to go home and is worried about HIV and other STIs. She wants to use condoms when she and her boyfriend have sex, but does not know how to bring it up (they’ve never used them before). She’s particularly worried because he has a bad temper and is jealous.

What should Carmen do? What should Carmen say to John? Develop possible responses and strategies for Carmen to effectively negotiate safer sex with John.

B. Large Group Summary

Directions for Exercise

1) The instructor will request one volunteer from each small group or dyad to summarize the strategies that they identified in response to their scenario. Offer additional responses (if appropriate) to emphasize prevention of HIV/STIs.

2) Discuss any questions or concerns of participants.

3) To wrap up the exercise, review the guidelines for negotiating safer sex.

Practice TALK:

T = Tell your partner “I am listening to what you are saying.” Acknowledge

them. Use “I” statements (speak for yourself).

A = Assert what you want in a positive way. State your goal or need. Be

positive. Use “I” statements (speak for yourself).

L = List your reasons for wanting to be safe (use condoms). Be brief. Use a

reason that is about you. Do not mention disease.

K = Know the alternatives (for safer sex) and your personal bottom line

(exactly what you are comfortable doing).

Be assertive, but not aggressive:

§ make sure you say what you want to say ;

§ use “I” statements (speak for yourself);

§ listen to what your partner is saying;

§ respect and acknowledge your partners’ feelings and options;

§ be positive;

§ use reasons for safe sex that are about you, not your partner.

If your partner is being negative (not wanting to practice safer sex):

§ Never blame the other person for not wanting to be safe, blame the environment or something else, but never the other person.

Remember, HIV is not all you can contract from not practicing safer sex. You can contract another STI or cause an unwanted pregnancy.

Instructor Note: If appropriate, use the following optional discussion to assist with the wrap-up of this exercise.

The process of negotiating safer sex is similar to the process of negotiation. The following analogy relates the steps of diplomacy, negotiation and action that uniformed service personnel are trained in to steps to take regarding talking about safer sex, negotiation and action.

Diplomacy = Talking together at the beginning of a relationship before having sex. This is an opportunity to express your point of view about safer sex and state your needs.

Negotiation = Trying to reach agreement on safer sex, so sexual activity will be comfortable for both individuals. You can use different words to talk about your preference for safer sex. For example, state that it is a matter of good health, it’s not just for my, but for your safety as well.

Action = Take action to ensure your safety. You can insist on using a condom, you can decide not to have sex if your partner refuses to use a condom or you can decide to do other activities besides penetrative sexual intercourse.

VI. You Are Leaders

Instructor Note: This exercise allows participants to develop a written personal contract for HIV and other STI risk reduction. Encourage participants to keep their contracts so they can refer to them after the course.

A. Elements of Effective HIV Prevention Messages

Instructor Note: Explain that after having completed this first section of the course, participants are now leaders in protecting themselves and others against HIV infection. Leaders can take opportunities to give protection messages to others. These messages help save lives. If everyone in the room gave 10 messages per week, think of all the people who might start staying healthy.

Guidelines for effective HIV prevention messages:

§ Help people feel good about acting safely.

§ Say “HIV is serious business and being concerned is smart.”

§ Say “Many people are changing their behaviours because of HIV, and so am I.”

§ Be specific in telling how you act safe - say “I wear condoms” or “my partner always wears a condom.”

§ Tell people what you have learned about HIV that has helped you.

§ Remember, more and more people are concerned about HIV and safer sex is a wise thing to do.

Instructor Note: Summarize the above guidelines as follows:

When you talk to people about staying healthy, you want to make them feel good about taking steps to protect themselves. Therefore, you can tell them that:

§ HIV/AIDS is very serious business so that being concerned is really smart.

§ These days, many people are talking to others, going to classes on HIV prevention, reading about it and taking steps to change their sexual patterns.

§ Be specific about safer sex. Wearing condoms, refusing to have sex and avoiding “risky” partners (such as injection drug users, prostitutes and individuals who have had unprotected sex with many people) are very wise moves to make.

§ You have learned a lot about HIV, are concerned and have made changes.

B. Practicing Effective HIV Prevention Messages

Instructor Note: This brief exercise gives participants an opportunity to practice developing effective HIV prevention messages to share with others.

Directions for Exercise

1) Distribute handout on “Guidelines for Effective HIV Prevention Messages” to

the participants.

2) Instructor next models an example of an effective message. For example:

You are really showing good sense by completing this course. HIV can have a serious impact on your life, so it is smart to find out what you can do. More and more people are starting to pay attention to HIV. You’re ahead of the others. Teaching this course has helped me a lot. I have changed the way I do things. I hope you and others do, too. That would be great.

