According to UNAIDS, at the end of 1999 nearly six million people in the AsiaPacific region were infected with HIV/AIDS, making it the region with the second largest number of infections after subSaharan Africa. And infection rates in the region are increasing quickly, much faster than in the rest of the world. The reasons for the spread of the epidemic are plentiful. Many countries still deny that HIV exists within their countries or that it is much of a problem. As a result, prevention programmes are scarce and ineffective, and care and treatment are nonexistent. Some countries may be aware of their HIV/AIDS problem but lack the resources to tackle it. In some cases, the lack of political and economic stability has made it difficult for countries to focus on HIV/AIDS, and their epidemics continue unabated. Even countries that have instituted prevention programmes have had limited effectiveness because prevention has not been approached from a multisectoral angle. Discrimination and stigma are not tackled, and women particularly suffer low status in society. These factors make marginalised groups more vulnerable to infection and women remain unable to protect themselves.

The need for advocacy

From the experience of other countries that have suffered from the effects of HIV/AIDS, change must clearly take place within countries for prevention to work. This change is not always obvious to policymakers and lawmakers and therefore has been slow. But many AIDS activists, NGOs, community groups and individuals understand that if the old ways of doing things not only do not work, but also exacerbate people's vulnerability to HIV, they must be changed. Advocacy work must be undertaken for change to occur.
Advocacy has been a factor in HIV/AIDS work from the beginning and indeed much of the thinking about prevention and care comes from the efforts of those early advocates, particularly those working in human rights issues. But most advocacy successes have occurred in the developed world, although most of the people living with HIV/AIDS (PLWHAs) live in the developing world.
Poverty and political instability are just two of the issues facing developing countries. Sudden changes in political and economic landscapes have affected the course of the epidemic in some countries, e.g. Indonesia. Advocacy issues and methods differ, as do advocacy successes.

Successful advocacy in Asia

Thailand is an often-cited example of where advocacy has succeeded. Thailand came out of denial in 1991 and instituted a national AIDS plan that was realistic and farreaching. Intense lobbying by NGOs such as the Thai Red Cross, prominent individuals such as Mechai Viravaidya and PLWHA networks contributed to its success. An AIDS bill that would have required mandatory testing for HIV was defeated in 1992, also as the result of pressure from lobby groups. More recently, NGOs have lobbied government to allow the Government Pharmaceutical Office to produce several antiretroviral drugs --including DDI, D40, AZT and Fluconazole-- at far lower prices than if imported.
The Philippines is another example where advocacy resulted in a National AIDS Prevention and Control Act. Amongst other things, the 1998 Act requires written informed consent and prohibits compulsory HIV testing. It guarantees the right to confidentiality, prohibits discrimination on the basis of actual, perceived or suspected HIV status in employment, schools, travel, public service, credit and insurance, healthcare and burial services. It also mandates HIV/AIDS information as a health service and recognises the role of affected individuals in information and education campaigns. It provides access to healthcare, communitybased services and selfhelp programmes. This Act was the culmination of a joint effort by a coalition of Philippine NGOs and human rights lawyers over several years, but obviously it was worth the effort.

In Singapore, advocacy work has been low-key. After several years of work, AIDS activists finally got the government to agree that people who died of AIDS did not have to be buried within 24 hours. Instead, families had up to three days to mourn properly. The earlier time limitation preventing wakes caused suspicion about the cause of death. Earlier this year, the Singapore government was also forced to reverse its decision to deport nine HIVpositive foreign spouses of Singapore citizens. As a result of media exposure with the help of the affected families, AIDS activists pointed out the contradiction between this policy and the government's vowed commitment to families.

Achievements in Malaysia

In Malaysia, advocacy efforts have focused more on effecting changes in policies than in laws. Malaysian NGOs persuaded the Ministry of Health to insist that health authorities issuing death certificates list the actual cause of death and not HIV or AIDS. They argued that insensitive documentation caused the deceased's families great hardship because they did not want anyone outside the family to see the death certificate. Their reluctance prevented them from applying for leave from work to attend the funeral, from claiming claim insurance or the estate of the deceased or the deceased's Employee Provident Fund proceeds. The Director of Medical Development from the Ministry of Health informed doctors in public and private hospitals that listing HIV or AIDS as the cause of death is unacceptable. Community workers are now able to insist on changes in any death certificates that contain unacceptable words.
Advocacy work in Malaysia has also been directed at influential public figures and policymakers, including religious leaders, particularly the Islamic leaders. AIDS activists consulted with Islamic leaders on how they should respond to the HIV/AIDS epidemic, providing them with basic facts about HIV and giving them examples of best practices used abroad, particularly among Muslim communities. To put a human face on AIDS, they invited PLWHAs and caregivers to talk about living with HIV/AIDS. As a result, Islamic leaders issued a set of resolutions calling for the provision of accurate and frank information to young people, including sex education, the use of condoms and harm reduction to prevent HIV among drug users.

