31374 HIV/AIDS Guide for the Mining Sector A Resource for Developing Stakeholder Competency and Compliance in Mining Communities in Southern Africa Draft for pilot testing 2004 Commissioned and funded by The Canadian International Development Agency (CIDA) through the International Finance Corporation (IFC) Developed by Golder Associates Ltd., with technical assistance from CARE Canada Researched and written by Rose Smart, HIV/AIDS Consultant Published by Golder Associates Ltd. 1796 Courtwood Crescent Ottawa, Ontario CANADA K2C 2B5 Tel: 613-224-5864 Fax: 613-224-9928 www.golder.com HIV/AIDS Guide for the Mining Sector A Resource for Developing Stakeholder Competency and Compliance in Mining Communities in Southern Africa ISBN: 0-6-620-31712-4 First published: 2004 Copyright © 2004 International Finance Corporation 2121 Pennsylvania Avenue, N.W. Washington, D.C. 20433 USA Tel: 202-473-3800 www.ifc.org/ifcagainstaids All rights reserved The Guide was developed to support stakeholders and organisations working in, or with, mining communities in Southern Africa. It may be freely used, reviewed, quoted, reproduced, translated or distributed, in part or in full, provided the source is acknowledged. The document may not be used for commercial purposes or for profit. For additional copies of this publication, please contact Corporate Relations, IFC, 2121 Pennsylvania Ave., N.W., Washington, D.C. 20433; tel: 202-473-3800. We invite you to visit our website at: www.ifc.org/ifcagainstaids. The conclusions and judgements contained herein should not be attributed to, and do not necessarily represent the views of, IFC or its Board of Directors or the World Bank or its Executive Directors, or the countries they represent. IFC and the World Bank do not guarantee the accuracy of the data included in this publication and accept no responsibility whatsoever for any consequence of their use. Some sources cited in this publication may be informal or unpublished documents that are not readily available. Layout: Hoge Presentations and Graphics Contents Foreword by Peter Woicke, Executive Vice President of the International Finance Corporation .............................................................................................................7 Foreword by Clem Sunter, Chairman of the Anglo American Chairman’s Fund ................9 International Finance Corporation and IFC Against AIDS ........................................11 Acronyms ...........................................................................................................................12 Section One: HIV/AIDS Guide for the Mining Sector: What, Why and How? ......15 Introducing the Guide ..........................................................................................................16 What is the HIV/AIDS Guide for the mining sector? .........................................................16 Why was it developed and for whom? .............................................................................16 Why the focus on contractors? .........................................................................................17 How should you use the Guide? ......................................................................................17 How was the Guide developed? ......................................................................................17 Overview of the Guide .........................................................................................................18 Contents of the Guide .....................................................................................................18 Format of the sub-sections or interventions ......................................................................18 The mining sector and the HIV/AIDS epidemic .....................................................................21 The HIV/AIDS epidemic in Southern Africa ......................................................................21 The HIV/AIDS epidemic and the workplace .....................................................................24 HIV/AIDS and the mining sector in Southern Africa..........................................................26 Framework for a “blue-chip” response to HIV/AIDS ..............................................................31 Roadmap towards a “blue-chip” response to HIV/AIDS .........................................................33 Template for customising the Guide for contractors and other sectors ...................................34 Section Two: Management Strategies ...........................................................................37 Organisational HIV/AIDS audit ..............................................................................................38 Workplace HIV/AIDS policy ..................................................................................................46 Co-ordinator and workplace HIV/AIDS structure ...................................................................54 HIV/AIDS leadership and management commitment ............................................................61 HIV/AIDS legal compliance ...................................................................................................65 Behavioural surveillance – the KAP survey .............................................................................71 Biological HIV surveillance ....................................................................................................77 HIV/AIDS risk and impact assessment ...................................................................................84 Managing the human resource implications of the HIV/AIDS epidemic .................................94 HIV/AIDS corporate social investment ...................................................................................100 Section Three: Workplace HIV/AIDS Programme.......................................................107 Prevention through behaviour change communication ..........................................................109 Peer education .....................................................................................................................115 Condom promotion and distribution .....................................................................................123 STI management ...................................................................................................................129 Safe working environment ....................................................................................................134 Voluntary counselling and testing ..........................................................................................139 Prevention of mother to child transmission (of HIV)...............................................................146 Wellness programme ............................................................................................................150 Nutritional advice and support .........................................................................................152 Lifestyle education ...........................................................................................................152 Treatment of minor ailments ............................................................................................152 Treatment of STIs .............................................................................................................152 Reproductive health services for women ..........................................................................152 Prevention of opportunistic infections ..............................................................................152 Treatment of opportunistic infections ...............................................................................152 Highly active antiretroviral therapy (HAART) ....................................................................153 Psychosocial support........................................................................................................154 Family support .................................................................................................................154 Referral networks and partnerships ..................................................................................155 Section Four: External or Outreach Response.............................................................161 The greater involvement of people living with HIV/AIDS .......................................................162 HIV/AIDS partnerships and collaborative relationships ..........................................................167 HIV/AIDS networks ...............................................................................................................175 Community entry strategies for HIV/AIDS interventions ........................................................180 Community outreach projects ...............................................................................................189 Section Five: Measuring and Monitoring an HIV/AIDS Response ...........................197 Monitoring, evaluating, and recording and reporting an organisation’s response to HIV/AIDS ...........................................................................................................198 Appendices ........................................................................................................................211 Appendix One: Comparative country data .......................................................................212 Appendix Two: Fact sheet on the mining sector in Southern Africa ...................................215 Appendix Three: IFC corporate roadmap on HIV/AIDS .......................................................218 Appendix Four: Resources, references and contacts ..........................................................220 Appendix Five: Glossary...................................................................................................226 Acknowledgements ..........................................................................................................233 List of Maps, Diagrams and Tables Section One: Countries in the Southern African Development Community (SADC) ....................................21 HIV/AIDS data for the 12 SADC countries .............................................................................22 The impact of HIV/AIDS on enterprises .................................................................................24 Framework for a comprehensive HIV/AIDS response .............................................................32 Roadmap towards a “blue-chip” response to HIV/AIDS .........................................................33 Template for customising the Guide ......................................................................................34 Section Two: Template for an organisational HIV/AIDS audit ......................................................................44 A workplace HIV/AIDS policy development process ..............................................................50 IFC framework for co-ordinated action .................................................................................54 Process for using a model of the HIV/AIDS epidemic.............................................................86 Analysis of the human resource costs of HIV/AIDS to an organisation ....................................88 Section Three: Factors