1995_4_editorial

Sexual Health Exchange, 1995 - no. 4

Reorienting health and social services

Renee Sabatier

Growing at the rate of 6000 new infections each day, the second decade of the global HIV/AIDS pandemic poses a particular challenge: how to concentrate action and resources on the regions and groups most affected and how to show results without simultaneously provoking stigmatization and social backlash. Greater concentration on those most at risk is essential if the available human and financial resources are to be effective.

954Editorial A clientcentred approach leads to alliances between clients, service providers and community leaders and advocates

HIV/AIDS and STDs are relatively focalized in certain highly vulnerable groups and places. The problem - not a new one - is that focused AIDS/STD programmes have an unusual potential to stimulate and reinforce discriminatory social responses. As fiscal regimes continue to tighten around the world, AIDS-based discrimination increasingly takes the form of unwillingness to fund AIDS programmes based on prejudice that AIDS is the infected person's fault. This type of discrimination is difficult to fight and makes a two-pronged approach essential. Health and social services, as they gear themselves for another decade in which AIDS and STD cases continue to mount, must reorient and renew their efforts in the face of this dilemma.

Non-stigmatizing and non-discriminatory approaches

Few other areas of health care must deal with the guilt, shame, fear, disapproval, judgement and rejection which a diagnosis of HIV or STDs can elicit. This means that STD and AIDS programmes bear a correspondingly heavy responsibilty to promote non-stigmatizing and non-discriminatory approaches. STD treatment and control programmes have generally acknowledged this responsibility to the extent of providing pre- and post-test counselling to their clients. But the broader responsibility to work pro-actively to reduce social stigmatization and discrimination has largely been carried by persons living with HIV/AIDS, AIDS service organizations and other non-clinical, non-governmental organizations.

The client of STD and AIDS services is not simply the individual seeking diagnosis and care but also the community of vulnerable individuals in which he or she lives. AIDS/STD programmes and services are responsible for more than the individual HIV/STD patient. In fact, the service they provide is only as good as their understanding of the everyday contexts in which their clients live. This means that most interaction between programmes and clients needs to occur outside clinic and hospital settings, in everyday community sites ranging from bars, hotels and brothels to homes, markets and workplaces.

A welldeveloped response to HIV/AIDS and STDs involves a wide range of service and programme providers, including community health workers, traditional health practitioners, general and private practitioners, pharmacists, traditional birth attendants, social workers, personnel staff and others. Where nonhealth workers can best perform a task, biomedically trained workers can be spared for tasks requiring their special skills. This means that the numbers of and support for "outreach" staff who work with clients in these settings will be much greater than has heretofore been the case. Outreach staff need to link with community workers and volunteers who are drawn from and close to the client groups.

Sharing power between the clinic and the community

To attain the specificity of contextual understanding and interaction required to influence sexual behaviours in vulnerable communities successfully, HIV/STD diagnosis and treatment programmes need to be coupled with intensive community-led prevention and support activities. This entails a sharing of power between the clinic and the community, based on the understanding that the clients' needs and rights are fundamental to the whole business of HIV/AIDS/STD prevention and care. Programmes conducted under these assumptions look quite different from the traditional clinic-based STD approach, although the clinic is still an essential part of the mix. They involve more and different types of people, share information more easily and completely, provide authoritative roles for non-biomedical workers and have goals and objectives which are clear to and supported by their clients. When they conduct research it is with community approval and participation, not only in the implementation but in the design. At each level of the system these programmes forge alliances between clients, service providers and community leaders and advocates. The conception of human rights which underlies such programmes goes beyond testing, counselling and confidentiality issues to a broader health and human rights persepctive which looks for the determinants of and remedies for vulnerability to HIV/STDs.

It is clear that HIV/AIDS/STDs must be fought simultaneously on two fronts, one against the virus and one against psychological distancing and social backlash. The reorientation of health and social services necessitated by this two-fold struggle is an ongoing one, centring on openness to partnerships and a management style which fosters them. Health and social services, including STD-related services, are being squeezed by a global trend towards reduced public funding. At the same time, they are being challenged to change by HIV-affected communities. AIDS has enlarged the possiblity for new partnerships for health and a deeper understanding of health and human rights. Health and social services all over the world must decide to what extent they can accept the challenge to join in new partnerships and reorient their structures and workers to meet it.

Renee Sabatier, Southern African AIDS Training Programme, SAT Regional Office, P.O. Box 390, Kopje, Harare, Zimbabwe; Tel: 263-4-725-915; Fax: 263-4-725-193; e-mail: sabatier@satp.stellar.zw