This project was made possible through Cooperative Agreement Number HRN-A-00-96-9006 between the US Agency for International Development and Tulane University

The Civil-Military Alliance to Combat HIV and AIDS A Collaborating Centre of the Joint United Nations Programme on HIV/AIDS (UNAIDS)

Goals:                       

• To educate participants about the kind of changes in behavior 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, AIDS and other STIs.                                               

(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 behaviors for HIV/STI transmission.

(6)         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.

(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/STIs

(9)         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:                    

4 hours; Part I is 2 hours and Part II is 2 hours

Format:                 

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

Materials:         

Items needed:

•       Flip chart or writing board
•       Tape
•       Slide or overhead projector and screen
•       Slide set for Module 7
•       “Strategies for HIV Prevention and Behavior Change Exercise Instruction Sheet” for Exercise IV.A.
•       “Strategies for HIV Prevention and Behavior Change Scenarios” for Exercise IV.A.
•       Male and female condoms
•       Cling wrap (used for food preparation)
•       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, STI information and HIV/STI prevention strategies.  Part II discusses HIV/STI prevention in crisis settings.

Part I: HIV Prevention and Behavior Change Issues

I.         Introduction

Part I of this session will include

1)         basic information about HIV and AIDS, the immune system and STIs;

2)         information about risk factors for HIV/STI transmission;

3)         information about correct condom usage;

4)         a skills building exercise on negotiating safer sex practices.

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

Instructor Note: This section has an exercise to discuss HIV/AIDS facts and myths, a summary presentation of HIV/AIDS facts along with information about STIs, statistics on the global picture of HIV infection, and a discussion of the impact HIV has on uniformed services.   Encourage participants to ask questions throughout the exercise, presentations and discussions.

A.       Facts Exercise: HIV and AIDS Myths and Facts

Instructor Note: This exercise provides an overview of HIV and AIDS facts; tailor your comments to the needs of the group, depending on the level of their knowledge about HIV and AIDS.

Directions for Exercise:

1)         Before the session, write each of the statements below on its own sheet of paper in large, easy-to-read letters (do not write Fact or Myth next to the statement).  You can add to or eliminate the statements depending on your audience.

2)         Tape two sheets of flip chart paper (one entitled “Facts”; the other “Myths”) on a wall where everyone can see them.  Tell participants that the group is going to do an exercise in which they will separate facts about HIV and AIDS from myths.  Go over what myth and fact mean with the participants.

3)         In turn, read each statement written on paper aloud, asking if it is a myth or a fact and calling for volunteers to give the answer.

4)         If the volunteer answers correctly, ask him/her to tape the sheet on the correct flip chart paper.

5)         Reinforce the correct answer with additional information.  If the participant does not answer correctly, acknowledge his or her effort and then give the right answer.

Instructor Note: If individual participation is or would be threatening to participants, you can run this as a group activity, asking the group to determine the answers.

Exercise Wrap Up

Instructor Note: Close this exercise by summarizing the following facts.  You can also use this information to explain incorrect or incomplete information offered by participants during the Myths and Facts exercise and to address participant’s questions and concerns.

AIDS Is Caused By:

H         =          human

I           =          immunodeficiency

V         =          virus

which is also referred to as the AIDS Virus.   HIV is an extremely small virus, you cannot see it with your eye.  It likes to be in dark, wet places like body fluids (blood, semen, vaginal fluid, breast milk).  It is a fragile virus – when exposed to the air it dies in seconds.  We will talk about how HIV gets into the body after we define AIDS.

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.  The immune system is 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, called immune cells that it needs to protect against infections.  HIV enters the body and acts like a patient sniper, hidden for as long as it takes to do its job to weaken the immune system.  Over time HIV kills more and more immune cells, the body's immune system becomes too weak to do its job and the person living with HIV becomes sick.

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.

Body fluids that can spread HIV are:

•          Semen                   
•          Vaginal fluid
•          Blood
•          Breast milk

HIV is spread: 

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

Vaginal sex means a man inserting his penis into a woman’s vagina.  Anal sex refers to a man putting his penis into the rectum, or anus, of a woman or a man.  Oral sex means sucking or licking of the genitals – a man can suck or lick a woman’s genitals or a man’s penis; a woman can suck or lick a man’s penis or a woman’s genitals.

 

Vaginal sex can let HIV in your body through any cuts or tears inside the vagina or on the penis.  HIV is contained in both semen and vaginal fluid, so a man can give HIV to a woman and a woman can pass HIV to a man.  When a man is aroused, his penis stretches.  Likewise, when a woman is aroused, her vagina stretches.  This stretching makes the membranes in the penis and vagina more porous and causes very tiny cuts and breaks that you cannot see. 