3) Ask participants to offer their own HIV prevention messages. Write participants examples on writing board/newsprint. Offer suggestions to participants to make their messages more effective. Refer to the guidelines discussed above.

VII. Part I Summary and Conclusions

The instructor should thank participants for their participation in this part of the training program. He or she should reinforce the importance of their mission and the need for them to protect their health and the health of their families.

Module 7, Part I: HIV Prevention and Behaviour Change Issues

Strategies for HIV Prevention and Behaviour Change

Exercise Instruction Sheet

Directions for Small Group Discussion

1) The facilitator identifies the notetaker in their group and makes sure they write down responses and strategies to their scenario on newsprint.

2) Distribute the scenario to your group and have them read it.

3) Lead a discussion with your group and get them to talk about the scenario and develop responses and strategies to it.

4) Agree on a presenter, or have the entire group present, when you get back together in a large group with the instructor.

Module 7, Part I: HIV Prevention and Behaviour Change Issues

Strategies for HIV Prevention and Behaviour Change Scenarios

Scenario #1: Peter and Sarah

Peter and Hector are in a social club drinking, after spending a great day on the beach. Peter meets Sarah at the club. They dance and talk and Peter can tell just by the way Sarah smiles and touches him that she’s sexually interested in him. Sarah invites Peter back to her place. Peter is worried about HIV and other STIs and wants to use a condom. After they get to Sarah’s apartment, they begin to move towards intimacy.

Peter: I should tell you now that it’s very important to me to use condoms. I have some with me.

Sarah: Why do you want to use one of those things? I’ve never met a man who wanted to use a condom!

Peter: Well, I think it might be a good idea…

Sarah: But Peter, it feels so much better without a condom.

What should Peter do? What should Peter say to Sarah? Develop possible responses and

strategies for Peter to effectively negotiate safer sex with Sarah.

Module 7, Part I: HIV Prevention and Behaviour Change Issues

Strategies for HIV Prevention and Behaviour Change Scenarios

Scenario #2: Carmen and John

What should Carmen do? What should Carmen say to John? Develop possible responses and strategies for Carmen to effectively negotiate safer sex with John.

Module 7, Part I: HIV Prevention and Behaviour Change Issues

Guidelines for Effective HIV Prevention Messages

The guidelines for developing effective HIV prevention messages are:

1) Help people feel good about acting safely.

2) Say “HIV is serious business and being concerned is smart.”

3) Say “Many people are changing their behaviours because of HIV, and so am I.”

4) Be specific in telling how you act safe - say “I wear condoms” or “my partner always wears a condom.”

5) Tell people what you have learned about HIV that has helped you.

6) Remember, more and more people are concerned about HIV and safer sex is a wise thing to do.

When you talk to people about staying healthy, you want to make them feel good about taking steps to protect themselves. Therefore, you can tell them that:

§ HIV/AIDS is very serious business so that being concerned is really smart.

§ These days, many people are talking to others, going to classes on HIV prevention, reading about it and taking steps to change their sexual patterns.

§ You have learned a lot about HIV, are concerned and have made changes.

Part II: HIV Prevention in Crisis Settings

I. Introduction

Part II of this session will include:

§ information about crisis settings and the role of the uniformed services in crisis;

§ information about what happens to civilians in crisis settings;

§ information on being an early warning sentinel for HIV/STIs in crisis settings;

§ review of professional conduct guidelines for uniformed service personnel;

§ information on the relationship between alcohol, drugs, sexual activity and HIV/AIDS;

§ problem-solving exercises for uniformed service personnel involved in crisis situations.

II. Speaking the Same Language

Instructor Note: This is a brief exercise to make sure participants are all using the same terms to describe civilian populations in crisis. Present these terms briefly and ask participants if they use other terms to describe civilian populations. List their responses on writing board or newsprint.

For the rest of this module, we will be talking about crisis and using certain terms to describe people in crisis. To make sure we are talking about the same thing, we’ll take a few minutes to define people in crisis settings.

Refugees. International law defines a refugee as a person who is outside his or her country and cannot return because of a well-founded fear of persecution, or who has fled because of war or civil conflict or the destruction of their homes and communities. Refugees fear persecution for many reasons including race, religion, nationality, membership in a particular social group or political opinion.

Economic Refugees. Sometimes refugees have left their country, not for fear of persecution or due to destruction of their home, but to make money. Employment opportunities may be rare in their own country and individuals leave to earn money in other countries in order to support themselves and their families.

Returnees. Refugees leave their homes under extreme duress and most of them want to return as soon as circumstances permit. They are called returnees when they return to their home country (repatriation), usually with the support of the United Nations or other international agency.