influencing and contributing to behaviour change .....................................................109 Different peer education approaches ....................................................................................116 Model for condom promotion and distribution .....................................................................125 Framework for a continuum of care ......................................................................................151 Section Four: Levels of involvement of PLWHAs .........................................................................................163 Template for mapping risk areas and activities .......................................................................182 Bambisanani Project advocacy checklist and report ...............................................................186 Model for moving towards an optimal outreach response ......................................................193 Section Five: Types of indicators ................................................................................................................200 M&E framework ...................................................................................................................201 GRI indicators .......................................................................................................................202 Template for an M&E plan ....................................................................................................204 Template for reporting on HIV/AIDS......................................................................................204 Different forms of economic evaluation ................................................................................206 Appendix One: Basic demographic data ........................................................................................................212 Key economic data ...............................................................................................................213 Development data ................................................................................................................214 Appendix Two: Estimates of the mining and minerals sector’s contribution to economies of continental SADC states in 1999 .......................................................................................216 Contribution of mining to GDP , selected countries ................................................................216 Employment of foreign migrants in the South African mining industry....................................217 List of Case Studies Section Two: An organisational HIV/AIDS audit – Unilever.........................................................................43 Workplace HIV/AIDS policy – South Deep Mine ...................................................................51 Terms of reference for a workplace HIV/AIDS Task Team – South African government departments ......................................................................................................58 HIV/AIDS leadership and management commitment – Anglovaal (AVMIN) ...........................63 HIV/AIDS legal compliance – South African Department of Labour .......................................69 KAP survey – Placer Dome....................................................................................................75 HIV surveillance study – Aurum Health Research and AngloGold ..........................................82 HIV/AIDS impact assessment – Anglovaal (AVMIN) ...............................................................92 HR data collection – Debswana ............................................................................................97 Corporate social investment – Anglo American, Richards Bay Minerals and ESKOM .............104 Section Three: Behaviour change activities – AngloGold ...............................................................................112 Peer education – NAMDEB ...................................................................................................120 Condom promotion and distribution – FB Vending ...............................................................126 Successful STI management – Harmony Gold Mining Company and others ...........................132 Universal infection control precautions as part of a workplace HIV/AIDS programme – “Working for Water” programme, South African Department of Water Affairs and Forestry .................................................................................................137 VCT programme – AngloGold ...............................................................................................143 Trade union policy on PMTCT – Sactwu ................................................................................148 Elements of wellness support and management – Gold Fields ................................................157 Section Four: GIPA field worker placement – ESKOM (South Africa) ...........................................................166 HIV/AIDS partnerships – Sishen Iron Ore Mine .....................................................................173 HIV/AIDS network – Namakwa Sands ...................................................................................178 Advocacy checklist and report – Bambisanani Project ...........................................................185 Powerbelt initiative – Anglo Coal, Ingwe Coal, Duiker Coal and others ..................................194 Home-based care for ex-mineworkers – TEBA and others .....................................................194 Section Five: Recording and reporting on an organisational HIV/AIDS response – Assmang ........................208 Foreword by Peter Woicke At IFC, we recognize that economic growth is sustainable only if environmentally and socially sound. HIV/AIDS reduces prospects for development and poses a major challenge for the private sector. In the developing countries, which account for 95 percent of all HIV infections, the epidemic is as much a business issue as it is a health and humanitarian concern. Southern Africa is particularly affected by HIV/AIDS. The disease already has a major impact on the economies in the region and especially on the mining sector, which is a key business driver. Based on southern African experience, the Guide for the mining sector is a valuable tool in the fight against AIDS. It provides practical advice and management guidance that will help companies implement intervention strategies. The Guide will become an integral tool of the “IFC Against AIDS” program, which we launched in 2000 as part of our commitment to sustainable development. The program helps clients understand the multiple impacts of the disease and provides guidance for corporate HIV/AIDS Action Plans. IFC’s anti-AIDS approach pays special attention to a company’s specific needs and resources, as well as existing corporate experiences and good practices. The Guide will contribute to IFC’s mission, which is to promote sustainable private sector investment in developing countries. Peter Woicke Executive Vice President International Finance Corporation Foreword by Clem Sunter The publication of this HIV/AIDS Guide for the mining sector in Southern Africa is most welcome. Not only is it comprehensive in its coverage of all the issues, it is set out in such a way that it is easy to read and, more importantly, to implement in the work situation. The author, Rose Smart, is to be congratulated. Indeed, this Guide can be used by any company in any industry as the elements that form an effective strategy to combat the epidemic are common to all industries. Broadly, for a company to rise to the challenge and make a comprehensive response in the war against HIV/AIDS, the framework should be as follows: 1. A clear policy should be agreed at Board level and it should be seen as a prime part of the CEO’s responsibility to turn the policy into action. HIV/AIDS is such a strategic issue that it cannot be delegated to the Human Resources Department to handle as just another personnel matter. Ideally, where the company can afford it, a dedicated HIV/AIDS Co-ordinator should be appointed to oversee the programmes that convert the policy into activities on the ground. He or she should report directly to the CEO and provide the Board with regular updates on progress. The prime objective of any policy must be to create an enabling, non-discriminatory environment in which HIV/AIDS is viewed as just another medical condition – albeit a very important one – that is handled professionally, compassionately and properly. 2. This ushers in the second point which is the necessity for monitoring the programmes which are implemented in terms of the HIV/AIDS strategy. Key performance indicators on prevention, care and treatment need to be drawn up and agreed. Part of the remuneration package of the managers responsible for achieving results in this area should depend on whether the indicators show a satisfactory trend or not. In other words, HIV/AIDS should be regarded in exactly the same light as safety. After all, it is a huge part of the ‘H’ in any SHE (Safety, Health and the Environment) programme. 3. In addition, corporate HIV/AIDS programmes have to be evaluated at regular intervals because knowledge of what is and what is not effective is still at an early stage. This will necessitate feedback loops on whether prevention programmes are actually achieving behavioural change and whether care and treatment initiatives are really improving the quality of life of those infected with the virus and their families. 4. More specifically, the centrepiece of any workplace programme should be voluntary counselling and testing. This in turn will only happen on a wide scale if a proper wellness programme is already in place, which includes treatment of opportunistic diseases such as TB and pneumonia as well as antiretroviral therapy (when a patient’s CD4 count falls below a certain threshold figure). It goes without saying that people will only come forward in large numbers to be tested if there is something in it for them in the event that they test positive. Another critical element of any prevention programme is to encourage employees to have regular check-ups for sexually transmitted infections in general as these vastly increase the chances of catching HIV and they can all be successfully treated. 