Preventing and Coping with HIV/AIDS in Post Conflict Societies:  Gender- Based Lessons from Sub-Saharan Africa

Symposium on:

Preventing and Coping with HIV/AIDS

In Post-Conflict Societies:

Gender-Based Lessons from Sub-Saharan Africa

Hosted by:

Tulane University Payson Center for

International Development and Technology Transfer

African Centre for the Constructive Resolution of Disputes (ACCORD)

Sponsored by:

United States Agency for International Development

In Association With:

Linking Complex Emergency Response and Transition Initiative (CERTI)

International Centre for Migration and Health - Geneva

World Bank – Pretoria

FINAL REPORT

Prepared for the

United States Agency for International Development (USAID)

Bureau for Africa (AFR)

Office of Sustainable Development (SD)

Crisis, Mitigation and Recovery Division (CMR)

By

Payson Conflict Study Group

May 2001

TABLE OF CONTENTS

EXECUTIVE SUMMARY

There is an urgent need to address the formidable threats to human security posed by the twin crises of violent conflict and HIV/AIDS in Sub-Saharan Africa (SSA). It is now understood that conflict and HIV/AIDS can reinforce one another by deepening the conditions that breed violence and disease. Throughout, vulnerable populations, such as women, suffer the most.

There have been important gains made in preventing and coping with HIV/AIDS in some areas, and a rich body of research and lessons from which to learn. Yet, there are also gaps in knowledge and practice, and one of which is limited understanding the effective approaches to preventing and coping with HIV/AIDS in post-conflict environments. There are, however, many initiatives. Across Africa, women especially are engaged in efforts to prevent and cope with HIV/AIDS. Too often their voices are not heard, and their lessons not learned by others. The Durban symposium was designed to provide a forum for African practitioners to share and build upon their rich and complex personal and professional experiences working on HIV/AIDS issues amongst conflict-affected populations, culminating in a consensus declaration. Participants also authored narratives to further share their experiences and insight.

Several common themes emerged from the discussion the African practitioners with diverse backgrounds assembled in Durban. These include:

DURBAN DECLARATION 2001:

Preventing and Coping with HIV/AIDS in Post Conflict Societies: Gender-Based Lessons from Sub-Saharan Africa

WHEREAS Sub-Saharan Africa is home to 630 million people of diverse racial and ethnic groups with a long and proud history and culture and has one of the richest natural resource bases in the world, with potential to be one of the most prosperous regions, nevertheless:

1. The twin scourges of violent conflict and HIV/AIDS have mutually reinforced each other though a multiplicity of mechanisms including large-scale population dislocation, the destruction of the public health infrastructure and the weakening of governance and economy. These twin scourges are destroying families, communities, nations and the African continent as a whole.

2. More than 50% of the world’s active violent internal and regional conflicts are in Africa. These conflicts have directly or indirectly affected over 75% percent of the region’s countries and populations, conscripted over 300,000 child soldiers, displaced over 30 million people from their homes, caused the deaths of over one million people, destroyed social and economic infrastructure, damaged the environment, weakened institutions of governance and generally retarded equitable, sustained and sustainable development.

3. More than 75% of the world’s HIV/AIDS cases are found in Africa. More than 11 million Africans have succumbed to AIDS over the past decade and the social and economic consequences are profound.

4. Gender roles play a crucial role in both the evolution of the problem and in the way forward to solutions. Women are disproportionately affected by the physical and psychological consequences of conflict and HIV.

5. Poverty is a key contributing factor to the spread of HIV/AIDS.

6. While there is recognition of these problems, and resources have been devoted to their solutions, current approaches are inadequate in both magnitude and scope. HIV, conflict and gender roles crosscut all development concerns and should be mainstreamed into all sectors.