 

Anal sex can let HIV in your body through cuts or tears in the rectum, or anus.  The rectum does not stretch readily (like the vagina) and because of this can tear and bleed more easily.  A woman can contract HIV through semen when a man ejaculates in her rectum.  A man can contract HIV through semen when a man ejaculates in his rectum.

 

Oral sex can let HIV in your body through any cuts or tears inside the mouth due to injury or gum disease.  Often you cannot see or even be aware of cuts or tears inside your mouth.  You can also have gum disease without your gums bleeding.  Men can contract HV through vaginal fluid when performing oral sex on a woman or through semen when performing oral sex on a man.  Women can contract HIV through semen when performing oral sex on a man or through vaginal fluid when performing oral sex on a woman.

•          By sharing needles or syringes with an HIV positive person, getting tattooed or body pierced with a needle contaminated with HIV or receiving body scars or markings with a needle or knife contaminated with HIV.  With tattoos or body scarification, the same needle or knife can be used among several people and not sterilized for each new person.  If one person is HIV positive, infection can be spread.

 

•          During pregnancy, birth or breastfeeding from an infected mother to her baby.  During pregnancy, HIV can be passed from mother to baby through the placenta.  At birth, HIV can be transmitted through blood from the birthing process.  HIV is present in breast milk and can be transmitted to a baby during breastfeeding.  The decision to breast feed if a mother is HIV positive is a difficult one only the mother can make.  Current statistics say there is a 30% change a mother can transmit HIV to her baby by breastfeeding.  

 

•          By receiving a blood transfusion that is contaminated with HIV.  Not all blood is routinely tested for HIV.  In Ghana, blood is now routinely being tested for HIV.  If contaminated with HIV, the blood is not used and is thrown away.

The Natural History of HIV – Stages of HIV Infection:

•          Window period.  Once a person becomes infected with HIV, that person does not immediately become “HIV positive.”  There is a period of 3 to 6 weeks (sometimes as long as 3 – 6 months) before the body reacts to the presence of this virus and produces antibodies (chemicals) that can be found in the blood by laboratory tests.  If these substances (antibodies) are found, the test result is “positive.”  The period of time that passes while the test is still negative is called the “window period.”  It is important to understand this, since the person can pass on the virus in these weeks, even through the HIV test is still negative.

 

•          Asymptomatic period.  After a person is infected with HIV, there is usually no change in that person’s health for quite a few years.  The person feels well, is able to work as before and shows no signs of being sick (this is what is meant by “asymptomatic”).  With the exception of having HIV in the body, the person is “fit for work.”  This asymptomatic period varies from a few years to up to as many as 12 years.  The average range is between 8 and 12 years.  However, individuals can begin to become sick from a few to 5 years after infection.

 

•          The symptomatic period when the person is sick with AIDS.  Remember, AIDS is a “syndrome,” a collection of condition that, taken together, allow us to make a diagnosis of AIDS.  Most of the conditions that start to appear are called “opportunistic infections” or OIs.  OIs are caused by bacteria or viruses that normally do not cause illness in a person with a strong immune system, but do cause illness in a person with a weakened immune system.  OIs are infections such as diarrhea, tuberculosis and pneumonia, and they repeatedly make the person sick.   When a person is diagnosed with AIDS, the length of time until death can be very individual depending on the number and type of OIs and the availability of treatment and drugs.  Individuals can live for 1-2 years or much longer (if receiving treatment with drugs).

 

•          HIV testing as a prevention strategy.   HIV testing is not a reliable prevention strategy because of the window period and asymptomatic infection (described above).  However, if a couple wants to stop using condoms or have a family, both individuals can be tested for HIV at the same time and then use condoms with every sexual act (vaginal, oral or anal intercourse) for a 6-month period.  They must agree to only have sex with each other and not sleep with anyone else. When the 6 months are over, the couple can get tested again for HIV at the same time.  If both still test HIV negative, then they can start having sex without using a condom or try to get pregnant.  Again, both individuals must agree to have sex only with each other and to not see anyone else.

HIV is not spread:

•          Through casual (non-sexual) social contact like shaking hands, touching or hugging, toilet seats or eating food fixed by someone living with HIV.

 

•          By kissing. Some people are concerned about tongue kissing (French or deep kissing). HIV has been found in saliva, but the amount of HIV in saliva is extremely small.  No one has ever contracted HIV by kissing.

 

•          By mosquitoes.   Mosquitoes are a problem and cause other diseases, but do not transmit HIV.  We all tend to blame something else when it comes to HIV, so we blame things like mosquitoes.  But this is too easy.  The fact is that we give ourselves HIV and we alone can take precautions to prevent it.