5. For a company to fulfil all three legs of the triple bottom line (profits, people and the planet) in regard to HIV/AIDS, outreach programmes in the neighbouring communities of the company’s operations must be added to workplace programmes. On a nation-wide scale, support should also be given to NGOs who are involved in such activities such as education for behavioural change, preventing mother to child transmission, looking after AIDS orphans and generally providing care and support for those infected and their families. Many opportunities already exist for partnerships between the public and private sectors and these partnerships should include the trade unions, NGOs and faith-based institutions as well. The war will only be won if past differences are set aside and all parties co-operate to defeat a common enemy. So read this Guide and then act on it. Instead of ‘ready, aim, have another workshop, aim …’, you need to fire! Begin by implementing some of the easily doable steps recommended within its pages. Get the momentum going and see where it leads. The war against HIV/AIDS within your company and its surrounding areas can be won, but it requires the Board and the CEO’s commitment at the top and workplace/ community participation at grassroots level to do so. Clem Sunter Chairman Anglo American Chairman’s Fund International Finance Corporation and IFC Against AIDS The International Finance Corporation (IFC), the private sector investment arm of the World Bank Group, promotes the economic development of its member countries. IFC is committed to providing industry with practical guidance and support in addressing key issues associated with sustainable development. INTE R NATIONAL FINANCE The IFC Against AIDS programme was created because many companies felt the need to do something about HIV/AIDS, but didn’t know where to start. IFC Against AIDS provides assistance COR POR ATION World B ank Group in the following areas: • Awareness: Helping client companies to understand the impact of HIV/AIDS on their business and to assess the risks; • Guidance on developing HIV/AIDS action plans: Providing tools and advisory services to design and implement effective responses for controlling the spread and effects of the disease; and • Networking: Facilitating linkages with local organisations and practitioners that can offer support and technical assistance to companies implementing HIV/AIDS programmes. The HIV/AIDS Guide for the mining sector is an initiative of the IFC. The Environment and Social Development Department of the IFC and the IFC Against AIDS programme commissioned the testing, publication and dissemination of the Guide as part of a corporate effort to raise awareness and build the capacity of the private sector to effectively manage the risk of HIV/AIDS in the workplace. The Guide is one of a series of tools that is being provided by the IFC to promote action and the sharing of best practice among IFC clients and the wider private sector that are engaged in the fight against HIV/AIDS. For more information on the IFC Against AIDS programme contact ifcagainstaids@ifc.org or visit their website at www.ifc.org/ifcagainstaids. Acronyms AGM Annual General Meeting AfA Aid for AIDS AHR Aurum Health Research AIC AIDS Information Centre (in Uganda) AIDS Acquired immune deficiency syndrome AMS HIV/AIDS Management System (from NOSA) ARC AIDS-related complex ART Antiretroviral therapy ARV Antiretroviral (drug) ASO AIDS Service Organisation AVMIN Anglovaal Mining Ltd. BCC Behaviour change communication CASM Community and small scale mining CBO Community-based organisation CDC Centers for Disease Control and Prevention CEO Chief Executive Officer CIDA Canadian International Development Agency CME Continuing medical education COSATU Congress of South African Trade Unions CSM Condom social marketing CSI Corporate social investment CSIR Council for Scientific and Industrial Research DCSA DaimlerChrysler South Africa DOTS Directly observed treatment (short course) (for TB) DRC Democratic Republic of the Congo DWAF Department of Water Affairs and Forestry (South Africa) EAP Employee Assistance Programme ECD Early childhood development EEA Employment Equity Act (South Africa) GDP Gross domestic product GFL Gold Fields Ltd. GIPA Greater involvement of people living with HIV/AIDS GNP+ Global Network of People Living with HIV and AIDS GRI Global Reporting Initiative HAART Highly active antiretroviral therapy HBC Home-based care HIV Human immunodeficiency virus HR Human resources ICFTU International Confederation of Free Trade Unions IEC Information, education and communication IFC International Finance Corporation IGA Income generating activity ILO International Labour Organisation JD Job description JSE Johannesburg Securities Exchange KABP Knowledge, attitudes, behaviours and practices KAP Knowledge, attitudes and practices KCM Konkola Copper Mines KPA Key performance area KYS Know Your Status (Sishen campaign) LSHTM London School of Hygiene and Tropical Medicine MDR Multi-drug resistant TB MIS Management information system MOU Memorandum of understanding MTCT Mother to child transmission (of HIV) NEDLAC National Economic Development and Labour Council NEPAD New Partnership for Africa’s Development NOSA National Occupational Safety Association NUM National Union of Mineworkers OH&S Occupational health and safety OVC Orphans and vulnerable children PIA Private Investors for Africa PEP Post exposure prophylaxis PHC Primary health care PLWHA/PLHA Person living with HIV/AIDS PMTCT Prevention of mother to child transmission (of HIV) PPT Periodic presumptive treatment (of STIs) PR Public relations PRA Participatory rural appraisal PSI Population Services International RBM Richards Bay Minerals SABCOHA The South African Business Coalition on HIV/AIDS SADC Southern African Development Community SFH Society for Family Health SHE Safety, health and environment SMME Small, medium and micro enterprise STD Sexually transmitted disease STI Sexually transmitted infection SWOT Strengths, weaknesses, opportunities and threats TB Tuberculosis TEBA (previously) The Employment Bureau of Africa TOR Terms of reference UNAIDS Joint United Nations Programme on HIV/AIDS VCT Voluntary counselling and testing VP Vice-President WEF World Economic Forum Section One HIV/AIDS Guide for the Mining Sector: What, Why and How? Section One contains: An introduction to the Guide; - What is the HIV/AIDS Guide for the mining sector? - Why was it developed and for whom? - Why the focus on contractors? - How should you use the Guide? - How was the Guide developed? If we are to reach the Millennium An overview of the Guide; Development Goal of halting the spread - Contents of the Guide of AIDS by the year 2015, there is literally - Format of the sub-sections or interventions no time to lose. We have to work really very, very hard. It means helping every The mining sector and the HIV/AIDS epidemic; country understand that speaking up - The HIV/AIDS epidemic in Southern Africa about AIDS is a point of honour, not - The HIV/AIDS epidemic and the workplace a point of shame. It means explaining - HIV/AIDS and the mining sector in Southern Africa to everyone that stigmatising high risk groups, and imagining that everyone else A framework for a “blue-chip” response to HIV/AIDS; is safe from infection, is both morally and factually wrong. No one should A roadmap towards a “blue-chip” response to HIV/AIDS; and imagine that we can protect ourselves by building barriers between ‘us’ and A template for customising the Guide for contractors and other sectors. ‘them’. In the ruthless world of AIDS, there is no us and them. Kofi Annan, UN Secretary General on a visit to the Ukraine Section One Introducing the HIV/AIDS Guide for the Mining Sector Introducing the HIV/AIDS Guide for the Mining Sector What is the HIV/AIDS Guide for the mining sector? The HIV/AIDS Guide for the mining sector, referred to throughout as the Guide, is a compendium of resources – information, tools and case studies – that can be used individually or collectively by stakeholders and organisations working within mining communities in Southern Africa, to initiate or strengthen their responses to the HIV/AIDS epidemic. Why was it developed and for whom? Mining communities constitute one of the most important and influential sectors in Southern Africa. They are also communities that are being severely impacted by the HIV/AIDS epidemic. HIV/AIDS Guide for the Mining Sector: What, Why and How? The Guide is intended to support the development of HIV/AIDS competencies and compliance in stakeholders and organisations operating in mining communities across Southern Africa. The Southern African mining sector comprises a range of actors, including small scale miners, mining companies, suppliers, contractors and associated industries, national ministries, NGOs, labour unions and research institutions. The primary users of the Guide will be emerging mining companies, trade unions, organisations providing goods or services to the large mining companies (eg contractors and service providers) and stakeholders from other related sectors (eg construction and transport). For ease of reference these diverse users are referred to throughout the Guide as contractors. The secondary users of the Guide will be large mining companies with well-established HIV/AIDS programmes, the partners of these companies, such as the Chambers of Mines, training and research institutions, government ministries, NGOs, consultants – from geologists to jewellers – and even SMMEs and informal sector operations. Page 16 Why the focus on Contractors? There are multiple organisations – some small, some larger – that interface with mining companies, such as contractors, suppliers, service providers or partners. For example, in many mining companies at any point in time, there could be as many contractors on site as permanent employees of the company. Understanding that contractors and employees interact with one another, and that Section One the spread of HIV occurs within sexual and social networks, mining companies have identified that the lack of opportunity to involve contractors in their workplace HIV/AIDS programme, or to ensure that contracting companies have their own synergistic programmes undermines the effectiveness of their own HIV/AIDS programmes. The Guide was therefore developed to assist in addressing this problem; whether Section Two it is used by the mining companies as a resource in their interactions with their contractors, or by the contractors themselves. How should you use the Guide? There are no rules about how the primary and secondary users should utilise the Section Three Guide; rather it is intended that every user will discover their own, individual uses for it. So, the Guide may be used when: • Embarking on an HIV/AIDS response; • Tackling a particular intervention for the first time; • Reviewing an existing HIV/AIDS response, with a view to modifying and Section Four strengthening the response; or • Reviewing a particular intervention for similar reasons. The Guide can also be used when assisting others, such as contractors, suppliers, unions and partners to establish or strengthen their HIV/AIDS responses. Section Five Because the users and the contexts within which the Guide will be applied will vary considerably, adaptation of the tools and score cards will make them more relevant and useful, and users are encouraged to make whatever modifications are necessary to suit their situations and needs. A template for customising the Guide can be found at the end of Section One. Appendices How was the Guide developed? The Guide was developed following an assessment of current responses to HIV/AIDS by the mining sector (conducted by Golder Associates Ltd. in association with CARE Canada, in 2002), and involved periodic consultation and dialogue with IFC and Acknowledgements specifically the IFC Against AIDS programme, and mining and social development specialists from the Corporation. The contents of the Guide was then defined based on the assessment results and a review of the emerging best practices in the workplace. Many of the tools and case studies in Sections Two, Three and Four of the Guide are drawn from these sources. The draft Guide was field tested in two phases; firstly with a range of mining sector HIV/AIDS experts and secondly with potential users. In 2004, the Guide was piloted in selected companies and settings – in South Africa, Botswana