Internally displaced persons (IDPs). IDPs are individuals who have left their homes under extreme duress and are living in another location within their country. They are “displaced” within their own country.

Worldwide, there are an estimated 50 million people who have been forced to flee their homes, these individuals are refugees, returnees and persons displaced within their own countries. This represents about 1 out of every 280 people on earth.

Crisis Defined and the Role of the Uniformed Services in Crisis

Instructor Note: This is a presentation to define crisis and describe what happens during a crisis. It is recommended to deliver this information using a facilitated discussion format (rather than a didactic lecture format), where the instructor can ask questions and then have participants provide responses. For example, the instructor asks participants to define what crisis is. After doing so, the instructor can then summarize using the information below.

A humanitarian crisis or emergency is a situation requiring an urgent response and action; such crisis situations may result from natural or man-made disasters, complex emergencies or other public health situations endangering the life or health of a significant number of people and demanding immediate action; or it may result from complex situations involving civil violence, war or the breakdown of authority; emergency situations such as these are often associated with extensive social and economic collapse, requiring a multi-sectoral response. (adapted from WHO, 1996)

Stages of crisis:

§ Destabilising event = natural disaster, war or civil conflict that threatens the lives or well-being of a population, forcing the massive displacement of people.

§ Acute phase = loss of essential goods and services, social disruption, loss of security, and the continuing displacement of people with exposure to violence.

§ Post-acute phase = when refugees & IDPs begin to settle and basic needs can be provided, with improved security and stability. Government and relief agencies can accelerate the step-wise restoration of essential services

§ Stabilisation phase = a transitional period when the “emergency” or crisis is at an end, characterised by a progressive return to normality, and personal / communal security is restored. Refugees and IDPs may consider returning to their home areas, and more comprehensive services have been or can be re-established.

Instructor Note: If appropriate (depending on the level of your audience), you can

discuss this more in-depth description of the stages of crisis:

§ The destabilizing event – results in a very chaotic situation

§ Loss of essential goods and services – breakdown of political and social infrastructure and cutting off access to basic needs

§ Restoration of essential services – a return to meeting most basic needs and the capacity to expand services, this is where most of the work of humanitarian agencies and peacekeepers takes place; restoration of essential services and protection of the population are the goals of humanitarian interventions into complex emergencies

§ Relative stability – services restored to the affected population that allows a greater development of interventions and care

§ Resumption of normality – circumstances that allow the return of displaced populations to their communities and homes

What happens during a crisis?

During a crisis, many things can happen that affect uniformed service and civilian populations:

§ Social disruption results in sudden, widespread, and profound poverty. One consequence of this situation is acute and often severe health and food insecurity suffered by displaced families.

§ Lack of income and employment opportunity leads to the sale of sex by women, men, and children (“survival sex”) as a last recourse to meet their basic needs.

§ Migration of surviving breadwinners to find wage employment further disrupts family integrity and local economies, and it exposes migrants to an enhanced possibility of acquiring HIV in labour camps.

§ Women are at least six times more likely to become HIV-infected in refugee and displacement camps than they were in more normal times.

§ Decimated health-care infrastructures become unable to maintain reproductive health services, blood-safety protocols, sterile equipment, STI/HIV counselling services, and facilities for care.

§ Food insecurity is a major feature of emergencies.

§ Conflict creates and exacerbates the conditions – and the human rights abuses – in which the HIV/AIDS crisis flourishes. These include the disintegration of communities, displacement, the separation of children from their families, and rape and sexual violence.

What is the role of the uniformed services during a crisis?

The uniformed services play many different roles in a crisis, depending on the nature of the crisis:

§ Combatant in an armed conflict. This is a tense, stressful situation. Lives are at risk and combatants are killed.

§ Peacekeeper in a peacekeeping mission. Peacekeeping missions are established after a conflict or war, to separate fighting factions and keep them from potentially explosive incidents that could lead to renewed conflict. For example, the United Nations comes in after the fighting has stopped and keeps separate the formerly fighting factions. The situation is tense, but there is no fighting. In Lebanon, Ghana was part of a UN peacekeeping mission to keep the Muslims separated from the Christian population who were having a civil war at the time. Their job was to man the truce line and keep both sides separated.

§ Peace enforcer. This is a complicated process that occurs when the fighting has stopped, but there has not been a firm truce yet – there is agreement by the fighting in sides in principal not to fight, but anything can happen. The job here is to make sure that the fighting does not start up again, and if necessary to fire back if fired upon. NATO does peace enforcing, like they did in Bosnia when the UN peacekeepers were fired on and could not fire back and had to be assisted by NATO. Peace enforcers help factions after a conflict to adhere to truces and cease-fires, deal with snipers and any violations of truces and cease-fires. Ghana and Nigeria were both involved with ECOMOG in Liberia and Sierra Leone. They went in as peace enforcers and peacemakers – they were able to shoot and their job was to separate the fighting groups.