You cannot get HIV from a mosquito, like you can malaria.  HIV affects people mostly in the 15-49 year age group, while malaria affects mostly children aged 6 months to 8 years.  It is clear that different populations are affected by HIV and malaria, and if mosquitoes transmitted HIV (like they do malaria), the same age group would be affected by HIV (the 6 month to 8 year old children). 

 

Mosquitoes bite people for blood, which is their food.  With malaria, a mosquito bites a person then goes into a 2-week life cycle to incubate the parasite.  After this 2-week period, they then go and bite someone else, infecting them with malaria.  This same situation does not happen with HIV because HIV cannot live within the mosquito for 2 weeks – it dies and the mosquito cannot transmit HIV when it bites another person.

Other facts about HIV and AIDS:

•          We are all at risk; anyone can become infected with HIV from one 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).

 

•          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 infection (STI) like syphilis or gonorrhea 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 behavior.  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 behavior.  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 or body scarred/marked with unsterile needles and knives/blades can result in infection with HIV and other STIs e.g., Hepatitis B.  Make sure needles and knives are sterilized or try to use your own needles/knives/blades.

 

•          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.     Information on Sexually Transmitted Infections (STIs)

Instructor Note:  Present this information as a brief interactive discussion.  Encourage questions from participants throughout the discussion.

There are many STIs.  We will discuss Gonorrhea, Chlamydia, Syphilis and Genital Herpes.

Gonorrhea 

• Gonorrhea is a disease caused by a bacteria called the gonococcus.

• Gonorrhea is caused by intimate contact with the sexual organs, rectum or mouth of an infected person.

• Approximately 10-20 percent of males have no symptoms at all.  In those who do, the first symptom is usually a burning pain when urinating and/or a discharge of pus from the penis. Symptoms usually occur 2-8 days after sexual contact, but they may occur as early as 1 day or as late as 30 days after contact.

• Most women do not notice that they have been infected since the infection generally begins high up in the cervical area.  The discharge of pus, if present, may be mistaken for the normal vaginal discharge.  There is usually no pain associated with this discharge, although some women may experience a slight burning sensation when urinating.

• Gonorrhea can be completely cured; however, it can be caught again, particularly if sex partners aren’t treated.

• If left untreated, gonorrhea can result in sterility, pelvic inflammatory disease (PID) in women which can lead to sterility and blindness in a baby if infected during birth.

Chlamydia

• Chlamydia trachomatis is a bacteria which causes significant genital infections in sexually active individuals, and eye and lung infections in infants born to infected mothers.

• The primary method of transmission is direct sexual contact with an infected person, usually sexual intercourse.

• Often Chlamydia shows no symptoms or can be mistaken for other STIs, such as gonorrhea.  Men may have a discharge from the penis, a burning sensation when urinating, or pain in the testicles.  Women may have an increased discharge from the vagina, a burning sensation when urinating, abnormal vaginal bleeding, abdominal pain, and a low-grade fever.  Symptoms usually appear within 1-3 weeks after exposure to an infected person.

• Chlamydia can be completely cured; however, it can be caught again, particularly if sex partners aren’t treated.

• In men, untreated Chlamydia can lead to complications, such as inflammation of the eyes and skin lesions may also be associated with genital Chlamydial infection.  The most common infection in women who do not receive treatment is an inflammation of the cervix.  Chlamydia is also a major cause of pelvic inflammatory disease (PID).  The consequences of PID include recurring pain, tubal pregnancies, infertility, and pelvic abscesses. Chlamydia can also cause inflammation of the tissues on the surface of the liver in both men and women.

• Newborns of mothers infected with Chlamydia may also develop pneumonia, infections of the eye, ear and other infections.

Syphilis

• Syphilis is a disease caused by a spiral shaped bacteria, and can involve every part of the body. 

• Syphilis is spread through direct contact with the sexual organs, rectum or mouth of an infected person.

• In the early stages, syphilis may go unnoticed by the infected person.  The first sign of syphilis is usually a single, small, firm, painless sore (chancre) at the site where the infection entered the body (penis, vagina, mouth). The chancre generally appears 10-90 days after contact with an infected person, and will last from 1-5 weeks.  The second stage of syphilis occurs approximately 0-10 weeks after disappearance of the primary lesion.  During this stage, the infected person may break out in a rash anywhere on the body. (The rash is unusual, because it appears identical on both the right and left sides of the body.)  Most commonly, it appears on the palms of the hands and/or the soles of the feet.  Rashes also go away but may reappear without treatment.  This rash may be accompanied by fever, tiredness, sores in the mouth, or loss of hair.  It is during these two stages (lasting up to one year) that the person is contagious.