and Zambia – following which it was finalised and officially launched. Page 17 Section One Overview of the Guide Contents of the Guide The Guide consists of five sections. Section One – which introduces the Guide, provides key background information on the mining sector and the HIV/AIDS epidemic, describes the contents of, and Overview of the Guide framework and roadmap for an optimal organisational response to the HIV/AIDS epidemic, and finally provides a template to customise the Guide. Section Two – which covers the strategies for managing the HIV/AIDS epidemic within a mining sector organisation. HIV/AIDS Guide for the Mining Sector: What, Why and How? Section Three – which deals with workplace or internal HIV/AIDS programmes. Section Four – which describes a number of outreach or external HIV/AIDS activities. Section Five – which contains information and tools for monitoring, evaluating, and recording and reporting on an organisational HIV/AIDS response. A number of appendices follow Section Five, providing: • Comparative country data for the SADC region; • Information on the mining sector in Southern Africa; • The IFC corporate roadmap on HIV/AIDS; • Lists of resources, references and contacts; and • A glossary of terms. Format of the sub-sections or interventions In Sections Two, Three and Four there are a number of sub-sections, each of which refers to a particular HIV/AIDS intervention, eg behavioural surveys, workplace HIV/AIDS policies, peer education, wellness programmes, partnerships etc. Page 18 Each sub-section consists of four parts. For easy reference, different icons introduce each part: INFO Part 1: Briefing Note The briefing note contains key background information about the intervention – such as what it is, why it is important for an organisation to include this as part of its HIV/AIDS response, what the components are of the intervention, and any issues Section One for contractors. Red flags or special challenges, where these exist, are indicated with this icon, serving to draw attention to issues and potential problems that have commonly been experienced by organisations in implementing the intervention. Section Two Part 2: Tool The tools can be used in implementing the intervention. They take many forms; checklists, processes, menus, rules, templates, sets of questions and so on. Typically they are drawn from the literature and have been tested in various circumstances (though not necessarily in the mining sector). They can be used as they appear in Section Three the Guide, or adapted as required for different contexts. Part 3: Score Card 10/10 The score card is a ranking system against which to measure an organisation’s status in relation to a particular intervention. In line with the National Occupational Safety Section Four Association (NOSA) HIV/AIDS Management System (AMS 16001: 2003)1, a minimal response equates to a 1 red ribbon rating, a good response earns 3 red ribbons and a “blue-chip” or best response qualifies for 5 red ribbons. The red ribbon is a symbol used all over the world to show awareness and understanding regarding HIV/AIDS and to demonstrate solidarity with those who Section Five are infected and affected. Rating Future Actions Appendices  Minimal Response  Good Response  “Blue-chip” Response Acknowledgements The actions included in each of the score cards are not comprehensive, but are indicative examples of different level responses. They are also, in the main, cumulative, i.e. an organisation should have implemented the actions against 1 red ribbon, as well as those against 3 red ribbons, in order to score 3 red ribbons, and all the actions listed, to qualify for 5 red ribbons. Page 19 The score cards are thus intended to enable users to identify and quantify (by allocating a rating to each of their interventions) their areas of strength and weakness and to record the next steps (future actions) to strengthen their responses. For example, you may rate each listed activity as follows: • 1 = poor or below average • 2 = average • 3 = good This allows for the calculation of a score for each intervention (HIV/AIDS risk and impact assessment, peer education, HIV/AIDS partnerships etc), a total for each of the 3 pillars of your HIV/AIDS response (management strategies, workplace programme and outreach programme), and a composite score for your entire HIV/AIDS response. Over time the score cards can be used as monitoring tools to track and measure progress. Following each score card, where data does exist, the costs of interventions are indicated, to guide decision-making regarding prioritising and financing interventions. Part 4: Case Study CASE The case studies describe a real life example of each intervention. These are drawn Overview of the Guide STUDY either from the literature or from the experiences of the informants during the field testing. The case studies are not necessarily best practices, but all contain valuable lessons from the field. Finally, where good sources for additional information about the intervention exist, these are listed at the end of each of the sub-sections. HIV/AIDS Guide for the Mining Sector: What, Why and How? Examples or quotes appear throughout the text, to illustrate key points. Remember, each of the Sections (Two to Four) and the sub-sections within these can be used individually or in combination. Footnotes 1 The NOSA AMS is an internationally recognised standard specification against which HIV/AIDS management systems can be assessed and certified. To access the AMS and the accompanying guideline document, go to www.nosa.co.za Page 20 Section One The Mining Sector and the HIV/AIDS Section One Epidemic Section Two The HIV/AIDS Epidemic in Southern Africa Countries in the Southern African Development Section Three Community (SADC) As the world enters the third decade of the AIDS epidemic, the evidence of its impact is undeniable. Wherever the epidemic has spread unchecked, it is Section Four robbing countries of the resources and DRC capacities on which human security and development depend. In some regions, Tanzania T HIV/AIDS, in combination with other crises, is driving ever-larger parts of nations towards destitution. Section Five Angola UNAIDS; AIDS epidemic update: Malawi December 2002 Zambia Zambia Zimbabwe Mozambique Appendices Namibia Botswana Swaziland Lesotho Acknowledgements South Africa Capital City UNAIDS estimated that, at the end of 2003, 26.6 million adults and children were living with HIV/AIDS in sub-Saharan Africa1, representing an adult prevalence rate of between 7.5% and 8.5%. Of the infected adults, more than half are women. A summary of key HIV/AIDS data for the SADC countries follows. Additional demographic, development and economic data about these countries can be found in Appendix One. Page 21 HIV/AIDS data for the 12 SADC countries Adults and children Adults Total orphans Orphans due living with HIV/AIDS (15-49 years) as % of all to AIDS as (End 20012) HIV children4 % of total prevalence orphans and Country rate3 absolute Low High number5 estimate estimate Angola 250 000 450 000 5.5% 10.7% 14.9% 104 000 70.5% The Mining Sector and the HIV/AIDS Epidemic Botswana 260 000 390 000 38.8% 15.1% 69 000 DRC 960 000 1 700 000 4.9% 9.4% 41.8% 1 366 000 Lesotho 230 000 480 000 31% 17% 53.5% 73 000 Malawi 720 000 1 100 000 15% 17.5% 49.9% 468 000 Mozambique 860 000 1 500 000 13% 15.5% 32.8% HIV/AIDS Guide for the Mining Sector: What, Why and How? 418 000 Namibia 150 000 230 000 22.5% 12.4% 48.5% 47 000 South Africa 4 000 000 6 000 000 20.1% 10.3% 43.3% 662 000 Swaziland 130 000 200 000 33.4% 15.2% 58.8% 35 000 Tanzania 1 200 000 1 700 000 7.8% 12% 42.3% 815 000 Zambia 930 000 1 400 000 21.5% 17.6% 65.4% 572 000 Zimbabwe 1 800 000 2 700 000 33.7% 17.6% 76.8% 782 000 Page 22 Southern Africa is home to about 30% of the global total of people living with HIV/AIDS (PLWHAs), yet this region has less than 2% of the world’s population. Countries in Southern Africa have the highest HIV prevalence rates in the world, with at least one in five adults infected in a number of the SADC countries. Amongst the factors that have contributed to this are: • Poverty associated with significant income inequalities and widespread unemployment – circumstances that have been linked to high-risk sexual Section One behaviour and the spread of HIV; • The low status of women, which increases their vulnerability to HIV infection; • High prevalence of other STIs, which increases the probability of HIV transmission; • Multiple sexual relationships; • Low levels of condom use; Section Two • Low levels of male circumcision; • Cultural practices, such as early sexual debuts, dry sex and widow inheritance; and • High mobility, settlement patterns, population dislocation in times of drought, conflict or war and worker migration. Section Three In all of the SADC countries these factors take different forms, and the HIV/AIDS epidemic too is different, not just between countries, but within countries. For example, Botswana, Namibia and South Africa are the least poor of the SADC countries, yet they both have very high levels of HIV prevalence, which may be related to some extent to the huge income disparities in these countries. Countries supplying large Section Four numbers of migrant workers to the mines in South Africa – Lesotho and Swaziland – have very rates of HIV infection, but Mozambique, which also falls into this category has a much lower level of infection. Countries emerging from conflict and war appear to have relatively low levels of HIV Section Five infection, though some of the data should be treated with caution as surveillance systems in these countries tend to be less robust than those in other countries. As an example, the following extract from the UNAIDS AIDS epidemic update (December 2003) describes the situation in Angola6. Angola gives cause for concern Appendices despite the comparatively low HIV levels detected to date. After almost four decades of war, huge population movements are underway. Millions of people have been able to leave the cities and towns they had been trapped in, internal and cross-border trading movements are resuming, and an estimated 450 000 refugees are returning (many from neighbouring countries with high HIV prevalence rates). Such conditions could prime a sudden eruption of the epidemic. Acknowledgements In the final analysis, one similarity does emerge across all countries, namely the very high rates of orphans as a percentage of all children – over 10% in every country, bar the DRC which is close, at 9.4%. As more and more parents succumb to AIDS, this problem will continue to grow, representing arguably the greatest challenge to the future of the Region; a challenge which countries are only very recently acknowledging and attempting to address. Page 23 … companies have lost top managers, The HIV/AIDS Epidemic and the workplace workers have lost colleagues and huge amounts of time, energy and emotion The HIV/AIDS epidemic impacts on all spheres of life. One of the most significant have been spent pre-occupied with features is its concentration in the working age population (aged 15-49) such that issues of illness and loss. Whole families those with critical social and economic roles are disproportionately affected. have collapsed, while companies strug- gling against a background of chronic HIV/AIDS hits the world of work in numerous ways, as illustrated in the diagram poverty have taken on deeper