7. Current financial resources are also inadequate to address the scope and magnitude of these complex social problems.

Noting that throughout the continent, every single day, women and men are actively preventing and coping with HIV/AIDS, conflict, and gender-based violence and that there are particularly remarkable lessons to be learned from African women who through a series of grass-roots efforts have evolved unique approaches towards these challenges;

Further noting that, there are growing networks, initiatives, and partnerships to address these intertwined challenges in Africa and that these efforts, already generating momentum towards creative solutions, need to be recognized and supported;

Now therefore, we the undersigned African members of the international development and health community who assembled in Durban South Africa and deliberated for three full days, at the invitation of the African Centre for the Constructive Resolution of Disputes (ACCORD) and the Tulane University Payson Center for International Development and Technology Transfer and sponsored by the United States Agency for International Development (USAID) in association with the Linking Complex Emergency Response and Transition Initiative (CERTI), the International Centre for Migration and Health (ICMH-Geneva) and the World Bank (Pretoria),

Taking special account of the community, national and regional experience and lessons learned of African strategists and implementers of programs and projects, especially at the sub-national and community level, to cope with and combat HIV/AIDS in conflict affected countries;

Acknowledging that conflict, HIV/AIDS and gender inequalities are inextricably related and therefore solutions to these problems must take in to account this complex interrelationship which requires interdisciplinary and intersectoral approaches.

Request that national governments, national NGOs, and the international community, including all bilateral and multilateral donors and international NGOs, must revisit their policies, strategies and programs to fight the twin scourges of violent conflict and HIV-AIDS and achieve sustainable peace based on:

1. Mainstreaming interventions to address HIV/AIDS, conflict prevention, mitigation and resolution/reconciliation and women’s empowerment into all sectoral programs;

2. Empowering women as key actors and community mobilizers to both address both HIV/AIDS and conflict resolution/peace building. Empowerment requires action at the policy (including legal framework), strategy and program levels at local, subnational, national and international legal levels;

3. Devising a conceptual framework that:

4. Recognizing that conflict and HIV/AIDS will require behavioural change at the individual, institutional, community, national and international levels;

5. Necessitating that approaches must address the problems of stigma and shame, which are underlined by fear on the parts of both, infected and affected. There is also a need to promote self-esteem and healthy relationships and hope, including hope for a cure;

6. Including as a priority psychosocial care for those affected by conflict and HIV/AIDS, with special attention given to trauma management and reintegration into communities for ex-combatants, especially former child soldiers;

7. Giving special consideration to vulnerable groups such as women, children, young adults, people with disabilities, orphans, refugees and internally displaced persons, child soldiers and ex-combatants;

8. Requiring broad and strategic partnerships, including the military sector, women’s groups, civil society groups, spiritual institutions and the private sector;

9. Embracing the importance of regional and locally-tailored solutions that are based on the common principals of women’s empowerment, intersectoral approaches, analysis of the needs of vulnerable groups, gender analysis, and peace;

10. Promoting national, regional, and international networking, dialogue and cooperation;

11. Mainstreaming conflict, gender and HIV/AIDS strategies and programs in the broader post-conflict development and democracy and governance framework;

12. Enhancing present programmes in areas of care and support for people living with HIV/AIDS, particularly in making medical treatment affordable and accessible and providing services that alleviate their suffering and protect their human rights.

We therefore recommend that:

1. As conflict, HIV/AIDS and gender are now inextricably linked in Sub-Saharan Africa; all conflict programs must adequately address the issues of HIV/AIDS, poverty and gender.

2. The proceedings of this forum be widely disseminated to the practitioners and policy community, including donors, international organizations, Non-Governmental Organizations (NGOs), including religious organizations, and governmental sectors, including the military;

3. Practical tools be developed to support the programming approaches articulated above for addressing the problems of HIV/AIDS and conflict/crisis through gender-based strategies;

4. Donors increase resource levels in support of programs to address these critical problems through a process of regular consultation that facilitates strategic partnerships, community ownership and mutual accountability;

5. There be increased donor coordination and programming and streamlined requirements;

6. All of the actors involved in addressing these problems utilize intersectoral approaches that address the complex inter-relationship between conflict, HIV/AIDS, poverty and gender roles;

7. Mechanisms be put in place to build a learning network of professionals and workers in order to improve the quality and efficacy of programs as well as to increase advocacy for these issues;

8. Empowering women and addressing the root causes of their vulnerability is key to preventing and coping with HIV/AIDS.

In witness, whereof, we the undersigned, being duly representative of African members of the international development and health community have assented to the declaration here in, concluded in Durban, Republic of South Africa on the 28^th day of March 2001.