§ Peacemakers. Peacemakers have the difficult task of fighting to separate the warring factions; soldiers are sent in as combatants. One example of this is the recent Gulf War.

§ Protector of civilian populations.

§ Peace builders. Uniformed services are often asked to help return the environment to normal after the fighting has stopped and warring sides have been disarmed. They are asked to build institutions like hospitals, assist in re-establishing trade, help and protect the new government, reconstruct roads, open schools and markets and resettle refugees or IDPs. This is a particularly hard role for uniformed services because individuals want to go home and do not consider these “civilian” tasks to be part of their mission.

III. Feelings and Opinions Exercise: Populations in Crisis Settings

Instructor Note: This exercise is designed to increase participant awareness of their

feelings and attitudes about working in crisis settings and populations in crisis. All of

the statements deal with aspects that can put uniformed service populations at risk for

infection with HIV and other STIs.

Directions for Exercise

1) Before the session, write each of the statements or questions below on its own sheet of paper in large, easy-to-read letters. Prepare multiple copies of each statement

2) Divide participants into small groups. Ask them to spend 15 minutes discussing their feelings and attitudes, spending a few minutes on each statement. Let participants know that they can frame their answers in the third person, rather than discuss their own personal responses (this may facilitate more open discussion).

3) You can remind them every few minutes to move on to the next statement, if they haven’t already done so. Wrap up the small group discussions after about 15 minutes.

4) Next, have one person from each group summarize their group’s responses for the larger group. To save time, have subsequent groups relate only responses that haven’t been mentioned.

5) Discuss each statement after all groups have given their responses (see discussion questions below). List responses to each statement on a writing board or newsprint.

Statements for Participants to Discuss:

Statement # 1: During a crisis, when civilians may be living in a war or occupied zone,

relocated to camps, forced to flee their home and become refugees or IDPs, how much

do uniformed service personnel need to worry about sexual violence or abuse toward

civilians? How does this relate to getting infected with HIV or other STIs?

Key points to discuss in large group for Statement #1:

Sexual violence and abuse

§ The potential for rape and violence is higher during a crisis.

§ Women, children and men are at increased risk of violence, including rape. They may lose protection if their spouse leaves to join the conflict or is removed from their home.

§ In some conflicts, rape is used as a systematic campaign of terror and intimidation against certain population groups.

§ AIDS can be used as a weapon of war where one military deliberately infects women with HIV (who will then infect their spouses or sexual partners).

§ Children can be forced into joining the conflict as soldiers, abduted from their homes or right off the street. Children also become soldiers when they become separated from their parents, by becoming soldiers they are given another “family,” along with food and shelter.

§ When refugees or IDPs live in camps, the potential for violence and abuse is great as people fight to get food, water and firewood. Sex is often traded for food, water and firewood. Women and girls are particularly at risk since coercive sex is likely to result in tears or other injuries to the genitals.

Statement #2: During a crisis, what types of things happen to civilian populations when

they have a limited ability to provide for their basic needs (food, money and shelter)?

How does this relate to getting infected with HIV or other STIs?

Key points to discuss in large group for Statement #2:

Lack of income and basic needs (food, money and shelter)

§ People cut off from their normal sources of income and basic needs may find that selling sex is one of few survival strategies open to them. In many refugee camps the sex industry has flourished, becoming part of the interaction between the refugee population and the local people in the host country.

§ Food may be difficult to get and women, men and children alike can exchange sex for food.

§ Sex can also be exchanged for money and shelter. Women turn to commercial sex work (CSW) as a way to support their families.

§ Women and children may be sold into sexual slavery against their will by their families or spouses in exchange for basic needs.

Statement #3: When places of employment, schools, and hospitals and clinics shut down or are changed because of a crisis situation, in what ways do you think this affects civilian populations? What happens when families get separated or members get killed? What do people do to cope with their situation? How does this relate to getting infected with HIV and other STIs?

Key points to emphasize in large group discussion for Statement #3:

Breakdown in social and cultural structures

§ The breaking up of community and family life causes stable relationships to break up, support to be lost and the cultural and family controls on individual behaviour to loosen.

§ Psychological damage can result from being a victim of sexual violence and abuse, losing a home or job, being forced into poverty, becoming a child soldier or losing parents or loved ones.