burdens below. of dependency. Loewenson, R (1998) The impact of HIV/AIDS on enterprises7 The Mining Sector and the HIV/AIDS Epidemic ncreased Increased Increased Loss Loss of tacit Declining absenteeism ff f turnover staff of skills knowledge morale Insurance cover Retirement funds for f Increasing demands fo r HIV/AIDS in training and recruitment recruitment safety fe f ty Health and safe Reduced Reduc rkets Declining markets, Declining f i foreign Medical assistance r, r labour, intellectual direct suppliers capital HIV/AIDS Guide for the Mining Sector: What, Why and How? investment Funeral costs Declining Declining re-investment reliability Increased costs Declining productivity Declining profits If you are an executive in a corporation In badly affected countries, it cuts the supply of labour and reduces income for many with operations in South Africa, or one of workers. Increased absenteeism raises labour costs for employers, and valuable skills its neighbours, chances are that anywhere and experience are lost. Often, a mismatch between human resources and labour from 10% to 40% of your employees requirements is the outcome. there are HIV positive. Harvard Business Review Stigma and discrimination negatively affects production and workplace morale8. February 2003 Associated with lower productivity and profitability, tax contributions also decline, while the need for public services increases. National economies are weakened further in a period when they are struggling to become more competitive in order to weather the challenges of globalisation. Page 24 Extract from the Harvard Business Review AIDS is your business, by Sydney Rosen et al (February 2003) Many corporations derive a competitive worker to handle two or three tasks, advantage from the low cost of labour in or they hire two or three workers for developing countries. AIDS is eroding every job on the expectation that at Section One that advantage by adding, both directly least one will die. AIDS has also forced and indirectly, to wage bills. The disease executives to spend more time coping not only drives up health care costs with lower morale in their organisations and benefits payments, it also reduces and addressing the difficult legal, social, productivity for years – not weeks or and political issues that stem from the months as other illnesses do. Rising epidemic. For instance, companies Section Two absenteeism and higher employee in many developing countries face turnover due to HIV/AIDS have forced considerable pressure from governments companies to employ and train more and nongovernmental organisations to people than usual. For instance, spend more on tackling AIDS and to managers in companies in Zambia provide jobs and additional money for Section Three and Congo invest in training each victims’ families. In short, the epidemic is affecting the size, growth rate, and age and skill composition of both current and future labour forces. At the same time, HIV/AIDS is raising the cost of labour in all Southern African countries and diminishing the competitiveness Section Four of African business in the global marketplace. Finally, the gender dimensions of the epidemic in general, and specifically in terms of the world of work must be acknowledged. • Gender inequality – linked to patterns of social, economic and cultural inequality Section Five – makes women more vulnerable to infection. The situation is worsened further by the biological differences between men and women. • As the epidemic spreads, women are faced with the double burden of having to work and cope with the additional responsibilities of providing care and support for family and community members who fall ill. Appendices • Most women are still confronted with limited access to secure livelihoods and socio-economic opportunities. This increases their dependence on male partners and their vulnerability in situations where there are risks of HIV infection. • Men, too, are subject to social and cultural pressures that increase their susceptibility to infection and their likelihood of spreading it. Multiple partners and sexual infidelity are condoned for men in many societies. Acknowledgements • Certain occupations tend to encourage risk-taking behaviour, especially those that involve men spending long periods away from their families. This in turn increases the risk of infection for their partners when they return home. Page 25 HIV/AIDS and the Mining Sector in Southern Africa 1. Historical milestones In countries across Southern Africa the mining sector was the first sector to respond to the HIV/AIDS epidemic. 1985-6: First screening conducted in the South African gold mining industry to detect HIV among mineworkers. 1986: First group of mineworkers tested positive from Malawi. 1988: TEBA’s healthcare services developed education and awareness campaigns on STIs and HIV/AIDS, including videos shown to The Mining Sector and the HIV/AIDS Epidemic all new employees. 1989: Knowledge, attitudes and practices study showed a high level of knowledge by mineworkers about STIs including HIV/AIDS. 1989: A study on truck drivers showed that 50% of the drivers were infected with HIV, while prevalence among mineworkers was negligible. 1990: Mining companies increasingly started introducing HIV/AIDS programmes. 1990 - 2000: A randomly-selected cohort of employees from one company was followed up annually for their HIV status. Prevalence HIV/AIDS Guide for the Mining Sector: What, Why and How? of the disease in the sample increased from 1% to 26% over the life of the study. 1993: The SA Chamber of Mines established a standing committee on HIV/AIDS. 1995: The SA Chamber of Mines commissioned a survey on HIV/ AIDS in Southern Africa. 1997: The Southern African Development Community (SADC) Code on HIV/AIDS and employment was adopted. 1998: The International Labour Organisation (ILO) Code on HIV/AIDS in the workplace was developed (and adopted in 2001). 1998: South Africa’s White Paper on Mining and Minerals outlined the need to develop an HIV/AIDS policy, the plight of migrant labour, housing and living conditions and the respective responsibilities of government and employers in addressing these issues. It also emphasised the need to protect human and labour rights in relation to education, counselling, testing and treatment. Page 26 2000: A SADC HIV/AIDS Strategic Framework and Programme of Action was established, which outlines plans and strategies for dealing with the epidemic for all SADC sectors. Within this strategic framework, a section relating to mining is enunciated, which includes: • Establishing the extent of HIV/AIDS in the SADC mining Section One sector; • Minimising the spread of HIV/AIDS in the mining sector; and • Providing adequate care for the infected and affected in the mining sector. Section Two 2001: In Zambia, the Ministry of Energy and Water Development recognised the loss of human resources, lower productivity due to illness and funeral attendance, and the costs of recruiting and retraining new staff as high HIV/AIDS mortality rates took its toll. The 2001 work plan included the training of designated HIV/AIDS focal persons and health committees, the distribution Section Three of male and female condoms, establishing counselling centres, and providing support through peer education. 2001: A tripartite HIV/AIDS committee for the mining industry – between government, labour and mining companies in South Africa – was established. Section Four 2001: Debswana introduced subsidised (90%) ART. 2001 and 2002: Mining companies signed specific agreements with TEBA to provide home-based care in 4 Southern African countries, for terminally-ill mineworkers who agree to return home to Section Five the rural areas. 2002: The MMSD report on mining, minerals and sustainable development in Southern Africa was published, with a strong emphasis on HIV/AIDS. Appendices August 2002: August 2002: Anglo American announced its ART programme for employees. 2003: The first South African summit on HIV/AIDS in the mining industry was held, attended by government, labour and mining companies. Resolutions included that: Acknowledgements • Every workplace will have workplace HIV/AIDS policies and programmes in place by the end of 2004; • Prevalence survey results will be shared within a national databank framework; and • Measures will be implemented to improve the standard of housing for mineworkers. Page 27 2. The impact of the epidemic on the mining sector The mining sector is a major sector in most national economies in the SADC region, not only in terms of the number of people employed but also the foreign exchange generated by mineral exports. In South Africa, experts believe that the industry hardest hit by HIV/AIDS will be mining. Studies of the sector show HIV infection rates from one-quarter to almost one-half of the country’s miners. Zambia has a similar problem, where copper accounts for 75% of the country’s export earnings, and 18% of the copper miners (a skilled workforce) are estimated to be HIV positive. In Botswana, where diamonds account for 80% of export earnings and half of the government’s total revenue, a third of the industry’s employees are estimated to be HIV positive. Labour is an essential input in mining and the sector’s use of labour leads to unique risk situations in respect of HIV transmission because: The Mining Sector and the HIV/AIDS Epidemic • In many mining situations mechanisation is difficult and the industry is very labour intensive; • Mineworkers tend to be young males – an age category most affected by HIV/AIDS. They engage in physically taxing and dangerous work for 8-12 hours a day, with infrequent breaks, limited access to food and water, and in sweltering and dusty conditions. They also live with the constant prospect of mutilating or fatal accidents; • The use of migrant labour is common with the attendant disruption of social support mechanisms and family structures, unpleasant living conditions and limited opportunities for leisure. This, in turn, creates situations conducive to the establishment of new and/or casual sexual relationships. • The migrant system that has serviced the mines of Southern Africa has also HIV/AIDS Guide for the Mining Sector: What, Why and How? generated exaggerated forms of masculine identity that now abet the spread of HIV. For mineworkers, the lack of control over their life circumstances results in a risk-taking mentality which advocates high levels of sexual activity (often associated with alcohol use) as a way of dealing with dangerous and stressful lives. • Apart from large numbers of semi-skilled workers, mines also require highly skilled and experienced professionals such as geologists and engineers. The illness or loss of these highly skilled professionals has the potential to disrupt operations significantly. Health is another important factor, as the nature of mining requires peak physical fitness yet it is also associated with the risk of severe occupational illnesses such as pneumoconiosis, asbestosis, silicosis and tuberculosis (TB). • Silicosis is a substantial risk factor for TB, as is HIV infection; research describes a multiplicative, rather than an additive effect of these three conditions. • STIs are an important co-factor for HIV transmission and rates of other STIs have, in many instances, been found to be higher amongst mineworkers than in the general population. Although mines may provide STI treatment