1. Towards AIDS Competence
Manila, November 25, 2002
Mr. Chairman, I would like to thank you very much for the invitation to address the 6th Asia Pacific Regional Conference of the Red Cross and Red Crescent. I am deeply honored to address the conference of your most respected organization.
Among you in this room, I recognize some of the most respected pioneers in the response to HIV/AIDS.

2. HIV/AIDS
one reality…
Every time we speak about HIV and AIDS, it is our duty to remind ourselves of the reality that is in front of us. A reality of tremendous loss of life, of tremendous loss of opportunity.

3. Changes in life expectancy in selected African countries with high and low HIV prevalence: 30 35 40 45 50 55 60 65
Life expectancy (years)
with high HIV prevalence:
Zimbabwe
South Africa
Botswana
with low HIV prevalence:
Madagascar
Presentations on HIV/AIDS often start with figures. So, I will give you figures. To me, the most telling is the one now on the screen. The three lines that are going straight up represent the increase of life expectancy in African countries with low HIV prevalence. But look at Zimbabwe, Botswana and the Republic of South Africa. In Botswana, a country that has had the greatest economic development per capita in the world for several consecutive years, sees its development threatened at the base, its people. Ten years ago, life expectancy at birth was about 60 years. Today, it is less than 40 years. In 10 years, life expectancy have been reduced by more than 20 years in Botswana. There is no other way we can comprehend the full extent of the loss of life and loss of opportunity which those countries have to deal with.
Senegal
Mali
1950–
1955
1955-
1960
1960-
1965
1965-
1970
1970-
1975
1975-
1980
1980-
1985
1985-
1990
1990-
1995
1995-
2000
2000-
2005
Source: UN Department of Economic and Social Affairs (2001) World Population Prospects, the 2000 Revision.

4. Adults and children estimated to be living with HIV/AIDS as of end 2001
Eastern Europe & Central Asia
1 million
Western Europe
North America
East Asia & Pacific
1 million
North Africa
& Middle East
Caribbean
South
& South-East Asia
5.6 million
Sub-Saharan Africa
28.5 million
Latin America
1.5 million
Australia
& New Zealand
15 000
These are the figures of last year. Tomorrow, we will make sure that as soon as the data are released, you will have the 2002 report.
Total: 40 million

5. another reality… Photo: Georgia Roessler
However, there is another reality about AIDS.
It is a reality of hope and of competence to effectively deal with the problem.
It is a reality of communities that are making sure that AIDS would not affect for ever the quality of their life.
Photo: Georgia Roessler

6. Phayao, Thailand HIV seroprevalence among 21 year old men18 16 14
HIV Seroprevalence, % 12 10 8 6
This is the evolution of the level of HIV sero-prevalence among young males age 21 in a province of Northern Thailand, Phayao. Five hundred thousand people are living there, near Laos and Myanmar.
The HIV prevalence level among young males was 18% just 10 years ago. Today, the prevalence among young males is less than 2%. 4 2
1998
2000
2002
1991
1992
1993
1994
1995
1996

7. Uganda: trends in antenatal HIV prevalence at selected sentinel sites
And progress is not confined to a particular country.
You can now see on the screen that progress is also registered in Uganda where prevalence levels of HIV in pregnant women have gone down in some sites from 30% to about 10%.
What can we learn from those places where focus is being made.

8. what have we learnt?
Effective responses to HIV/AIDS are people-driven, not commodity driven
Technology, money and information can support but do not substitute for people driven responses
Country wide responses require facilitative leadership
What are the lessons can we learn from that progress?
We have learned that effective responses to AIDS are people-driven, not commodity driven.
We have learned that technology, money and information can support but do not substitute for people driven responses.
And we are learning that country-wide responses require facilitative leadership.
I will in particular dwell on the first, and on the last points.

9. effective responses are people-driven
That is what members of the Phayao AIDS Action Center identified as the key lesson.
“Yes, we are providing information; yes we are distributing condoms; yes, we are implementing the 100% condoms policy. But at the end of the day, people made the difference, They have decided to change. They saw the issue and they have changed”.
To earn the right of continuing to speak in front of you and other audiences like this, I have to recognize my own errors. When we wrote the first document for the World Bank on AIDS in Africa in 1987, we were assuming that the provision of services, commodities and information would somehow be sufficient to resolve the problem. Not so long ago, we had participated in the eradication of smallpox. With smallpox we could target people as the passive objects of vaccination campaigns. With AIDS it is not possible.
The battle against smallpox was won in health centers and outreach posts. The battle against AIDS is decided in bedrooms, not in health centers. If we want to see progress on HIV/AIDS, that is the big difference we need to understand.