§ Sex can be used as a coping mechanism, along with alcohol and drugs. Drugs and sex are very available near refugee camps. If a population with a large number of injection drug users is forced to flee an area, the traffickers and dealers flee as well to maintain their business. Likewise, the commercial sex industry moves near refugee camps.

§ Young people may have no strong and positive role models or parental protection. Youth in refugee camps tend to become sexually active at an earlier age than they would under normal conditions.

§ Boredom and stress from not having work or going to school can lead to alcohol and drug use to relieve boredom and stress.

Lack of education

§ With no formal education system in place and in some cases the absence of parents, young people lack knowledge about HIV and other sexually transmitted diseases.

§ Young people can engage in sex at earlier ages and the rate of unplanned pregnancy can rise.

Lack of health care

§ Limited or no access to medical care, including sexual health services can lead to greater numbers of persons with infectious diseases which, if left untreated, can be spread to others such as tuberculosis and STIs.

§ Condoms are seldom available in a crisis, as well as testing for HIV/STIs and other infectious diseases.

§ In crisis settings, the risk of HIV transmission through the transfusion of infected blood may be high. More transfusions than usual may be needed because of war or civil unrest. It may be difficult to screen blood for HIV due to lack of equipment.

Statement #4: In what ways do you think working in crisis situations affects uniformed service personnel and relief workers? What do they do to cope with working in difficult settings (war zones, refugee or relocation camps)? How do they relieve stress? How does this relate to getting infected with HIV and other STIs?

Key points to discuss for Statement #4:

Impact on uniformed service personnel and relief workers

§ Uniformed service personnel and relief (humanitarian) workers do not always receive training in what happens to civilians in crisis settings. They are often not prepared for the hardships and conditions civilians are forced to deal with.

§ Uniformed service personnel do not always receive training in protection of human rights or issues that confront civilians, refugees and IDPs living in crisis settings. There are abuses that can occur when uniformed service and civilian personnel have “power” over the civilian population. They offer protection, food, medicine and shelter.

§ Uniformed service personnel and relief workers alike are not always prepared for what they will have to deal with in a crisis. They can become stressed and lonely and turn to alcohol, drugs and sex (among themselves as well as with the civilian population) to relieve their stress and loneliness.

§ The commercial sex industry and drug traffickers often set up near refugee camps and peacekeeping missions. They know uniformed service personnel have money. Uniformed service personnel and relief workers take advantage of these “services” as ways to relieve stress. Condoms and clean drug injection equipment are seldom available.

Key Points to Remember about

Populations in Crisis Settings

Instructor Note: This exercise is designed to increase participant awareness of the factors that operate in crisis settings and among populations in crisis. All of the statements deal with aspects that can put uniformed service populations at risk for infection with HIV and other STIs.

§ In crisis settings, all population groups present are exposed to high risk HIV transmission – uniformed service personnel (combatants, police and peacekeepers), local and displaced civilians, as well as international relief workers – all are at risk for HIV/STI infection.

§ The potential for rape and sexual violence is high in times of crisis.

§ When sexual violence or abuse occurs, it can leave a life-long psychological and emotional impact on its victims.

§ HIV can be used as a weapon of war, forever changing the lives of its victims.

§ Children may be forced to become child soldiers, especially if they have lost their parents or are separated from family – thus, the protection of children is a prime responsibility of the uniformed services.

§ The lack of income, food and shelter creates serious problems for civilians; individuals can be forced to exchange sex for money, food and shelter.

§ Many people in these settings use alcohol or drugs to relieve stress, loneliness, trauma.

§ Not being able to get medical care, condoms and education cause more people to practice unsafe sex, putting them at risk for HIV/STI infection.

§ Uniformed service personnel and relief workers may try to cope with stress by using alcohol and drugs and engaging in unprotected sex.

IV. Professional Conduct Guidelines for Uniformed Service Personnel

Instructor Note: This section emphasizes aspects of uniformed service professional conduct that reinforce avoidance of behaviours that place uniformed service personnel at risk for infection with STIs/HIV. The instructor may consider inviting their commander to present these guidelines or participate in this discussion. These professional guidelines are based on the United Nations Code of Conduct for Peacekeepers.

Professional Conduct Guidelines Highlights

We want to stress that your role and responsibility as uniformed service personnel is to protect civilian communities, your families and each other. You are protecting all these individuals, including yourself, when you prevent transmission of HIV/STIs. We also want to stress the impact individual behaviour can have on an entire mission or organization. You are part of a group and your behaviour reflects directly on the group as a whole and can impact the successful achievement of your objectives. What follows are general guidelines we all can agree on as uniformed service personnel:

We will:

§ At all times conduct ourselves in a professional and disciplined manner.

§ Support and encourage proper conduct among ourselves.