Lessons learned

Advocacy work in Asia still has a long way to go, but there are some lessons learnt from past successes, including:

1. Understanding that success results from incremental efforts over time. Many efforts have been lowkey, requiring patience, persistence and knowledge of how government works.
2. As in many areas in Asia, building relationships with key targets is important. Sometimes this is difficult as government officials often change and new relationships have to be forged. If, however, cordial relationships with the right people can be sustained over time, there is a greater chance of effecting change.
3. If not thought through properly, highprofile advocacy can have negative effects. The media should be used judiciously; sometimes it helps to talk about something in the papers, sometimes it does not. Bad mouthing government officials only causes a hardening of attitudes and slows down change.
4. Advocacy methods of developed countries are not always applicable in the developing world. The violent methods of some activist groups abroad do little to change attitudes among government officials. Sometimes the volume needs to be raised to heighten the focus on HIV/AIDS issues. But it must be culturally appropriate and never violent or personalised so that the targeted official loses face, thus hardening attitudes towards NGOs and AIDS in general. Like it or not, governments set policies and it is foolish to set up barriers to any relationship with government.
5. Just as prevention programmes must be localised, so too must advocacy efforts. What works in one country will not necessarily work in another, because of the differences in environments --politically, socially, culturally and economically. Local advocacy efforts have the advantage of training local people how to work and how to react to changing circumstances, something that cannot be predicted from a distance.
6. Advocates must be better informed and more knowledgeable about HIV/AIDS than the people they are targeting. They must also be aware of situations in different countries in order to adapt local policies. For instance, western countries might reverse their stand on partner notification because of changed circumstances on the availability of treatments. Similar policy changes can be justified in developing countries, despite different circumstances.
7. Patience, creativity and openness to strategic partnerships are essential elements of advocacy. Advocacy takes time and while time is a limited commodity for PLWHAs, rushing things can have the wrong effect in the long term. Furthermore, many avenues are open to create awareness among the public and policymakers. While direct advocacy is a must, indirect advocacy --specifically through the media-- can also be done. Forming strategic partnerships that can provide good data --such as research institutions, or with synergistic concerns such as trade unions, religious organisations and the private sector-- can also help bolster the perception that the nation's citizens are concerned about these issues. Better education overall about HIV/AIDS and creating an understanding that the epidemic is constantly evolving and that what works one time will become obsolete are the most effective ways to create a desire for change.

Is there an Asian style of advocacy?

At the closing of the Community Indaba at the XIII World AIDS Conference in Durban, South Africa, in last July 2000, community participants resolved that advocacy efforts should be nonconfrontational. Many AIDS activists in developing countries would like to press for change in HIV/AIDS policies in their own way and understand that the advocacy styles of developed countries may not suit the reality of their political environments. Like it or not, we live in systems that are not always democratic, or that are based on traditional perspectives of respect and courtesy. Importing certain forms of advocacy may be alien to our traditions and values, which may create a backlash rather than advance the cause.
An Asian form of advocacy should be intelligent, marrying local knowledge about how things work with the same determination to achieve an objective that has effected change in other parts of the world. The saying that "Where there is a will, there is a way" holds true in HIV/AIDS work. It has been the common thread in all advocacy efforts around the world. What differed has only been a matter of style, not substance.

Advocacy has been most successful in the Asian countries that allow freedom of expression. Countries that allow for critical assessments of government policies and laws have environments where advocacy efforts can bear fruit much faster than in more restricted ones. This issue is one all advocates, of whatever cause, must deal with. Yet, it cannot be an excuse to do nothing, nor must it be assumed that in countries that are less democratic, there are no advocacy efforts at all. Activists are highly motivated people and they will always do the best they can, despite limitations.

Even though advocacy styles may differ from Asian country to Asian country, the success of one country may be used as an example in advocacy efforts in another country. The successes in the Philippines, Thailand or India may not be achieved in the same way in other parts of the region, but they can be achieved nevertheless by advocates who are sensitive to their own environments and are motivated by the same desire for change. The success of one country allows activists and advocates to say "Why not?" to their own governments, and their refusal to accept that "We are different" as an answer is the beginning of the path to change.

Future challenges

In October 1999, the Malaysian Prime Minister called for a summit of Asian Heads of Governments on HIV/AIDS. For AIDS advocates this is an opportunity for advocacy work. Leading up to the Association of South East Asian Nations (ASEAN) Summit, each of the ten countries will hold incountry consultations on AIDS to discuss relevant issues. These issues will then be collated at an intercountry consultation from which the statement for the Summit will be drawn. This statement, as well as the mechanisms to implement all its resolutions, will make a major difference in the way each individual country as well as ASEAN on the whole responds to HIV/AIDS. It could be a major step forward for all of ASEAN as well as Asia.