REPORT OF THE SYMPOSIUM ON

“PREVENTING AND COPING WITH HIV/AIDS IN POST CONFLICT SOCIETIES: GENDER-BASED LESSONS FROM SUB-SAHARAN AFRICA”

“The HIV epidemic rages in situations where power is exercised without regard of others, whether that power be economic, social, sexual, psychological or the power of force. It spreads where there is a disregard for life, an intolerance of difference, a devaluing of women, a lack of a will to live, a breakdown of community values, violence and conflict. (…) What is required to respond to it is a way of perceiving and constructing social reality in its interconnectedness.”

Ever more Effective Responses to HIV/AIDS Discussion: HIV in Situations of Conflict¹

INTRODUCTION

There is an urgent need to develop an integrated approach to address the formidable threats to human security posed by the twin crises of violent conflict and HIV/AIDS in Sub-Saharan Africa (SSA). There is a rich and growing body of research on HIV/AIDS prevention/mitigation in humanitarian emergencies, particularly in refugee camp settings. Resources on best practices to guide policy and programming for addressing HIV/AIDS in post-conflict environments and other crisis/transition settings are less available. There are, however, many initiatives. All across Africa, people from all walks of life, women especially, are engaged in formal and informal initiatives that not only confront the scourge of HIV/AIDS in the context of crisis and reconstruction, but also contribute to environments that enhance human security in all its dimensions.

To tap on this experience, Tulane University’s Payson Center for International Development and Technology Transfer and the African Center for the Constructive Resolution of Disputes (ACCORD), in collaboration with USAID's Africa Bureau Conflict, Mitigation and Recovery Division organized the symposium “Preventing and Coping with HIV/AIDS in Post Conflict Situations: Gender-Based Lessons,” held March 26 – 28, 2001 in Durban, South Africa. Tulane University’s Linking Complex Emergency Response and Transition Initiative (CERTI), the International Centre for Migration and Health-Geneva (ICMH), and World Bank – Pretoria also extended support. This report briefly outlines the background that led to this initiative and describes the principal findings of the symposium.

BACKGROUND

The number, and nature of violent conflicts and related complex emergencies, coupled with the HIV/AIDS pandemic are now setting development in SSA back and negating many of the gains achieved over the last 50 years. Half of all the world’s conflicts in 1999 were located in SSA, involving two-thirds of the countries in the region. Six high-intensity conflicts (causing over a thousand deaths per year), were still raging there in late 2000. Africa is also the part of the globe that has been hardest hit by AIDS. Over 25 million people, or nearly 70% of the world’s infections, and 90% of deaths from AIDS are to be found in a region that is home to just 10% of the world’s population².

Although little cross-country epidemiological data is available, there is evidence to suggest that conflicts increase the risk and impact of HIV/AIDS in several ways. Conflicts dislocate communities, create flows of refugees and internally displaced persons (IDPs), and seriously disrupt family life. They also bring soldiers and fighters into contact with civilians in situations where women and youths are highly vulnerable to sexual violence and sexual exploitation, and combatants, especially child soldiers, may have experienced intense traumas that make them particularly susceptible to violent and other high-risk behaviour. Breakdown of basic services and psycho-social stress compound the situation. The magnitude of these problems has prompted efforts among national and international actors to mainstream HIV/AIDS prevention and control into humanitarian response, developmental efforts, and post-conflict reconstruction.