§ Treat the inhabitants of the host country with respect, courtesy and consideration when stationed away from home.

§ Respect local customs and practices wherever we work through awareness and respect for the culture, religion, traditions and gender issues. We recognize that social rules governing relations between men and women often have very different norms from one culture to the next, so that what may be interpreted as innocent behaviour in one culture context may be taken as an offence in another culture.

§ Always be aware of the human rights of women and children and never violate them.

We will never:

§ Bring discredit upon our organizations through improper personal conduct, failure to perform our duties or abuse of our positions as uniformed service personnel.

§ Take any action that might jeopardize our work or our organization’s mission.

§ Abuse alcohol, use or traffic in drugs.

§ Commit any act that could result in physical, sexual or psychological harm or suffering to members of the civilian population, especially women and children.

We realize the consequences of failing to act within these guidelines may:

§ Erode confidence and trust in the uniformed services.

§ Jeopardize the achievement of our work or our organization’s mission.

§ Jeopardize our status and security as uniformed service personnel.

Instructor Note: To summarize, emphasize that adherence to these professional conduct guidelines will greatly reduce an individual’s risk for contracting STIs/HIV or transmitting STIs/HIV to other persons.

V. The Uniformed Services as Early Warning Sentinels

Instructor Note: This discussion focuses on how uniformed service personnel can act as early warning sentinels in crisis settings, particularly for HIV/STIs but also for other emerging threats to health and security. First define what a sentinel is and then lead a facilitated discussion around how uniformed service personnel can act as sentinels for early warning especially regarding HIV/STIs, but also for other threats to health and security. Emphasize that this is a very important role to play in a pending health crisis.

Sentinel Defined

A sentinel is a guard, whose duties can range from watching or observing, preventing entry and informing. For uniformed services, sentinels can be:

§ peacekeepers on an observation mission;

§ guards posted to borders of countries to prevent smuggling or the entry of illegal immigrants;

§ observers or “look outs” in armed conflict to warn of enemy movements or operations.

Directions for Facilitated Discussion Exercise

1) Ask participants to identify steps uniformed service personnel can take to identify situations that may place a community or area at increased risk for HIV/STIs; write their responses on newsprint or writing board.

2) Ask participants to discuss ways in which uniformed service personnel can warn about increased risk for HIV/STIs and who they should alert; write their responses on newsprint or writing board.

3) Review with participants the following points after the discussion:

Uniformed service personnel can take the steps of observing, listening and talking to identify developing problems that could lead to increased risk for a community/region for HIV/STIs:

§ Observe people, both civilians and uniformed service personnel. Are more people going to sexual or reproductive health clinics and military medical clinics?

§ Listen to what people are saying in the community, on the street, in the barracks – are they talking about themselves or their friends getting infected with STIs?

§ Talk to health care providers, community social workers and police. Ask them if they see an increase in people experiencing STIs? Ask them about related issues - are there more rapes occurring? Are there more families experiencing violence and being broken apart? Are people losing their jobs? Is the crime rate rising for theft? Is the community experiencing any food shortages?

Once a potential or real problem is discovered, uniformed service personnel need to:

§ Quickly inform through their immediate chain of command.

§ Notify public health institutions – government offices, major hospitals and clinics.

§ Notify humanitarian/relief offices in the area.

Exercise Wrap Up

Instructor Note: Conclude the discussion by asking participants for any final thoughts or comments.

VI. Alcohol and Drugs, Sexual Activity and HIV/STIs

A. Alcohol and Other Drugs Effects and Their Relationship To Behaviours That Put You At Risk For HIV/STIs

Instructor Note: This interactive presentation addresses the effects alcohol and other drugs can have on sexual decision-making and how this relates to HIV/STI prevention. Use “Alcohol, Drugs and HIV” slide during the presentation. Encourage questions and discussion throughout the presentation.

The Effects of Alcohol and Other Drugs

Instructor Note: Emphasize to participants:

§ The use of alcohol and other drugs can impair thinking and judgment. When people are under the influence of drugs or alcohol, they sometimes take risks they would not otherwise take. These can include doing things that may place them at risk for STIs, including HIV infection, such as having sex without using a latex condom or sharing needles and syringes. People may take HIV/STI-related risks when using alcohol or other drugs. Even just one incident of having sex without using a condom or sharing needles with a partner infected with an STI or HIV may lead to infection.

§ Alcohol and other drugs can impair thinking and judgment in other situations as well. When people decide to get a tattoo while they are under the influence of drugs or alcohol, they may take risks they otherwise would not take. For example, not checking to make sure the needles used for the tattoo are sterile or deciding to risk it if they are unsterile. Unsterile needles can transmit HIV and other STIs i.e., hepatitis.

