Tibet Autonomous Region

Join in circuit on AIDS, love and sexuality

Von Monika Christofori & Sybille N’Zebo / Schweizerisches Rotes Kreuz SRK

The news about HIV is still not spread to all corners of the globe. However, once the information reaches, the impact is immense. The evaluation of the ‘Join in circuit’ carried out with the rural population in Shigatse Prefecture of the Tibet Autonomous Region has shown impressive results in terms of knowledge increase.

Along term impact on behavior change will, among other factors, depend on the broadening of scope to merge family planning and disease control in order to bring sexual reproductive health and dual protection forward within the Chinese health policy.

Since 1986 the Swiss Red Cross (SRC) is engaged in the Shigatse Prefecture of the Tibet Autonomous Region (TAR) of the Peoples Republic of China providing different health care interventions to the rural and urban population. HIV prevention has been part of the project activities since 2002.

The situation of Sexual Reproductive Health and HIV/AIDS in Tibet

Risk factors in the Tibet Autonomous Region (TAR) are many fold: a large migrant population within TAR and from ‘mainland’ China induces prostitution. Polyandry is still practiced in more than one third of the families. Sex outside marriage is generally tolerated well in Tibetan society. Knowledge about HIV is very low and condoms not well known. Even though family planning is compulsory in China, the condom is not well promoted for family planning, let alone for protection of HIV. Sexually Transmitted Infections (STIs) are wide spread. Underreporting of STIs appears to be high since health workers at grass root level are not trained to sufficiently detect them.

Official data on HIV prevalence in TAR are not published. However, the HIV prevalence is estimated to be on a sharp increase. While 70 cases were reported by the local Center for Disease Control (CDC) during 1993-2008, the figure increased by 130 new cases in 2009-2010. In recent years the response to HIV has been much scaled up. The CDC carries out Voluntary Counseling and Testing (VCT) at Prefecture level with some person groups being compelled to go for VCT. Since 2010 anti-retroviral treatment is also supplied there. Rapid tests are done in the county. All persons living with HIV and AIDS are registered in a central database. Once their status is confirmed they are sent back to their place of home. Even though officially the names and data of the positive persons are not disclosed, their exclusion from the workplace and forced return to their homeland indicates the high level of stigmatization and discrimination in the country.

Within the Chinese health system, the CDC is mandated to work on communicable disease control including HIV and AIDS. The health system maintains a separate department for family planning. Both departments work completely independently due to the fact that the present national health policy does not foresee a link between Sexual Reproductive Health (SRH) and HIV/AIDS. The importance to collaborate or even merge both departments with the aim to have a better impact on sexual reproductive health, has not been realized yet. Since condoms are not promoted as important family planning device, the potential of condoms for dual protection is not tapped at all. On the contrary, the family planning department claims to always be short of condoms. This underlines the fact that an integrated approach has not yet been internalized at central level.

HIV Prevention and Join in circuit by the SRC

The SRC is the first NGO in TAR which implements an integrated approach of SRH and HIV/AIDS in all the HIV prevention activities. HIV prevention is tailored to the needs and scope of the different target groups. During peer education for vocational school students, information stands for the general public, the HIV Join in circuit or workshops and counseling for individual bar girls, the SRC team always imparts knowledge on sexual reproductive health equally with knowledge on HIV and AIDS. In the HIV Join in circuit (developed by the BzGA Germany and first adapted to different cultural contexts by GIZ) these elements are attractively presented and locally conceptualized, creating a lively learning environment. Working with pictures and games enhances the participation of equally literate and illiterate participants. Likewise all information is given in Chinese and Tibetan language. The HIV Join in circuit has mostly been used by the project in rural areas as part of the Health Promotion component.

In the five tents of the HIV Join in circuit different topics related to SRH and HIV are discussed. In a community, each family is invited to send one male and one female representative as participants. Up to 75 people can participate at once. In groups of maximum 15 persons they visit each tent for about 20 minutes. Each session is guided by a trained facilitator, who are staff of the SRC and the local Red Cross partner.

Tent transmission ways: ‘Be informed’. Participants learn about the transmission ways of the HI-virus. They discuss the different procures according to risk.

Tent love and sexuality: ‘No taboo’. In a question-answer game participants are challenged about their views, perception and values related to love, sex and relationships. Stigma and discrimination are important topics that guide the discussion.

Tent family planning: ‘Plan your life’: The different family planning methods are introduced and participants have the chance to see them, feel them and be informed. For many this is the first time they hear that condoms are a family planning device.

Tent STI: ‘Everybody is at risk’: How can STIs be recognized? Signs and symptoms as well as how to get help is explained to avoid the consequences of untreated STIs.

Tent condom use: ‘Protect yourself’: For many participants this is the first time they see a condom and learn how to use it. The importance for dual protection is emphasized.

After the circuit, all participants get together to summarize the learning’s. Each participant receives various information leaflets, brochures and a packet of condoms and is requested to inform the remaining members of their household about SRH and HIV.

The impact of the HIV Join in circuit in regards to knowledge, attitude and behavior

While the SRC team observed the enthusiasm and interest of the participants during the HIV Join in circuit since its initiation in 2008, the impact of the methodology and integrated approach in terms of knowledge, attitude and behavior change has never been measured. Thus the team conducted a Knowledge, Attitude and Practice (KAP) survey in winter 2010/2011. 206 individual interviews were conducted with 104 respondents from rural areas in Namling county, an intervention area, where the HIV Join in circuit took place in 2009 and with 102 respondents from a non-intervention area (rural areas of Tingri county), where the HIV Join in circuit has never taken place. The two counties were purposefully chosen on the basis of similar socio-cultural characteristics. Equal participation of male and female respondents was sought. Within the two groups, respondents were randomly selected. A questionnaire with 19 closed questions related to the 5 topics of the HIV market was administered. The questionnaires were filled in by the two enumerators. Generally the female enumerator questioned the female respondents, with a few exceptions.