10. we are the subjects of the response to HIV/AIDS
community
family
personal
our spheres of
action
To deal effectively with HIV and AIDS, we have to realize that we, and not someone else out there, are the subjects of the response to AIDS.
AIDS is affecting my life as an individual, as a father, as a member of my community. It is affecting my work as well as the stands I am taking in society.
The picture Dr. Nesbit showed us of a AIDS Day Care Center in Northern Thailand that made me think of the story of Khun Nongkran, the head of such a Center in Dokkamtai.. Khun Nongkran and other many others nurses were suffering of burn out. There were so many cases of AIDS coming to them. And the head of the Provincial health office of the province noticed the situation. She took everyone on a retreat for a week. She said: “I don’t care what your solution is but I want you to think about what AIDS does for your life”. Nongkran told us that after that week, she was at peace with the issue, Now that she understood herself, she could understand others. That process is absolutely central to effective responses to AIDS.
work
policy

11. local partnerships on HIV/AIDS – the key for AIDS competence
People of influence
Providers of services
Teachers
Political Leaders
LFT
Nurses and doctors
Religious Leaders
Journalists
People living
with HIV/AIDS
Traditional Leaders
For sure, we should not conclude: “Let people decide on their own and that’s it”. No. In effective local responses, we observe partnerships between key actors and other local actors. Who are those key actors? The key actors in the response to AIDS are the members of the vulnerable groups. People living with AIDS, people involved in prostitution, young people, women are the key actors in this response These are the same people. Or, if you prefer,if you look at the vulnerability ma, you are also looking at the opportunity map.. And once key actors accept that AIDS is affecting their lives, then they seek support in their environment. They partner with the teacher, the doctor, the nurse, whoever in their environment can support their actions.
Often, these partnerships do not happen spontaneously. One can observe a facilitating agent playing a key role. It can be someone from the community, a traditional leader, a mayor, a priest.
Families
Women Groups
Youth Clubs
Civil society
LFT: Local Facilitation Team

12. country-wide AIDS competence
horizontal sharing of AIDS-competence from community to community
scaling-up of locally available services and financial resources
facilitative, catalytic leadership
You might say: this is all good and well, but you are talking of micro level responses. How can you imagine that thousands of local partnerships required for an effective national response flourish countrywide?
With the increasing confidence, we can state that there are three concurrent processes at work. The first one is horizontal sharing of AIDS competence from community to community; the second one is scaling-up of locally available services and financial resources; and third, facilitative, catalytic leadership.
Please note that generally one focuses on the second process. I will therefore rather focus on the first and the third one.

13. large-scale responses... … are based on organic relationships
Large-scale responses are based on ever-growing organic relationships. Competence grows like a tree, indeed spreads like the virus spreads. The growth of AIDS competence is primarily based on the exchange between father and son; between mother and daughter; between auntie and niece. This is the most plausible explanation for progress in Uganda, in neighboring countries. The leadership, not only of the President, but also of people affected by AIDS made it possible to dialogue on HIV/AIDS; so that experience could be shared between various members of the community, and from community to community,. Even in areas where services are not being provided to a satisfactory way, you see progress in response to AIDS. For instance, young girls postpone their first sexual encounter in Districts where there is no significant coverage of AIDS related services.
Therefore, country wide response to HIV/AIDS require support to the horizontal sharing of experience between church leaders, young people, you name it. Are we dreaming? No, we are not. There is actual evidence that this sharing of competence is taking place. If you see a community taking charge of AIDS, members of that community will share their experience in radius as far as 30 – 50 km depending on their relations with neighboring communities.
Photo: unhcr

14. creation & sharing of competence
Churches UN
Business F
Civil society
DFT
Government sectors
Once local partnerships on AIDS are built, linkages start develop in ways which we cannot control. Hope, skills, self-confidence spreads so that social immunity to the virus progressively develops nation-wide. F
CBOs
NGOs F
Persons living with HIV/AIDS
DFT: District Facilitation Team; F: Facilitation

15. the facilitative leader
appreciates local strengths
seeks to understand, rather than judge
encourages interaction between various actors
values:
listening
participating
questioning
learning
Country-wide responses require facilitative leaders. You need leadership, but not any kind of leadership. You need a leader who is able to appreciate strengths. In the development business, we go and look for needs so that we can respond to those needs. Of course, its clear that there are needs out there. At the same time, how much do we appreciate strength? Are we seriously attempting to learn from what people really do in response to major development challenges such as AIDS? How much do we seek to understand rather than judge? How much do we try to understand the situation of a sex worker who has HIV rather to judge him or her. How much do we try to understand the woman who is at home who has only has her husband who happens to have HIV? How much do we try to understand instead of judge? This is absolutely critical if we want to launch an effective response to AIDS. Our values must be clear. They must consist of listening, of participation, of learning. If we want to support strengthening of local responses on AIDS, we have to become the learners from those experiences. By validating what people do, they will have the strength to do a better job and to share with others what they are learning from what they do.