Despite the persistence of violent conflict, it is important to recognize that in the past ten years, some intra-state and regional wars have come to an end in Africa, and progress towards transitions have been made in others. Some post-conflict countries, like Mozambique, have gone on to obtain sustained economic growth and others, such as Uganda, are considered to have achieved some success in preventing growth of HIV rates. Others have not. So what are the factors driving the pandemic in post-conflict countries? What interventions make a difference in such countries? What conditions favor action, and what hinders success in building the capacity of people affected by conflict, to prevent HIV infections and provide essential services to those who are directly affected by AIDS? Most importantly, what are the special considerations that must be taken into account in designing HIV-AIDS programs in post-conflict countries and communities that are confronted with problems such as demobilization of ex-combatants and single-parent families mostly headed by women? These were some of the principal questions that were addressed at the Durban symposium.

Why Gender-Based Lessons?

The importance of exploring gender-sensitive approaches to the AIDS pandemic is widely recognized, for in SSA, AIDS especially impacts women. Over 50% of new HIV infections in SSA occur in women; their vulnerability is compounded by lack of control over their own sexual health. At the same time, women also carry the main burden of care of family members with HIV/AIDS. In conflict and post-conflict contexts, the burdens on women escalate, at the same time that their coping capacities are diminished. For these reasons, it is especially important that any HIV/AIDS prevention or mitigation approach for conflict-affected populations address not only the clinical health aspects of the disease, but the underlying social and economic determinants of vulnerability as well, of which gender is among the most significant.

There is also a need to understand better the impact of conflict and HIV/AIDs on African men, as they too are suffering and dying. Countries with a population “youth bulge,” especially concentrations of young males who are out of school also have higher risk of violent political conflict. Anecdotal accounts suggest that during high intensity conflicts boys and men are vulnerable to sexual violence as much as women. Furthermore, overall rates of infection among the military --traditionally an almost exclusive male domain -- is significantly above the average rate of the general population. The needs of these young men are too often overlooked, to the detriment and danger of themselves and their communities. Sometimes they are even demonized, rather than having their needs respected or their suffering acknowledged.

SYMPOSIUM OBJECTIVES

The main objectives of the symposium were:

1. To provide an overview of gender-sensitive practices and knowledge in preventing and coping with HIV/AIDS in the aftermath of violent conflict.

2. To expand this knowledge base by sharing and disseminating the experiences of Africans who are confronting these issues in their countries.

3. To work towards consensus on strategies, programs and policies for practitioners, policymakers and donors.
   

SELECTION OF PARTICIPANTS

A “call for participants” was drafted and broadcast via email and fax to organizations and individuals in SSA actively involved in HIV/AIDS prevention, peace-building, and gender issues. There was an enthusiastic response, and organizers received a large number of outstanding applications. The symposium was planned for a modest number of participants, and organizers considered geographic diversity, professional expertise, diversity in professions and backgrounds, and writing skills of the applicants. Twenty-five selected participants from twelve countries attended. The countries were Ethiopia, Rwanda, DRC, South Africa, Tanzania, Zambia, Uganda, Namibia, Burundi, Mozambique, Congo-Brazzaville, and Kenya (see list of participants in the appendix). In addition, background papers were commissioned from two resource persons, Dr. Manuel Carballo of the International Centre for Migration and Health (ICMH) and Dr. Millicent Malaza-Debose of Save Africa. International observers from USAID, the International Organization of Migration (IOM), and International Committee of the Red Cross (ICRC) were also present.

OVERVIEW OF THE SYMPOSIUM

Too often, the voices of Africans working at the forefront of issues they are facing in their countries are not heard, and their lessons are not learned by others. Thus the Durban symposium agenda was designed to provide a forum for African practitioners to share and build upon their rich and complex personal and professional experiences working on HIV/AIDS issues amongst conflict-affected populations.

