In a remote region of central Asia, far from the international spotlight, Mongolia is on the frontline in the fight against HIV/AIDS. Although the reported number of HIV/AIDS cases in Mongolia is still low, a growing number of other sexually transmitted infections (STIs) indicates a relaxed attitude toward safe sex. Health officials from Mongolia and around the world are working to increase public awareness and implement prevention programmes before it is too late.

Mongolia presents a unique set of challenges for organisations working to stop the spread of HIV. The sprawling steppes and vast expanses of the country's rugged Altai Mountains and Gobi Desert make travel and communication difficult. Only 2.7 million Mongolians live in an area three times the size of France. Many live in remote rural settlements or in nomadic groups tending their herds of horses, cattle and sheep. The reminder of the population lives in several sprawling cities, with more than 800,000 people in the capital Ulaan Bataar.

But it is not just the topography of Mongolia that presents challenges: more than half the population is under 30 years of age. These young people are more sexually active than previous generations. Rising levels of STIs and the first reported cases of HIV/AIDS are the warning signs of health-care problems to come.

Following the disintegration of the Soviet Union, Mongolian officials, along with UN agencies, implemented small-scale HIV prevention initiatives, but there was no coordinated mass media campaigning to educate the public. Although only two cases of HIV/AIDS have been officially reported in Mongolia to date, indications are that the stage is set for a significant epidemic. Registered cases of STIs, such as syphilis and gonorrhoea, are sharply increasing and many researchers feel the official figures underestimate the actual HIV/AIDS situation.

Mongolian health authorities acknowledge the danger of an epidemic and the necessity of starting prevention activities. In 1999, they contacted Médecins Sans Frontières (MSF), an international humanitarian organisation which had already been implementing HIV prevention programmes in Russia for three years. That same year, an MSF team began a two-pronged approach – the country's first safe sex mass media campaign and the first pre- and post-HIV counselling programme – to fight HIV/AIDS in Mongolia.

Mass media campaigns

At the end of 1999, MSF and the Mongolian Ministry of Health (MOH) began a mass media campaign to increase public awareness about HIV/AIDS. The campaign, entitled "A Healthy and Wise Choice," targeted 15-25-year-olds, one of the principal vulnerable groups. Using public service announcements on radio and TV, billboard and bus ads, and distributing 200,000 leaflets, the campaign worked to break down cultural taboos that make it difficult to discuss sexuality and to create a social atmosphere in which young people could feel more comfortable learning about, and implementing, safer sex practices.

Although the campaign was originally designed only for Ulaan Bataar youth, interest and demand by doctors and other health-care providers soon spread the message across the country. A survey following completion of the campaign showed overwhelming support for the campaign message, with nine out of ten Mongolian respondents saying the education effort should continue.

Still, MSF programme coordinators continued to find many youth reluctant to discuss safe sex issues with their partners. While most were aware of the campaign, less than one-third were regularly using condoms, mostly because they were too shy or reluctant to broach the issue.

Therefore, the second campaign was designed to encourage partners to talk about, and practice safer sex and to search for more information. The second, follow-up mass media campaign – "Safe Sex, A Healthy and Wise Choice" – was launched at the end of 2000. This time the message included the words "sex" and "condom" for the first time, something project coordinators had been reluctant to do during the first campaign for fear of alienating the more conservative segments of Mongolian society.

Although a survey of the effectiveness of the second campaign is still underway, initial indications are that more and more Mongolians are getting the message and heeding the warning. The campaigns appear to be relaxing many of the traditional cultural barriers and improving the knowledge, attitudes and behaviour of Mongolian young people towards HIV/AIDS and safer sex issues. Mass media campaigns are scheduled to continue under the joint supervision of Mongolian government and NGOs.

Pre- and post-HIV/STI test counselling programmes

In the past, Mongolia has implemented involuntary HIV testing or testing without informed consent. Presently, HIV testing is performed among pregnant women, blood donors and individuals considered at high risk, including STI patients. Often no pre- and post-HIV/STI test counselling was offered and the privacy of test results was not guaranteed, especially in the out-lying provinces. MSF has worked to change this policy through the implementation of a voluntary counselling and testing programme with the results incorporated into a countrywide HIV prevention approach.

In 1999, MSF and the Mongolian MOH initiated Mongolia's first pre- and post-HIV/STI test counselling programme. This programme provides important training for health professionals who administer HIV/STI tests. The training programme, which was developed and adapted with the help of local health providers, resulted in the creation of a national training team representing many different disciplines, including psychology, venerology and gynaecology.

To date, more than 250 health-care providers from all 21 provinces of Mongolia have participated in comprehensive training courses. The training programme has been supported by teaching materials, round table discussions and evaluation visits to training sites. Training teams have also received additional instruction in basic psychology, social marketing and fundraising. About a third of those who have participated in the training programme have gone on to conduct their own programmes, sharing facts, information and strategies and continuing the spread of the programme throughout the country.

The voluntary HIV/STI counselling and testing programme has become an integral part in the development of an overall approach to combating the spread of both HIV and STIs in Mongolia. The programme is scheduled to be handed over to a Mongolian NGO, which will continue to gather critical information and provide counselling training for public health workers.

In the summer of 2001, MSF will conclude its operations in Mongolia. With the help of the Mongolian MOH, local health providers and other organisations, the country is now prepared to continue efforts to prevent HIV infection. Thanks to these groups, the Mongolian people are better educated, informed, and able to fight the spread of a disease they will inevitably face.