• Syphilis can be completely cured; however, it can be caught again, particularly if sex partners aren’t treated.

• If Syphilis goes untreated, after the second stage the organism may remain dormant (be present in the body but causing no harm) for a length of time.  After a period of time, the bacteria may begin to damage the brain, spinal cord, heart or other organs.  This late stage (possibly occurring 2-25 years after stage one) can result in mental illness, paralysis, heart disease, blindness or death.

• A pregnant woman may transmit the disease to her unborn child if she has not been completely cured.  Premature birth, miscarriage, stillbirth and deformities of the unborn child are possible complications.

Genital Herpes 

• Genital herpes is a disease caused by the herpes simplex virus.

• Genital herpes is transmitted through close physical contact, usually sexual intercourse with an infected partner.

• Approximately 2-12 days after contact with an infected person, a small sore (or several sores) similar to a fever blister will appear at the site where the infection entered the body (penis, vagina).  The sore may be very painful, accompanied by swelling in the surrounding area.  These symptoms may disappear in a few weeks with the disease remaining hidden for months or years.  Some people experience recurrences of these symptoms, which usually involve the same area as the primary infection but are less severe and heal more quickly.

• At present, there is no cure for herpes.  Treatment for herpes includes taking a medication (Acyclovir) which can reduce the severity of the symptoms during the initial infection and suppress future episodes.  Keeping the sores clean and dry can also be helpful.

• The full effects of herpes are not known.  Since a history of herpes infection may be linked with the occurrence of cervical cancer, women with herpes should have pap smears at least once a year.

• A pregnant woman may transmit the disease to her child at birth as it passes through the birth canal.  In infants, serious infection or even death may result.  To avoid this possibility, pregnant women with herpes need careful prenatal screening, and sometimes delivery by Caesarean section. 

C.     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.

D.         Impact of HIV on Uniformed Service Personnel and Institutions

Instructor Note: This discussion focuses on why uniformed service personnel are especially at risk for HIV infection and how HIV impacts both readiness and health of the communities where uniformed service personnel train and work.  Conduct this session as a facilitated discussion.

Directions for Discussion:

1)         Ask participants how they think uniformed service personnel are at risk for HIV; write their responses on a flip chart or writing board.

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

• 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 behaviors, 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 behavior.  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. 

• There may be “initiation rituals” in a uniformed service such as cutting or marking yourself, exchanging blood in a “blood brothers” ritual, raping a woman that can put a person at risk for HIV/STI infection.

• 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 and work together 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 behaviors.

• 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 center.  Carefully unroll into a rectangular piece of latex and place over the opening to the woman’s vagina before beginning cunnilingus.  You can also use a square of cling wrap (used in food preparation) to place over the opening to the woman’s vagina.

Using Condoms When You Are Living with HIV

People who are living with HIV often ask what is the point of using condoms if I have HIV and so does my partner.  It is very important to keep using condoms when you and your partner are HIV positive.  The reason for doing so is that when you are HIV positive you can transmit the virus to you partner over and over again.  When you keep passing the virus to another person, you can increase the amount of HIV they have in their body.  People who have higher amounts of HIV in their body get sicker faster.  To maintain optimal health for you are your partner, it is very important to keep using condoms with every act of vaginal, anal or oral sex.

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 Behavior 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).  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 flip chart paper and writing materials. Give each dyad or facilitator in the small group a “Strategies for HIV Prevention and Behavior Change Exercise Instruction Sheet.”

2)         Give each dyad or small group a scenario (described below) from the “Strategies for HIV Prevention and Behavior Change Scenarios.” There are two scenarios; be sure to distribute them evenly.  You can change the names on the scenarios to make them more real for the participants.  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 flip chart paper (which they can use for their presentation to the larger group). 

Small Group Discussion Scenarios

Scenario #1: Mahama and Naa

This is Mahama’s first mission outside of his country and it’s the first time he has ever been in another country.  Mahama 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 Mahama trying to adjust to so many different types of people and this new environment.  He has formed a friendship with Frank, 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.  Mahama and Frank are in a social club drinking, after spending a great day on the beach.  Mahama meets Naa at the club.  They dance and talk and Mahama can tell just by the way Naa smiles and touches him that she’s sexually interested in him.  Naa invites Mahama back to her place.  Mahama is worried about HIV and other STIs and wants to use a condom.  After they get to Naa’s apartment, they begin to move towards intimacy.

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

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

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

Naa:                But Mahama, it feels so much better without a condom.