With the exception of two background papers presented by the two resource persons, all the speakers were drawn from the pool African participants. In addition to formal presentations, substantial time was devoted to open discussions as well as small group work to prioritize strategies and issues on a regional basis. Throughout, there was an emphasis on identifying practical strategies and approaches. The organizers also encouraged the participants to meet in informal groups to discuss questions and themes of common interest; several such gatherings took place during evenings and meals.

Each of the participants was asked to submit a narrative prior to the symposium. These narratives were compiled and distributed at the symposium, and are also available online (http://www.certi.org/news_events/prev_coping_w_aids/papers_and_narrativesi.htm). These narratives represent a remarkable and diverse collection of the experiences of African practitioners, in their own voices, who are working at the grassroots, who are working to meet the challenges of HIV/AIDS, conflict, and the empowerment of women.

PRINCIPLES, PRACTICES AND LESSONS LEARNED: KEY THEMES OF THE DURBAN SYMPOSIUM

A few key issues emerged that were emphasized by participants throughout the symposium. Despite tremendous differences in the backgrounds of the participants and countries they work in, these common themes were returned to time and again. For ease of analysis and to draw the appropriate policy conclusions we have presented them under three main areas:

1. Strategic Frameworks and Approaches for HIV/AIDS Programs in Post Conflict Societies

2. Developing HIV/AIDS Policies in Post Conflict Societies

3. Implementation of HIV/AIDS Programmes in Post Conflict Societies

Under each of these three headings we have identified one or more general principles that may be taken into account in HIV/AIDS programs in post-conflict settings, cited “lessons learned” from recent African experience, and where appropriate briefly mentioned an illustrative practice from the continent to underline the validity of the principle. It is the firm and sincere conviction of the participants, as expressed in the “Durban Declaration” that African governments, national and international PVOs and the donor community give serious consideration to the principles and lessons learned outlined in this report when designing future HIV-AIDS programs for post-conflict societies and communities.

1. Strategic Frameworks and Approaches for HIV/AIDS Programs in Post Conflict Societies: Principles, Lessons Learned, and Practices

Lesson Learned: Focusing on medical aspects of the disease without addressing the social, political, and economic context in which it is spread and coped with may be more “comfortable,” but is ultimately inadequate. A program that teaches about safe sex without addressing the cultural context in which infection is spread runs the risk of being irrelevant under any circumstances. In post-conflict environments, it is especially important to address the underlying determinants of high-risk behaviours.

Lesson Learned: As participant Mary Balikungeri of Rwanda commented in her essay, “The only response to the HIV epidemic in post conflict societies” is to address the disease “holistically due to social realities and its interconnectedness if we are to achieve a lasting peace.”

Practice: A good example of this principle in action is an initiative in Zimbabwe which seeks to reduce transmission of the disease through promoting healthy interpersonal relationships. Participants agreed that such an approach represents an excellent model; unfortunately, as many do not consider such issues as “development” or “health”, there is little support available.

Practice: Participant Bogaletch Gebre (Ethiopia) wrote about her program working with demobilized Ethiopian soldiers and their families, “The ex-soldiers had joined the army mainly for the reasons of economic survival. Thus, trying to introduce psycho-social health and HIV/AIDS education without considering means for economic survival of the demobilized population would be unrealistic and abstract to them, and a futile exercise on the part of any organization that is trying to improve their health risks.”

Lesson Learned: Empowering women and addressing the root causes of their vulnerability is key to preventing and coping with HIV/AIDS. Just as educating women is a foundation for sustainable development, empowering them represents a vital step for supporting the capacity of African societies to prevent and cope with the disease.

Lesson Learned: In times of conflict and crisis, women and girls are particularly vulnerable. They often lose means of economic and social protection, leaving them extraordinarily vulnerable at the same time that burdens of caring for children and the sick are magnified.

Practice: In DRC and elsewhere in Africa, having to shoulder a disproportionate burden of the disease has galvanized women into action, especially through the creation of new women’s civil society organizations, especially in urban areas. These organizations should be embraced and nurtured, and their reach expanded to rural women.