services for their workers, few provide treatment for their sexual partners and rapid re-infection is common. • Mineworkers who become disabled as a result of advanced HIV disease are medically retired and frequently return home to remote rural areas where resources and care are limited. With their return, the flow of income to their household ceases, resulting in increased impoverishment. For more detailed information, the MMSD9 report provides a comprehensive analysis of the impact of HIV/AIDS on mining communities. Page 28 3. Future responses by the mining sector to the HIV/AIDS epidemic Throughout Southern Africa, the mining sector has been at the forefront of efforts to respond to the HIV/AIDS epidemic. Nowhere is this more true than in respect of providing antiretroviral treatment (ART) to infected employees. Trade unions, like the National Union of Mineworkers (NUM) have also played an important role in raising the profile of HIV/AIDS as an issue and in educating workers Section One regarding HIV transmission risks, often as joint initiatives with mine management. The MMSD report made important recommendations for future responses by the mining sector to the HIV/AIDS epidemic. These included the following: • To urgently shift from IEC approaches (information, education and communication) to address the root causes of transmission: poverty alleviation, cultural norms Section Two around sex, and social and economic instability. • To establish an international charter on key prevention and care strategies to be followed throughout sub-Saharan Africa. • To shift from negative messages to ones that emphasise the need to accept HIV/AIDS and take greater responsibility for personal behaviour. Section Three • To build capacity to deliver community-based interventions by channelling resources into CBOs and NGOs; to allow communities a greater say in the course of interventions; and to provide long-term funding. • To monitor and analyse HIV/AIDS intervention programme outcomes to develop and improve quantitative understandings of cost-benefit relationships. • For company stakeholders to continue to take the initiative, but in partnership Section Four so as to play a greater role in capacity building and developing best practice. • To stimulate economic development, particularly in rural recruitment catchment areas; to subcontract services relating to HIV/AIDS care; to retrain medically boarded employees; and to encourage participation in benefit schemes. • To employ a multi-stakeholder approach to address all aspects of the problem Section Five through a combination of measures including GIPA (the greater involvement of people living with HIV/AIDS) and the protection of individual rights. • To establish alternative lower risk living conditions. • That treatments must follow a logical sequence within the limits of available resources, with priority given to interventions that address problems with highest morbidity Appendices and best cost-benefit in terms of quality of life and ability to live productively. • In order for drug costs to be affordable to those in employment, to encourage the introduction of mandatory medical benefit schemes for those in employment and to require participation in wellness schemes. • To produce guidelines for assessing the equivalent value of the non-cash elements of HIV/AIDS interventions, eg voluntary work, etc. Acknowledgements • To establish and maintain resource inventories to provide stakeholders with information on available resources. • To ensure the ability for programmes to incorporate the facility to collect quality research data and for monitoring and evaluation to be carried out in order to develop best practice. • To build capacity by co-ordinating stakeholders, seconding staff, developing individuals and subcontracting services. Page 29 Additional Information The MMSD report gives an excellent summary of the history of mining in Southern Africa, available on www.iied.org/mmsd/rrep/s_afr.html. As part of the MMSD process, research topic 2 examined the effect of HIV/AIDS on the mining sector and proposed recommendations for management of the pandemic in alignment with sustainable development in the sector. The report is available on www.iied.org/mmsd/rrep/s_afr.html. The mining sector is also well covered in a recent document from IOM, SIDA and UNAIDS entitled Mobile Populations and HIV/AIDS in the Southern African Region: recommendations for action (May 2003). The Mining Sector and the HIV/AIDS Epidemic UNAIDS publishes regular reports on the HIV/AIDS epidemic, which detail the status of the epidemic in all countries. These reports are available on www.unaids.org. HIV/AIDS Guide for the Mining Sector: What, Why and How? Footnotes 1 UNAIDS: Epidemic update (December 2003), available on www.unaids.org In sub-Saharan Africa at the end of 2003, between 25.0 and 28.2 million adults and children were living with HIV/AIDS; 3.0 to 3.4 million were newly infected with HIV; and between 2.2 and 2.4 million adults and children had died. 2 UNAIDS; Report on the global HIV/AIDS epidemic (July 2002) 3 UNAIDS; Report on the global HIV/AIDS epidemic (July 2002) 4 UNAIDS, UNICEF & USAID; Children on the brink 2002: A joint report on orphan estimates and program strategies (November 2002) 5 UNAIDS, UNICEF & USAID; Children on the brink 2002: A joint report on orphan estimates and program strategies (November 2002) 6 Additional information about the epidemics in Southern Africa can be found in the UNAIDS AIDS epidemic update (December 2003), available on www.unaids.org 7 Source: UNAIDS; adapted from The business response to HIV/AIDS: impact and lessons learned (2000) 8 HIV/AIDS-related stigma is a real or perceived negative response to a person or persons by individuals, communities or society. It is characterized by rejection, denial, discrediting, disregarding, underrating and social distance. It frequently leads to discrimination and violation of human rights. (Definition produced from Stigma-AIDS 2001 discussions and Regional Consultation on Stigma and HIV/AIDS in East and Southern Africa, 2001) 9 Available on www.iied.org/mmsd/rrep/s_afr.html Page 30 Section One A Framework for a “Blue-chip” Response Section One to HIV/AIDS Section Two Every organisation operating in Southern Africa is aware of HIV/AIDS and will have taken some steps to address the consequences of the epidemic in their organisation. These steps vary significantly – from ad hoc prevention activities to more considered Section Three responses, where the risks are analysed and dealt with in much the same way as other risks to an organisation’s operations. Regardless of the approach your organisation has adopted, there will always be scope for improvement. The Guide is intended to support the development of improved HIV/AIDS competencies and compliance in organisations, at every level. Section Four There are many ways to describe a comprehensive and optimal organisational response to HIV/AIDS. For the purpose of the Guide, a framework is used that clusters a number of interventions into one of three broad areas, namely: • Management strategies; Section Five • A workplace (or internal) programme, which has two main focuses; prevention, and care and support; and • An outreach (or external) programme. In striving for a “blue-chip” HIV/AIDS response, an organisation adopting this Appendices framework would set goals as follows: Goal of the management strategies To manage and mitigate the impact of the epidemic through a range of governance, assessment, surveillance, planning and monitoring strategies. Acknowledgements Goal of the workplace programme To prevent new HIV infections and provide care and support for infected and affected employees. Goal of the outreach programme To contribute to broader community, sectoral and societal HIV/AIDS responses, in areas of comparative advantage. Page 31 It is important to stress two points: 1. That this categorisation does not mean that there is no interaction, or overlap between the three areas. In fact the opposite is true, as the following examples indicate: • The results of behavioural surveillance, such as KAP surveys (which appear in the Guide as a management strategy) are used to inform the content of workplace prevention programmes; and • Peer educators (part of a workplace programme in the Guide) frequently use their knowledge and skills in outreach activities with community groups. 2. That large and small organisations can do some, but not all of the same things, A Framework for a “Blue-chip” Response to HIV/AIDS as part of their HIV/AIDS response. In many instances, however, where small organisations cannot tackle certain interventions on their own, they can achieve a great deal in partnership with larger organisations, or by finding other creative ways to achieve what large organisations may be able to achieve in more traditional ways. This framework, upon which the Guide is based, can be depicted graphically as follows: Framework for a comprehensive HIV/AIDS response Management Strategies Workplace Prevention Programme HIV/AIDS Guide for the Mining Sector: What, Why and How? Strategies to: Activities to: and evaluat Create an enabling, or ing ion Prevent new HIV non-discriminatory it pl and STI infections; environment; on ent Strategies a and Encourage M n Understand the em voluntary n ag epidemic; Ma Workp counselling and Manage and l ac eP testing. r mitigate its og ram impact; and me Proactively alter Y LI C factors that PO e ach Programm exacerbate HIV transmission. tre Workplace Ou Care and n Outreach on la p M Support Programme ito on ri n g a n d e va l u ati Programme Projects and partnerships to: Activities to: Reinforce the workplace programme; Provide holistic treatment for Enhance community and sectoral responses to infected employees; and HIV/AIDS; and Contribute to broader development Provide care and support for those and poverty alleviation targets. infected and affected. Page 32 Section One Roadmap Towards a “Blue-chip” Response Section One to HIV/AIDS Section Two List of possible priorities The roadmap, below, is a visual representation of the important elements of an for an HIV/AIDS response: HIV/AIDS response, and a way of positioning an organisation at a point along the Section Three • Organisational HIV/AIDS road towards a “blue-chip” response to HIV/AIDS, based on the interventions in audit the Guide. • Workplace HIV/AIDS policy • Co-ordinator and workplace Create your own roadmap, with a selection and sequence of interventions that reflects HIV/AIDS structure the priorities that you have set for your HIV/AIDS response. Remember, there is • HIV/AIDS leadership and management commitment more than one way to reach your destination. Section Four • HIV/AIDS legal compliance • Behavioural surveillance – the KAP survey  HIV/AIDS corporate social investment • Biological HIV surveillance Blue-chip Response Monitoring an organisational response to HIV/AIDS • HIV/AIDS risk and impact Managing the HR implications of the HIV/AIDS epidemic assessment Section Five • Managing the human Prevention of mother to child transmission of HIV resource implications of the Wellness programme HIV/AIDS epidemic • HIV/AIDS corporate social HIV/AIDS partnerships and collaborative relationships investment Biological HIV surveillance • Prevention through Appendices HIV/AIDS legal compliance behaviour change communication HIV/AIDS leadership and management commitment • Peer education