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

Scenario #2: Christina and Olufemi

Christina suspects her boyfriend Olufemi 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 Christina do?  What should Christina say to Olufemi?  Develop possible responses and strategies for Christina to effectively negotiate safer sex with Olufemi.

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):

•          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.

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.     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 Behavior Change Issues

Strategies for HIV Prevention and Behavior 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 flip chart paper.

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.

Scenario #1: Mahama and Naa

This is Mahama’s first mission outside of his country and it’s also the first time he has ever been in another country.  Mahama 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 Mahama trying to adjust to so many different types of people and this new environment.  He has formed a friendship with Frank, 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. 

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

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

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

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

Naa:                  But Mahama, it feels so much better without a condom.

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

Scenario #2: Christina and Olufemi

Christina suspects her boyfriend Olufemi 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 Christina do?  What should Christina say to Olufemi?  Develop possible responses and strategies for Christina to effectively negotiate safer sex with Olufemi.

 Part II: 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 Refugee.  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.

Crisis is defined as a breakdown of normal conditions (whatever conditions a country, region or community are used to), which results in an unstable environment.  Crisis includes war and armed conflict as well as natural disasters, like floods and earthquakes.  We will talk about crisis that includes war and armed conflict. 

Crisis is:

•          conflict - armed conflict and war (fighting between two or more countries)
•          internal civil unrest or disorder (fighting among opposing or rebel factions, ethnic cleansing)

Stages of crisis:

•          pre-crisis where normal systems begin to break down and affect daily life (health care, markets, employment)
•          crisis stage itself where there is active conflict and civilian populations may flee their homes or be forced to leave their homes; sometimes civilians must go to another country
•          post-crisis where the community or region works to return to normal; this may involve civilians returning to their homes if they fled or were forced to leave

Instructor Note: If appropriate (depending on the level of your audience), you can discuss this more in-depth description of the stages of crisis:

Stage 1:   The destabilizing event – results in a very chaotic situation

Stage 2:   Loss of essential services – breakdown of political and social infrastructure and cutting off access to basic needs

Stage 3:   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

Stage 4:   Relative stability – services restored to the affected population that allows a greater development of interventions and care

Stage 5:   Resumption of normality – circumstances that allow the return of displaced populations to their communities and homes

What causes a crisis?

•          Crises happen within, between and among nation-states over clashes of interests that the disagreeing sides believe are so basis to their identity and survival that little or no opportunity seems possible for peaceful resolution.

•          Causes of crises include religious and cultural competition, territorial disputes and differences between groups that limit opportunity for social and financial advancement and political autonomy.

•          Crises occur among peoples who often live close to each other in a common physical environment.

•          At their worst, crises lead people and leaders to de-humanize their opponents.  This can result in periods of violence and armed conflict that create injury, sickness and death, large numbers of refugees and IDPs and loss of basic human security and social/political order.  More suffering and death may be caused by environmental problems such as flooding and earthquakes, famines, mental illness and waves of diseases.  HIV thrives in crisis situations.

What happens during a crisis?

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

•          Combatants enter an area, people may move from their homes to get away from the conflict or live under difficult conditions (no electricity, running water, heat, not being able to leave their homes) because of fighting.

•          Health care, educational and government institutions close down or limit their services.  Stores close down or limit their hours.  Civilians become vulnerable because they have limited or no access to needed medical care, food and safe drinking water.  They may lose their jobs and have no money.  Families can become separated.  Adolescents and children have nowhere to go because schools are closed, may spend time on the streets and get involved with crime or the conflict itself by becoming child soldiers. Persons may be discriminated against because of their race, religion or gender and be denied access to medical care, employment, food and shelter.

•          Uniformed service organizations spend most of their time dealing with the conflict and less of their time protecting civilians.  Civilians become more at risk for discrimination and acts of violence (like rape).  Human rights become hard to protect during a crisis.

•          Civilians become more and more affected by the crisis as time goes by, and may choose to flee to another part of the country or a different country in order to be safe from violence or persecution and be able to get their basic needs met for safe drinking water, food and shelter.  In some circumstances, civilians are forced to leave their homes and are relocated to camps or institutions.   When large numbers of civilians flee their homes, refugee camps are set up in other countries to help them and provide food and shelter.  The crisis in Kosovo is one recent example of a mass fleeing of persons to safer countries.

•          Humanitarian missions are set up to care for civilian populations and provide shelter, food, water and medical care.  This often involves the creation of camps for refugees and IDPs.

•          Peacekeeping missions are organized for when the crisis is over, often involving many different countries to contain disputes and maintain peace and stability.

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 peace makers – 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 reestablishing 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 flip chart paper.

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. 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 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 behavior 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.
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