16. facilitation teams
stimulate local ownership of the problem and of its solution
stimulate the creation and sharing of knowledge
maintain the facilitation “spirit”
apply lessons learnt within organizations
Of course, that style of management is not an easy one to take on. That is why we propose the establishment of the facilitation teams. Those teams stimulate local ownership of the problem and of its solution; stimulate the creation and sharing of knowledge; maintain the facilitation “spirit” and apply lessons learned to organizations.

17. HIV/AIDS: the challenge to organisations
We believe in our own expertise to provide solutions
We believe in people’s strengths to respond
We control a disease
We facilitate responses
We respond to need
We reveal strength
You have a problem
Together, you and we have solutions
AIDS is not only challenging sexual behavior. It is also challenging institutional behavior. Organizations accepting the reality of HIV and AIDS need to review their own style of management, their own style in doing business.
We use to rely in our own expertise to provide solutions; we now need to appreciate people’s strengths to respond. We used to picture ourselves in control of a disease; we now realize that we only can influence other people’s responses. We used to see our job as primarily consisting in responding to needs; in responding to these needs, let us start with what people are already doing. If we thought that the right approach consists in telling people that they have a problem, let us think twice. We have the problem together. And together we might find the solution.

18. people living with AIDS
Play a key role in Thailand, Uganda, Brazil
Help face reality
Transform organisations
In all countries making progress on HIV/AIDS, a special category of people exert facilitative leadership. These are people with HIV and AIDS. In Uganda around 1985, a well known singer, Philly Lutaya came out and said he had AIDS. “I don’t think my behavior is different from men. If we want to deal with this problem, we all will need to change our behavior.” A little later, my own colleague Noreen Kaleeba told her community that her husband had died of AIDS. She started a support group for families affected by AIDS, which became TASO. These are the individuals who, together with their President, opened up society on HIV/AIDS.
So let us do something about it. Its not just about making sure that there are few people who lives out there who can be called in for meetings. It is about making sure that they are really involved in the design of responses. A friend from Western Africa was saying: “Too bad, only poor people disclose their sero-status. Where are the intellectuals? Where are the managers? How about directors, where are they? We need them to come out as well so that we can correct their misconceptions that AIDS is just for the poor. We need their skills to respond more forcefully.

19. people with AIDS Inclusion Care Access to ARV: US$ 1/ day
People with AIDS reveal that AIDS give a human face to figures. They help transform organizations in the way I tried to sketch here. Beyond non discrimination, discrimination, it is conclusive. When I first came to Phayao and I was using the word “success” , Dr Petshri, the director of the Provincial Health Office told me: “First, if you want to work with us you are not going to talk about success because there is no success yet; and two, we are proud not only of the reduction of the HIV levels but also about the inclusion of people with AIDS in our social life. They can come to weddings, they participate in all social events. They are still discriminated – but people with AIDS will tell you that the quality of their lives has improved just because they feel respected and included in our society.” Therefore, in countries with low HIV levels let us care for people with AIDS and make sure that they can effectively use anti-retro-viral drugs. People living with AIDS are ready to be part of the solution, they just want to be cared for and appreciated as human beings.

20. In AIDS competent societies…
people are able to maintain and even improve the quality of their lives by:
facing up to the reality HIV and AIDS,
acting so as to reduce their vulnerability and their risks, and
ensuring that they live out their potential, irrespective of their sero-status.
So finally, we mentioned already that the people in Phayao were not wanting us to talk about success. So we started to figure out what might constitute success. This is the suggestion of a group working in Phayao.
Their vision of success is an AIDS competence society where people are able to maintain and enhance the quality of their lives because they face up to the reality of AIDS; they deal effectively with their specific factors of vulnerability of risk; and they make sure that everyone lives his or her potential, irrespective of sero-status.

21. a concrete vision of shared success
This is the vision of a community somewhere in Chiang Rai, in Thailand. This is how that community sees an AIDS competent village. Let us act as subjects of the response to AIDS at home at work and in society at large. We will contribute in Asia and everywhere in the world to the realization of a vision of communities that can maintain and enhance the quality of their lives in the face of AIDS. Thank you.