Voluntary counselling and testing • Condom promotion and  distribution Good Response Organisational HIV/AIDS audit • STI management Behavioural surveillance Acknowledgements • Safe working environment STI management • Voluntary counselling and Prevention through behaviour change communication testing • Prevention of mother to Safe working environment child transmission (of HIV) Condom promotion and distribution • Wellness programme Peer education • The greater involvement of people living with HIV/AIDS  Co-ordinator and workplace HIV/AIDS structure • HIV/AIDS partnerships and Minimal Response Workplace HIV/AIDS policy collaborative relationships • HIV/AIDS networks • Community entry strategies for HIV/AIDS interventions • Community outreach projects Page 33 Section One Template for Customising the Guide The Guide will always be more useful if it has been adapted to suit the context of each organisation. These organisations may be in sectors other than mining, eg Template for Customising the Guide transport, construction, agribusiness etc, or they may be operating in Regions other than Southern Africa. The following template identifies those areas where adaptations are most likely to be required. Section One: HIV/AIDS Guide for the Mining Sector: What, Why and How? HIV/AIDS Guide for the Mining Sector: What, Why and How? What is the HIV/AIDS Guide for the Change focus from the mining sector mining sector? to your sector Why was it developed and for Add the rationale for why your sector whom? requires priority attention Overview of the Guide: format of Amend the score card to reflect a rating the sub-sections or interventions system with which you are familiar Replace the red ribbons with symbols that apply to your sector and/or geographical area The mining sector and the HIV/AIDS Replace this information with background epidemic information about: • The HIV/AIDS epidemic in • The HIV/AIDS epidemic in your Southern Africa Region • HIV/AIDS and the mining sector • The interactions between your sector in Southern Africa and the HIV/AIDS epidemic Framework for a “blue-chip” Change the “blue chip” concept to response to HIV/AIDS something that relates to your sector Roadmap towards a “blue-chip” response to HIV/AIDS Page 34 Section Two: Management Strategies • Organisational HIV/AIDS audit In all the management strategies: • Workplace HIV/AIDS policy • Delete examples, in boxes, that do • Co-ordinator and workplace not relate to your sector, and replace Section One HIV/AIDS structure with ones that are more relevant • HIV/AIDS leadership and • Review the “Red flags and special management commitment challenges” and add/amend/delete • HIV/AIDS legal compliance to more closely reflect the reality in • Behavioural surveillance – the your sector KAP survey • Change the score cards to the format Section Two • Biological HIV surveillance you have decided upon and have • HIV/AIDS risk and impact described in Section One assessment • Under “Costs”, add any cost-related • Managing the human resource information for your sector implications of the HIV/AIDS • Replace the case studies with case Section Three epidemic studies from your sector • HIV/AIDS corporate social • Delete non relevant information from investment the “Additional information” box and add sources of information from your sector and/or Region Section Four Section Three: Workplace HIV/AIDS Programme • Prevention through behaviour Conduct the same review as for the change communication management strategies, ensuring that Section Five • Peer education the information is grounded in the reality • Condom promotion and of your sector, eg the extent to which distribution health services – for STI management, • STI management PMTCT and wellness programmes – are • Safe working environment available to employees Appendices • Voluntary counselling and testing • Prevention of mother to child The provision of antiretroviral therapy transmission (of HIV) to infected employees is becoming • Wellness programme increasingly more commonly available in many sectors. When amending the Guide, make sure that this section most Acknowledgements accurately reflects the current situation in your sector Page 35 Section Four: External or Outreach Response • The greater involvement of people Conduct the same review as for the living with HIV/AIDS management strategies and workplace • HIV/AIDS partnerships and programme, ensuring that the information collaborative relationships is grounded in the reality of your sector, • HIV/AIDS networks eg the particular features of your sector • Community entry strategies for will dictate how the sector interacts with HIV/AIDS interventions the communities in which it operates • Community outreach projects Section Five: Measuring and Monitoring an HIV/AIDS Response Template for Customising the Guide Monitoring, evaluating, and recording Add/amend/delete information so that and reporting an organisation’s response this section is relevant to your sector. to HIV/AIDS For example, you may operate in areas where other systems than the NOSA standards and certification are used. If your system has any HIV/AIDS-related standards, these should be documented here. HIV/AIDS Guide for the Mining Sector: What, Why and How? Appendices Appendix One: Comparative country data Remove and replace (if required) with information that is relevant to your Region Appendix Two: Fact sheet on the mining sector in Remove and replace with information Southern Africa that is relevant to your sector Appendix Four: Resources, references and contacts Add/amend/delete with information relevant to your Region and sector Appendix Five: Glossary Add/amend/delete to reflect terminology used in your Region and sector Page 36 Section Two Management Strategies Section Two contains a number of management strategies. The goal of the management strategies is to manage and mitigate the impact of the epidemic on an organisation through a range of governance, assessment, surveillance, planning and monitoring intervention. These are: • Conducting an organisational HIV/AIDS audit; • Developing a workplace HIV/AIDS policy; • Appointing an HIV/AIDS Co-ordinator and putting a workplace HIV/AIDS structure in place; • Demonstrating HIV/AIDS leadership and management commitment; Unlike the virus, we have not been aggres- • Ensuring HIV/AIDS legal compliance; sive enough. Unlike the virus, we have not • Conducting or commissioning behavioural surveillance – the KAP been integrated and comprehensive in our survey; strategies. Unlike the virus, we have not been • Conducting or commissioning biological HIV surveillance; unrelenting in our commitment. • Conducting or commissioning an HIV/AIDS risk and impact assessment; Graca Machel at the International HIV/AIDS • Managing the human resource implications of the epidemic; and Conference in Barcelona (2002) • Corporate social investment that prioritises HIV/AIDS. Page 37 Section Two Organisational HIV/AIDS Audit INFO Briefing Note What is an organisational HIV/AIDS audit? Organisational HIV/AIDS Audit An organisational HIV/AIDS audit is a “snap shot” of the organisation’s HIV/AIDS programme at a certain point in time. Why does an organisation need to conduct HIV/AIDS audits? It is necessary to conduct regular audits in order to track progress over time from a base-line position. In the absence of regular audits, organisational responses tend to be “spray and pray” as opposed to well-considered, planned responses that build on the current reality and past achievements. Management Strategies Contractors should also conduct base-line and then regular audits, as this is one way of ensuring that resources are targeted and used optimally. Circumstances will dictate if it is preferable to conduct the audit of their own organisational response, or whether to participate in the audits of larger companies with whom they are partnering in joint HIV/AIDS programmes. What are the elements of an organisational HIV/AIDS audit? An organisational audit consists of two main components: 1. A descriptive component that: • Describes the macro-environment within which the organisation operates, including the status of the HIV/AIDS epidemic, and the dynamics that drive the epidemic; • Describes the organisation’s operations, in terms of its vulnerability to the impact of HIV/AIDS; and • Provides a profile of the workforce, specifically focusing on factors that may be linked to vulnerability to HIV infection. 2. An analytical component that: • Critically assesses the organisation’s HIV/AIDS programme, in terms of best practices in the sector and progress against plans; and • Identifies areas for remedial action and those activities that should be included in the programme in future. Page 38 Red Flags and Special Challenges Too often an audit is done by a single person, such as a Human Resource Manager, and the chances are that there will be areas and interventions where he/she does not have sufficient in-depth knowledge to do them justice. For an audit to be optimal, a multidisciplinary team – with policy, planning, legal, IR, HR, health, HIV/AIDS and community outreach experience – should be involved right from the development Section One stage, as well as during the actual audit process. Alternatively, there are a number of organisations that offer HIV/AIDS audits as one of the menu of HIV/AIDS-related services they offer to the private sector. Section Two Tool: Template for an organisational HIV/AIDS audit Instructions Section Three Use this template to develop an audit tool that is appropriate for your organisation. It is important to invest time and effort in developing a tool that can be used over and over, as this will allow for comparisons to be made when future audits are done. Decide if the audit will include non-employees working on site, either short-term Section Four or long-term. Often company HIV/AIDS programmes are extended to such groups, like contractors, and it is then advisable to include them in the audit. This tool can also be used to monitor an organisation’s HIV/AIDS response, as indicators can be developed related to each of the elements. Different categories under the “STATUS” column could be defined, for example: “non-existent”, “in Section Five place” and “evaluated”. Management strategies Appendices Element Description Status Policy An HIV/AIDS policy describes the company’s commitment to addressing the epidemic. Monitoring and review mechanisms are Acknowledgements institutionalised. HIV/AIDS Co-ordinator appointed and structure Co-ordinator established with responsibility for planning and and structure implementing the policy and programme, as well as for monitoring and reporting. Depending on the size and distribution of company operations, committees exist at business unit level. Work plan is developed and costed annually. Page 39 Element Description Status Governance, HIV/AIDS is a strategic priority. leadership and Board member is responsible for reporting on the commitment programme. Strategic decision-making on HIV/AIDS is done at Board level, including decisions on mechanisation, outsourcing, market changes and modifying risk situations, such as hostel accommodation. HIV/AIDS budget is a line item in all business unit budgets. HIV/AIDS KPAs are included in all management JDs and performance appraisals. Corporate social investment (CSI) funds earmarked for HIV/AIDS projects. Organisational HIV/AIDS Audit Legal Review of company policies ensures