Practice: In an Ethiopian program to prevent HIV/AIDS infection among demobilized soldiers, the Kembatta Women’s Self-Help Center developed separate but complementary activities targeted at both the ex-combatants and their partners. Similarly, HIV/AIDS prevention efforts for the Namibian armed forces have also developed programs aimed at their wives and other sexual partners. Participants agreed that this was the only appropriate approach.

Practice: Mozambican participant Guilhermina Langa Milice observed that it was more difficult to recruit male peer educators in her country. She noted that there is little formal study as to why this was so, or how men could more effectively be reached.

2. Developing HIV/AIDS Policies in Post Conflict Societies: Principles, Lessons Learned, and Practices

Lesson Learned: The dearth of networking and horizontal communication has contributed to failed projects, repetition of mistakes, and lost opportunities to replicate success. In post-conflict environments, practitioners are often isolated, and benefit greatly from opportunities to collaborate with peers within their own countries and across the continent.

Lesson Learned: Government decentralization creates opportunities for broader partnership and dialogue with grassroots NGOs, who do not have access to top-level decision-makers. However, care should be taken to ensure that capacity at lower levels is sufficient to handle additional responsibilities. In post-conflict environments, the level of local capacity often varies dramatically within a country, making decentralization and capacity-building especially challenging. Extra efforts must be taken to work in concert with existing civil society and (informal) leadership structures around issues of concern to the public, such as health and peace.

Practice: While the potential of information technology is increasingly being realized, it is not accessible to many Africans. As a result the “digital divide” is quite stark, especially in conflict-affected areas. Some of the participants at this conference do not even have email; others have email but no web access. Greater care must be made to ensure that those with little or no access to information technology are not “left out.”

Practice: Participants agreed that associations and networks for African practitioners, such as the Women as Partners for Peace in Africa (WOPPA), are very valuable in breaking down the isolation that many practitioners in post-conflict environments experience and in serving as a resource to support more effective initiatives.

Lesson Learned: Just as NGOs must do their “homework” about what donors are willing/able to fund, donors should be investigating what NGOs perceive the greatest needs and opportunities to be. The need for improved coordination and communication is particularly important in a post-conflict setting where, in the effort to rapidly move forward, rumors and assumptions are not considered as critically as they should be.

Lesson Learned: In post-conflict environments, lack of adequate coordination and communication may be exacerbated by confusion about who non-governmental stakeholders are or misperception that civil society is too weak or nascent to effectively participate in policy and programming. These issues are often exacerbated in a context of a rapid influx of new international agencies and “experts” whose actions frequently contribute to marginalization of indigenous civil society participation and leadership.

Lesson Learned: One of the main obstacles to implementing integrated programs in post-conflict environments is that donors prefer funding programmes within narrow parameters. What is necessary, however, is that NGOs have more flexibility to address the complex social context in which the disease is spread and coped with. It is also frustrating that some of the most effective approaches to confronting the disease, such as confronting stigmatization or promoting healthy interpersonal relationships, are not considered to be “development” or “health” and so are routinely under-funded.

Lesson Learned: There is an urgent need for donors to streamline and coordinate their reporting requirements. Tremendous amounts of time and energy are wasted on writing multiple reports to different donors on the same project/organization. Identical, or at least similar, reporting criteria would be a tremendous boost to cost-effectiveness. Participants were far more concerned with donors coordinating their reporting requirements than with coordinating their policies!

Lesson Learned: Governments and international donors are unwilling to provide adequate funds for administration and salaries. Lack of sufficient administrative and paid program staff takes its toll on the overall success of the programs in post-conflict settings where necessary skills are scarce.