§ Remember that when you drink or take drugs, regardless of whether it is a lot or a little, this will interfere with your judgment about many things, including sex. Chances are you will be more likely to engage in unsafe sex (i.e., sexual activity without a condom) because you were drinking or using drugs. This includes drugs like marijuana, cocaine, crack cocaine, amyl nitrites (“poppers”) or ecstasy.

§ Give some thought to what you do. You would never drive a vehicle or go into a risky professional situation if you were drunk. Why not? Because you would not be able to think as clearly as you should, and you could be killed or injured.

§ Remember to take care of each other by using the “buddy system” (where friends agree to take care of and look out for each other), especially when you are in situations where your risk for getting infected with HIV may be high (for example, going out drinking, going on leave). If you do choose to put your self in a potentially risky situation (like going out drinking), make sure you bring a “buddy” with you who agrees not to drink so they can take care of you (drive you home safely, give you condoms so you can have protected sex).

B. How Can You Tell?

Instructor Note: This is a discussion that makes an analogy between safe weapons and safer sex. It addresses the misperception that one can “tell” if someone is likely to have an STI just by looking at them. In studies with United States military, many individuals felt they could tell if someone had an STI/HIV if they had dirty hair and blemished skin. Emphasize to participants that you can not tell someone’s HIV/STI status simply by looking at them! Ask participants to think about how they “size up” potential sexual partners at the end of the slide /overhead presentation. Emphasize that civilians are not the “enemy.” Uniformed service personnel and civilians alike are infected with HIV/STIs and it is not helpful to have an “us” versus “them” mentality; we (meaning both uniformed service personnel and civilians) are all in this together and together we can work on developing and maintaining safer behaviours.

Is this weapon loaded or unloaded? Using the training you have received in weapon safety, what must you assume? Would you take this weapon and point it at your head and pull the trigger? The point is that you would not place yourself at risk with this weapon by not thoroughly checking it out, making sure it is safe.

The same safety issues hold true for people, especially strangers, when you are “sizing up” a potential sexual partner. You can't tell by looking at them if they are carriers of STIs or the AIDS virus. What about these couples? Can you tell who among them might have an STI or is HIV positive?

C. HIV/STI Butterfly

Instructor Note: The next few slides /overheads are the HIV/STI butterfly. The butterfly consists of a series of seven slides/overheads and shows how a person really doesn't have sex with just one person, but with every person that person ever had sex with before. Tailor the scenario to fit the group you are presenting to.

To demonstrate how STIs, including HIV, are transmitted from one person to another let's imagine the following situation:

Imagine that you're at a bar. You're out with some of your friends from your unit. It was a difficult week at work and you and your friends just want to relax and have a good time. In fact, you get a jump-start by having a few drinks in your living quarters prior to setting out on the town. You're sitting there when a group of beautiful young women come into the bar. You and your friends start talking to them and before you know it you're all coupled off. You start talking and dancing with one of these lovely young women and eventually decide to leave the bar with her. You go with her to her home and as things work out, decide to have sex. Because you weren't planning for this to happen, you didn't grab a condom on the way out of your home. But you think to yourself “just this one time” nothing can happen. Besides, she's so fine she can't possibly have anything. So, you have sex without using condoms. As you lay in bed you think what a romantic evening it has been ... just the two of you. But, let's imagine for a second that your new friend had made an exception and had unprotected sex “just this one time” at least twice before.

What your new friend didn't know was that the guy she picked up from the bar two months ago had gotten drunk at a party and had sex with a total stranger “just once.” She didn't know that on another occasion he had made an exception “just this one time” and had unprotected sex with someone he had been dating for only a week. She didn't know that the other guy she had unprotected sex with had made an exception “just this one time” with at least two different sex partners.

Each of these people had also put themselves at risk “just this one time” at least twice before.

And imagine if their sexual partners made exceptions and had unprotected sex "just this one time" at least twice before. Now let's think about who's in the bed ... you think it is just the two of you ... there are at least thirty people in bed with you and your beautiful new friend and any one of them could have an STI. The thing of it is, you don't know which one. It could be anyone ...

Now let's take a look at you and your other sexual partners.

Before, you thought it was just you and your new friend having a romantic evening. Now, in fact, there are at least sixty people in bed with you.

Think about if this woman was a commercial sex worker (prostitute). How big would the bed have to be to hold all the people you were having unprotected sex with? Could be as much as a battalion! Think this is an exaggeration? Any time two people on the butterfly have unprotected sex, you are potentially at risk for getting an STI, including HIV. What if one of those red people on your side had herpes? Or if one of the purple people had HIV? It's that easy for you to get HIV or other STIs too.

