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 7
HIV Prevention in Conflict and Crisis Settings: Purpose,
Goals and Objectives 17
Part I: HIV Prevention and Behaviour Change Issues 21
Part II: HIV Prevention in Crisis Settings 43
Appendix A: Instructor’s Notes 65
Appendix B: Slides/Overheads to Accompany Module7 89
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 STD/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
Throughout the programme, 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 infection (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 programme 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 programme will help you 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.
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 programme 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 programme should not be discussed with those who are not participating in the programme. 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 all participants 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.
Module 7: HIV Prevention in Conflict and Crisis Settings
Purpose: To help men and women engaged in uniformed service work to learn about HIV, AIDS and STIs and how to promote good health.
Goals: 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 define the particular threat of HIV/STIs in pre- and post-crisis situations for uniformed service personnel (i.e., military, peacekeepers, police) as well as local civilian populations.
(2) To explore the relationship between sexual activity, STIs and HIV in crisis situations and their immediate aftermath.
(3) To increase participant awareness of the duty to protect themselves and civilian populations, not just from immediate harm, but also the threat of HIV/STIs
(4) 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.
(5) 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.
(6) 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: 2-3 hours
Format: Information and skills building exercises, group discussions, and interactive slide presentations.
Materials: Items needed:
ü Flip chart 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 Cling wrap (used for food preparation)
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.
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.
HIV Prevention in Crisis Settings
I. Introduction
Part II of this session will include:
1) information about crisis settings and the role of the uniformed services in crisis;
2) information about what happens to civilians in crisis settings;
3) information on being an early warning sentinel for HIV/STIs in crisis settings;
4) review of professional conduct guidelines for uniformed service personnel;
5) information on the relationship between alcohol, drugs, sexual activity and HIV/STIs;
6) 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 flip chart paper.
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.
§ Peace makers. 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.
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 circumstances use alcohol and drugs to relieve stress, loneliness and 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.
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 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. Women and girls are particularly at risk since coercive sex is likely to result in tears or other injuries to the genitals.
§ 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, abducted 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. When Ghana was in Sierra Leone and Liberia, a soldier could easily get sex from a woman for only a cup of rice to eat.
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 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 discuss 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 professional 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.
§ Uniformed service personnel are under significant levels of stress during a crisis on conflict situation including normal stress (like anxiety of having to fight, being deployed); traumatic stress (from witnessing atrocities like the killing of women and children); and cumulative stress (stress not just from the current crisis, but from all the crises a soldier might have been deployed for). Stress management is difficult in crisis situations, long stretches of boredom are often interspersed with short episodes of sheer terror.
Exercise Wrap Up
Instructor Note: Conclude the discussion by asking for any final thoughts or comments. Suggest that participants think back on this discussion when they find themselves working in crisis situations.
In summary, emphasize the following key issues for populations in crisis:
§ In crisis settings, both uniformed service personnel and civilians alike are at risk for infection with HIV and other STIs.
§ The potential for rape and sexual violence is higher in a crisis.
§ When sexual violence and abuse occurs, it can leave a life-long psychological impact on its victims.
§ HIV can be used as a weapon of war, forever changing the lives of its victims.
§ Children can be forced into becoming child soldiers, often they are orphaned or separated from their families.
§ The lack of income and basic needs (food and shelter) creates serious problems for civilians; individuals can be forced to turn to exchanging sex for money, food and shelter.
§ Alcohol and drugs are used to relieve stress, loneliness and trauma.
§ Lack of access to medical care, condoms and education cause more people to practice unsafe sex, making them vulnerable to HIV/STI infection.
§ Crisis affects not just civilian populations. Uniformed service personnel and relief workers sometimes cope with the stress by turning to alcohol and drugs. They can also engage in unsafe 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 should encourage discussion of these aspects and 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
Before we discuss general guidelines for professional conduct, 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 flip chart paper 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 flip chart paper 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: Emphasizeto 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 B.
§ 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, and cocaine.
§ 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. 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.
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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.
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What about these couples? Can you tell who among them might have an STI or is HIV positive?
To close this module and to provide a good moment to stimulate further discussion on these topics, make these statements and then see what the reaction of the participants is:
Here is an important thought that may help each of you better understand what the risks are when you have unsafe sex:
A person never has sex with just one other person, but with everyperson that other person ever had sex with before !!!
Evaluation
Instructors often overlook the value or carrying out an evaluation of a training course. Yet, this type of feedback is critical for instructors and will help improve future course content and an instructor’s training technique. Evaluation can be conducted using written forms and/or verbal discussion. Sample evaluation questions to ask are:
§ Were the training course objectives met?
§ What was your objective in taking this course? Did the course meet this objective?
§ Identify at least two topics covered in the course that you believe will be valuable to you. Explain why.
§ Identify the topics you regard as being of least value to you and explain why.
§ What topics, if any, need to be added?
§ What topics, if any, need to be covered in greater depth
§ What topics, if any, need to be dropped?
§ What three things were most helpful to you?
§ What was least helpful to you?
§ What improvements would you suggest for the course?
§ How would you rate the training environment?
§ How would you rate the instructor’s knowledge of the material and ability to maintain interest?
§ How would you rate the presentation of the course (excellent, good, fair, or poor)?
§ How would you rate the content of the course (excellent, good, fair, or poor)?