Practice: Uganda is an example of the gap between “good” policies and “good” practice; participants from that country asserted that the policies are donor-driven, with little ownership by, or input from, the grassroots. This has led to serious disconnect between the stated policies and the actual practices on the ground. The pattern in Uganda is that the central government and international donors dialogue, with some consultation with a “second tier” of civil society and junior government officials. It is this second tier that receives money to implement projects, with a “third tier” – the grassroots – as the beneficiaries. However, the intended beneficiaries are largely excluded from the decision-making process, resulting in lack of ownership of the process and inappropriate initiatives. Instead, all stakeholders should be involved in the dialogue from the very beginning, with more emphasis on transparency and accountability throughout the process.

Lesson Learned: Too often, the efforts and organizations of African practitioners are “studied” by outsiders, but they are not involved in the process, nor do they benefit from the results of the research.

Lesson Learned: With a rapid influx of foreign assistance during and in the aftermath of a humanitarian emergency, indigenous leadership, especially civil society, may be pushed aside in favor of international “experts.” Results include loss of local momentum, lack of “ownership” over the reconstruction process, inappropriate approaches, and unsustainable initiatives.

Lesson Learned: Derivation of best practices and lessons learned needs to result from a more participatory process that can help those at the grassroots refine their own efforts. They should be subjects, not objects, of evaluation and research.

3. Implementation of HIV/AIDS Programmes in Post Conflict Societies: Principles, Lessons Learned, and Practices

Lesson Learned: Approaches that are community-based and culturally appropriate, and implemented by those who are sincere, thoughtful, and committed are more successful. Technical capacity is necessary, but not sufficient. Qualities such as compassion and dedication are as vital as skills and finances. This was one of the most often-repeated themes of the symposium.

Lesson Leaned: A common theme in the participants’ writing was that the key to a project’s success was a committed, dedicated, and sensitive team. With grassroots work, the human character of staff was seen as more important than their expertise or qualifications.

Practice: Yene Assegid (Ethiopia) wrote, “One of the main factors contributing to the project success was not just the qualification of each team member but the human character of each team member. A college degree was not enough per se. Most important was rather what each team member had to contribute as an individual to the project.” Remarks similar to these are echoed in many of the participants’ narratives.

Lesson Learned: Mental health is not a luxury: it constitutes a foundation for healthy families and communities. Particularly in post-conflict contexts, addressing the needs of trauma survivors is an essential building block to a transition to sustainable peace and behaviour change to prevent and cope with HIV/AIDS.

Lesson learned: Addressing the stigma attached to AIDS makes it easier to effectively confront the spread and impacts of the disease. Stigma, fear, and prejudice may be particularly strong in conflict-affected societies – impeding reconciliation as well as HIV/AIDS prevention/management.

Lesson learned: Role models and peer counselors can play an enormously effective role in HIV/AIDS prevention, and can be particularly in a context of social stress and for individuals who have lost some or all of their family in violent conflict. For example, “ordinary” people going public about their HIV infections demonstrate, especially to young people, that everyone is vulnerable, even those who don’t look sick, and serve as a beacon of hope to those hiding their infection. Mutual support associations for populations such as people living with AIDS and sexual assault survivors can play an invaluable role to support other affected people and enable them to live productive lives, as well as to educate the public. For orphans or survivors of violence, such associations often become a surrogate family for those who would otherwise be very much alone in their suffering.

Practice: In Ethiopia, there are no comprehensive efforts to address the psychological needs of soldiers who are being demobilized, although many are survivors of intense trauma, the impact of which makes them highly vulnerable to high-risk and violent behaviours.

Practice: In East Africa, churches can be a powerful base for psychosocial programs. Reaching out to churches and other religious institutions can be a very effective way to deliver community-based services and confront cultural issues related to trauma, such as violence against women or reintegrating former child soldiers.

Lesson Learned: Funding for health programs is often too restrictive in scope to develop integrated approaches.

Lesson Learned: Peace, war, and culture are not just backgrounds within which health programs are (or are not) carried out; health programs themselves can influence social contexts.

Lesson Learned: Health professionals can and should be trained in conflict resolution, human rights, ethics, and women’s issues to better equip them to address these crucial issues that they encounter in their daily work.