This slide shows how one person on the butterfly can end up infected with HIV or an STI.

D. What Would You Do If?

Instructor Note: This exercise is intended to help participants assimilate the information presented in this section, by participating in an exercise to learn about their potential HIV status and discussing how they would react to the news that they were either HIV positive or HIV negative.

Directions for Exercise:

1) Prepare small pieces of paper folded in half for the number of participants in your session. On half of the slips of paper, write “HIV positive.” On the other half of the slips of paper, write “HIV negative.”

2) Hand out the slips of paper to participants instructing them not to open them until you tell them to do so.

3) Take them through the following scenario: You are getting ready to come home from a remote posting on the border of your country or from a peacekeeping mission and you are really looking forward to getting back to normal life and seeing your family. It’s been a hard mission and you are ready to go home. Before leaving, each of you will be tested for HIV. What is in the folded slips of paper you have is the results of your HIV test.

4) Instruct participants to now open their slips of paper and lead a discussion about how they feel about: 1) learning their HIV status; 2) how they think it will affect their lives; 3) how they think it will affect the lives of their families and their community. Place a blank sheet of newsprint for each of these areas on the wall, or write on a writing board, participant’s responses.

5) Close the exercise by asking for any additional comments and emphasize the following points:

§ Alcohol and drugs can impair thinking and judgment and place a person at risk for getting infected with HIV and other STIs.

§ Unsterile drug injection equipment and tattoo needles can place a person at risk for HIV/STIs.

§ When you have sex with one person, you are also having sex with every other person you and your partner ever had sex with. It is critical to always use condoms correctly every time you have vaginal, oral or anal sex.

§ It is not possible to tell if someone is infected with HIV or another STI just by looking at them. Many HIV positive people look and feel healthy for years.

§ We are all at risk for HIV.

VII. Problem Solving Scenarios for HIV Prevention in Crisis Settings

Instructor Note: This exercise gives participants an opportunity to put the knowledge and skills they’ve acquired in the course to potential real-life situations. Participants will be presented with scenarios where they will make choices and develop strategies with the ultimate goal of preventing getting infected with STIs, including HIV. Encourage participants to draw on their experiences as uniformed service personnel. This exercise may be challenging to participants because it may be very different from the type of training they are accustomed to. Let the group know before you do the exercise that this may be difficult for them, but emphasize they will learn important skills and ideas from this discussion. Be sure to tailor the discussion to best meet your audience’s needs, taking into account cultural issues. Tailor the small group discussion scenarios to your audience as well.

A. Dyad or Small Group Practice

Scenarios will be developed to enable participants to put into practice what they’ve learned in Part II of Module 7.

Scenarios will cover problem-solving exercises in the following areas:

§ sensitising participants to needs of special populations

§ conveying the importance of observation i.e., what you can do to assess a specific situation

§ conveying the importance of being a part of a community/area in conflict as an active change agent i.e., how you can promote safety in an area that you will be stationed in for an extended period of time, particularly when normal rules of conduct do not apply and it is not always possible to identify the “enemy”

§ becoming a leader and peer educator in your community when you return home from a conflict/crisis situation

Directions for Exercise

1) Have participants work in small groups or have them form pairs of two (dyads).

2) If dyads are formed, one person will need to volunteer as a notetaker. If small groups are formed, the group will need both a facilitator and a notetaker. Give each dyad or small group newsprint and writing materials. Give each dyad or facilitator in the small group a “Problem Solving Scenarios for HIV Prevention in Crisis Settings” exercise instruction sheet.

3) Give each dyad or small group a scenario. Be sure to distribute them evenly. Ask participants to review and discuss their scenario and develop responses/strategies to it. Each dyad or small group notetaker should write down the responses/strategies developed on paper or on newsprint (which they can use for their presentation to the larger group).

B. Large Group Summary

Directions for Exercise

2) Discuss any questions or concerns of participants.

3) To wrap up the exercise, highlight key points identified by participants.

VIII. Part II Summary and Conclusions

The instructor should thank participants for their participation in this part of the training program. Reinforce the importance of their mission and the need for them to protect their health and the health of their families.

Module 7, Part II: Problem Solving Scenarios

for HIV Prevention in Crisis Settings

Exercise Instruction Sheet

Directions for Small Group Discussion

1) The facilitator identifies the notetaker in their group and makes sure they write down responses and strategies to their scenario on newsprint.

2) Distribute the scenario to your group and have them read it.

3) Lead a discussion with your group and get them to talk about the scenario and develop responses and strategies to it.

4) Agree on a presenter, or have the entire group present, when you get back together in a large group with the instructor.