Findings of the KAP survey: While in the intervention area all respondents stated to have heard about HIV, only 13 % of respondents in the non-intervention area ever heard about it. Knowledge about ways of transmission as well as what a condom is also differed significantly between the groups. Similarly a high percentage of respondents in the intervention area could name different STIs. Only 16 % reported not to know STIs. The knowledge level about family planning methods, particularly the temporary ones also show a large difference among intervention and non-intervention areas. While only 4 % of respondents in the non-intervention area mention condom as a family planning device, almost 60 % of respondents in the intervention area mention condom for dual protection. More than 90 % of respondents have shared their learning’s from the HIV join in circuit with their partner.

In regards to attitude, only 31 % of respondents in the intervention area stated to negotiate sex with their partner versus 20 % in the non-intervention area. Among the interviewees who knew what a condom was, only 48 % stated that man and woman can equally suggest the use of a condom. Mostly male dominance is observed in suggesting using condoms. 42 % of the respondents in the intervention area are of the opinion that HIV positive persons need to be isolated and segregated versus 44 % opting for integration. Interestingly more men propagate integration than women (59 % versus 31 %). 50 % of respondents in the non-intervention area do not know what to do with HIV positive persons in the community.

At practise level, 38 % of the respondents in the intervention area said that they have already used a condom, exclusively the condoms distributed by the SRC team after the Join in circuit. Only 1 respondent from the non intervention area stated to having ever used a condom. 85 % of condom users used it with the regular, 18 % with irregular partners.

Conclusions of the KAP survey: Very important differences were observed in terms of significantly increased knowledge in the intervention area after the HIV Join in circuit. Interestingly the respondents from Namling immediately associated the tents with SRH and HIV giving an indication how the extraordinary methodology left long lasting memory in the people which also seemed to induce some behaviour change. The participants appreciated the HIV Join in circuit as the methodology is attractive and 97 % found the messages easy to comprehend. The fact that a high percentage of respondents was able to name and describe symptoms of different STIs is remarkable.

Behaviour has started to change with condom use inside and outside marriage. However, persons still seem to be not sufficiently empowered to negotiate sex. Discrimination and stigma towards HIV positive people seemed to rather have increased after the HIV Join in circuit in comparison to the indifferent respondents of the non-intervention areas. The SRC team particularly needs to address this in the future.

Can the SRC project influence SRH rights in TAR?

The family planning policy of the Government has been appreciated and welcomed in TAR. Families have recognised the economic value of a small family. In the past mainly long term temporary family planning methods were propagated. Recently the Government has announced further relaxation of the present one-child policy. The HIV Join in circuit explains all available methods to the participants and strongly emphasises the advantage for condoms in dual protection. The SRC hopes that through the newly acquired knowledge on family planning devices and the advantage of dual protection, participants can make an informed choice about their family planning method and feel empowered to take own decisions. With a higher demand in condoms the supply may increase. The absence of condom promotion as a family planning device, let alone for dual protection has severely limited the access to condoms. Persons living in rural areas and small towns wanting to protect themselves need to travel to the next bigger city to buy condoms in sex shops or pharmacies. Upon the request of the local xiang clinics the SRC donates some condoms, which are then given to the villagers. A further barrier is the availability of condoms for unmarried persons and youth through the public system. Since condom supply is steered through the department for family planning, only married persons have access to free condoms. Thus particularly young people are exposed to contract STIs and HIV.

The prevention activities aim to sensitize people to integrate, take care and support HIV positive persons in the community. The Government policy clearly spells out the social protection and rights for HIV positive persons. However, these rights are not yet put into practise. The SRC team endeavours to live and exemplify these rights in their work with risk groups and tries to counteract prejudice and stigma. If the social protection for HIV positive persons was guaranteed they could have positively been integrated in the HIV prevention work, helping to further break barriers. Examples of the SRC staff may gradually change peoples’ behaviour. For sure the smile and care received will make a big difference in the life of an individual.

Even though the Chinese health policy does not foresee the integration of SRH and HIV/AIDS, the local Red Cross Government partners are gradually convinced about its benefits. They have shown strong interest in the Join-in-circuit and have replicated the circuit for their own use. Government staff has been trained to carry out the circuit, mainly at county level. Implementation however has still been limited. Furthermore the CDC and Department of family planning have both increased their collaboration with the SRC project as well as among each other. In a recent joint meeting between the SRC, the CDC and Family Planning department in Ngamring county, the Family Planning department has promised to increase the supply of condoms to rural health clinics. These first steps are very important and need to be nourished. In how far these positive examples from the grassroot level will gradually stimulate and induce a policy change at central level remains to be seen.

* Monika CHRISTOFORI-KHADKA is Programm Coordinator with the Swiss Red Cross, Switzerland where she manages the Swiss Red Cross country programs with special focus on Nepal, China/Tibet and Kyrgystan. Contact: monika.christofori-Khadka@redcross.ch

* Sybille N'Zebo worked as a Health Delegate of the Swiss Red Cross in the Health Projects in China/ Tibet Autonomous Region with special emphasis on HIV prevention and health promotion. Contact: ybille_n@hotmail.com