Practice: It was difficult to “build upon” one effort for sex workers in Ethiopia because funds were available only for narrowly-defined health programs – despite the fact that related efforts also directly impacted the health of the women.

Practice: Rwanda’s Polyclinic of Hope is a remarkable example of a program that evolved from mental health into many other fields, including peacebuilding, women’s empowerment, and economic opportunity. MAP International’s Rwanda Women’s Healing and Reconciliation programme has similarly pursued twin goals of trauma healing and peacebuilding. Rwandan participants agreed that there could be no peace without psychological healing.

Practice: In the Lake Victoria zone of Tanzania, an evaluation of one HIV/AIDS programme found that among the most important factors behind success was the focus on conflict resolution on the community and family level – not just the political level. As peace became the social responsibility of everyone, individuals became less likely to replay their experiences in conflict with further violence.

Practice: Participant Yene Assegid (Ethiopia) wrote about her experience doing HIV/AIDS prevention among Ethiopian sex workers: “The counseling and income generating aspect of the programme actually empowered the women…The income generating programme in particular allowed the woman more strength in negotiating the use of condoms.”

Practice: Donors do not always have leeway to redirect funds due to earmarks.

Lesson Learned: Too often, vulnerable groups are underserved – or even dismissed as “lost causes.” This disregard is unacceptable and dangerous to the health – physical and otherwise – of affected societies. For example, HIV/AIDS programs are often pulled out of areas affected by conflict. Instead, HIV/AIDS interventions that are appropriate to crisis settings should be developed and implemented.

Lesson Learned: Although there are many widely-acknowledged “best practices” for HIV/AIDS programs, there is less knowledge and research about how to best support efforts to prevent/cope with HIV/AIDS in post-conflict and transition environments.

Lesson Learned: People living with AIDS in Africa urgently require access to antiretroviral medications. Such medications are not only unaffordable, but many countries including post-conflict ones, lack the health service infrastructure to effectively administer them.

Lesson Learned: While there are successful examples from which to learn, strategies, resources and a commitment to truly confront the needs of orphans and internally displaced persons are lacking.

Lesson Learned: The design and management of refugee camps needs to be drastically modified, as their structures physical and otherwise compound vulnerability to HIV/AIDS, both by disempowering them, and by placing women at risk for sexual violence or coercion.

Lesson Learned: The role of poverty and other root causes of vulnerability to HIV/AIDS should be recognized. In post-conflict environments, economic desperation is a particularly crucial factor contributing to high-risk behaviour.

Practice: Some HIV/AIDS programs even contribute to denial and vulnerability of certain groups. For example, an Ethiopian condom advertisement on television features a “smart” man and a “loose” woman. The implication is that men must protect themselves from wanton women; HIV/AIDS does not affect respectable women. This is precisely the kind of assumption that needs to be challenged. This advertisement reinforces a very dangerous attitude.

CONCLUSION

The challenges posed by conflict, HIV/AIDS, and achieving gender equality in Africa are great, but African practitioners, working at the forefront of these issues, have a great many lessons to share with one another and with the international community. Although there is no “magic bullet” or easy solution to apply indiscriminately in all situations, qualities such as courage, compassion, and commitment are integral to successful programs, and these are traits that Africa is rich in. Common themes do emerge, however, from the diversity of experiences across the continent that can be applied to policies and programs concerning HIV/AIDS and conflict in Africa. One is that, sadly, many efforts are not working and that resources are inadequate in the face of an overwhelming crisis; participants also attributed inadequacies to the lack of consideration of the social contexts in which infection is spread and disease is coped with. Other themes include the necessity of respectful, transparent, and accountable dialogue between top-level and grassroots actors; the importance mental health; and the urgent need for integrated, multi-disciplinary efforts to confront complex social problems. Perhaps most of all is the call for empowering women, and partnering with men, to prevent and cope with HIV/AIDS in post-conflict societies by confronting the root causes of vulnerabilities.