compliance compliance with relevant laws. and personnel HR guidelines cover recruitment, confidentiality issues and disclosure, protection against discrimination, access to training, promotion, benefits, performance management, grievance procedures and reasonable accommodation. Management Strategies Surveillance HIV prevalence survey is commissioned and results and impact are used to inform an impact assessment. assessment Employment data is analysed on an on-going basis and trends are reported regularly to management. Analysis of costs (direct and indirect costs) is done on an annual basis. An impact assessment is commissioned, or conducted in-house with models/scenarios developed for the future. Management information system (MIS) is modified (if necessary) to capture and provide HIV/AIDS- related information. Skills Critical positions have been identified, and inter- succession ventions put in place that include multiskilling, plan shadowing, mentoring and bursary provision for students acquiring the necessary technical qualifications. Page 40 Workplace/internal programme Element Description Status HIV/AIDS Knowledge, attitudes and practices (KAP) survey prevention conducted regularly, to inform the programme activities and to monitor trends. Section One Awareness activities, using varied techniques, are scheduled on an on-going basis, according to an agenda of priority issues. Training on HIV/AIDS is conducted for managers. Section Two HIV/AIDS is included in induction courses. Peer Peer educators identified, and receive initial education and on-going training. Peer educators conduct informal sessions Section Three weekly. Condom Condom promotion activities take place promotion regularly. and Male condoms available free of charge, or distribution dispensed for a subsidised fee, in every toilet Section Four facility in the company. Female condoms available free of charge, or dispensed for a subsidised fee, in all female toilets. Condom uptake is monitored. Section Five STI STI health-seeking behaviours are regularly management promoted. STI services are accessible, on site, or at health facilities in the community. Appendices STI trends are monitored. Voluntary VCT is promoted on a regular basis. counselling VCT services are accessible, on site, or at and testing agencies in the community. Acknowledgements VCT uptake is monitored. HIV/AIDS counsellors are identified, trained, and mentored. Infection Equipment and training provided for first aiders control according to workplace legislation. Protocol for managing occupational exposure is operational. Starter packs for post exposure prophylaxis (PEP) are available. Page 41 Element Description Status Wellness Company wellness programme promoted. programme Infected employees who enrol in the programme receive nutritional advice and supplements, immune supporting medications, prophylaxis and treatment for opportunistic infections. When appropriate, infected employees, and their immediate dependents, who are also infected, receive antiretroviral therapy (ART) and medical monitoring. Terminally ill employees, who are dismissed due to incapacity, are referred to community services, such as home-based care (HBC) services. On-going counselling is offered on site, as a dedicated service, or as part of the Employee Organisational HIV/AIDS Audit Assistance Programme (EAP). Outreach/external programme Element Description Status Partnerships Partner/stakeholder analysis conducted. Member of business forum that deals with Management Strategies HIV/AIDS. Business partners engaged in relation to their own HIV/AIDS programmes. Engagement with local public health providers on-going. Supplier HIV/AIDS compliance requirements advertised and enforced. Person’s living with HIV/AIDS involved in all workplace and outreach activities. Development Regular participation in meetings and activities of and local multisectoral HIV/AIDS network. community Identified staff trained to work at community HIV/AIDS level, and accountable for community-based projects HIV/AIDS activities Peer educators involvement in community HIV/AIDS projects supported. Company resources shared with NGOs and CBOs to strengthen community HIV/AIDS initiatives. Page 42 IFC, in conjunction with Unilever and the Private Investors for Africa (PIA) HIV/AIDS Working Group developed a Corporate Road Map on HIV/AIDS, which is available in the IFC Good Practice Note: HIV/AIDS in the workplace1 (see also Appendix Three). Programme items are listed under 3 headings: Section One • Awareness, education and prevention; • Treatment and care; and • Monitoring and leveraging the programme. Section Two Score Card: Organisational HIV/AIDS audit 10/10 Instructions Review the actions in the score card, where the sections are indicative of a minimal Section Three (1 red ribbon), good (3 red ribbons) and “blue-chip” (5 red ribbons) response. Assess your organisation’s level of competence in each. Then decide on future actions to improve your organisation’s rating. Score Card Description Rating Future Actions Section Four • Once-off SWOT analysis of HIV/AIDS  programme conducted by HIV/AIDS Minimal Response committee • Annual review conducted by HR Manager and reported to the Section Five Management Committee • Comprehensive audit conducted  annually Good Response • Findings and recommendations Appendices presented to the Board • HIV/AIDS plan amended in light of findings and recommendations • Multi-disciplinary team conducts  annual audit of HIV/AIDS programme Blue-chip Response Acknowledgements • Audit report constitutes an input into annual planning and budgeting process • Summary of findings published in company newsletter Costs There may be costs associated with modifying existing information systems to capture data for the audits. Otherwise there are not likely to be significant costs associated with conducting an organisational HIV/AIDS audit, except in terms of the time of personnel. Page 43 Case Study: An organisational HIV/AIDS CASE STUDY audit Unilever developed an HIV/AIDS checklist that can be used to audit an organisational HIV/AIDS response. The interventions are clustered into five main areas: • Policies, responsibilities and management; • Awareness, education and prevention; • Treatment and care; • Impact assessment; and • External interactions and contributions. The following table includes all interventions in the “Policies, responsibilities and management” area. Policies, responsibilities and management Organisational HIV/AIDS Audit Programme Description Status Rating Item Policy ‘A public’ policy statement In draft * statement endorsing the company’s commitment in respect Formally adopted ** of HIV/AIDS for internal briefing and, on request, provision to third party. Annual review *** Management Strategies The company Board should Board level sponser/ * Board level be clearly identified with champion programme the programme, with a responsibility Board member formally Board member ** responsible and the quar- terly Board review of the directly responsible programme and associated strategic decisions. Quarterly Board *** review HIV/AIDS Company/National com- Company committee * committee mittee responsible for appointed developing the detail of policies and programmes and for on-going review of Company committee ** progress, reporting back meeting quarterly to the Board. Dependant upon company size and Unit HIV/AIDS *** geography, subordinate committees committees should be in place for units of >200 appointed people. Management This document should In draft or 3rd party * provide the detail of the guide guide adopted HR response to HIV/AIDS. What should and should not be done in respect of Own guide formally ** employees with HIV/AIDS. adopted May be based upon adop- tion of third party best Annual review *** practice documents. Page 44 Training HIV/AIDS education Employee induction * modules should be a component module or all new employee induction programmes and Plus management ** there should be a training training module module of managers. Plus>50% managers *** Section One through training Targeting High risk groups, such as Analysis to identify * of high risk long-distance drivers and groups completed groups migrant workers should be targeted. Programmes for ** Section Two these groups in place >50% trained *** or analysis has confirmed no Section Three specific high risk group in company Additional Information Section Four For the full Unilever checklist, go to www.weforum.org/globalhealth/ cases. The NOSA AMS (HIV/AIDS Management System) can be used to conduct an Section Five organisational HIV/AIDS audit. The tool is available on www.nosa.co.za. A generic HIV/AIDS competency assessment framework has been developed by UNAIDS that can used by any group (whether a nation, district, organisation or community). For further information, contact Jean-Louis Lamboray at Appendices lamborayj@unaids.org or Geoff Parcell at parcellg@unaids.org. Techniques for assessing institutional vulnerability are included in the UNAIDS publication, Guidelines for studies of the social and economic impact of HIV/AIDS (2000), available on www.unaids.org. Acknowledgements Footnotes 1 Available on www.ifc.org/ifcagainstaids Page 45 Section Two Workplace HIV/AIDS Policy INFO Briefing Note What is a workplace HIV/AIDS policy? Workplace HIV/AIDS Policy A workplace HIV/AIDS policy defines an organisation’s position on HIV/AIDS and spells out the way in which the organisation will deal with the epidemic. Like other organisational policies, a workplace HIV/AIDS policy must be an integral part of the organisation’s HIV/AIDS management system, informing the continuous process of planning, implementing, reviewing and improving the processes and actions required to meet the policy goals and targets1. Management Strategies Key elements of a workplace HIV/AIDS policy • Elimination of stigma and discrimination; • Confidentiality for infected workers; • Management response to the epidemic; • Workplace programmes; and • Benefits, including treatment and care. Why does an organisation need a workplace HIV/AIDS policy? There are many sound reasons why an organisation needs to develop a workplace HIV/AIDS policy. These include that: • It sends a strong message that HIV/AIDS is a serious workplace issue, and that there is commitment to dealing with it as such; • It provides a framework for consistency of practice and a foundation for the workplace response activities; • It protects rights and specifies responsibilities related to HIV/AIDS, equity, non-discrimination and fair labour practices; • It sets standards of behaviour expected of employers and employees; • It informs infected and affected employees of assistance that is available; • It sets standards of communication about HIV/AIDS; • It ensures consistency with national and international legislation and good practices; • It involves external stakeholders (customers, clients, suppliers and contractors); and • It provides a framework for monitoring the workplace HIV/AIDS response. Page 46 Contractors are also encouraged to embark on an HIV/AIDS policy development process, or, alternatively, to participate in a sector-wide policy process that will provide them with an enabling framework for their HIV/AIDS programme. What should a workplace HIV/AIDS policy contain? A workplace HIV/AIDS policy should include the following: Section One Introduction • Reason(s) why the company has an HIV/AIDS policy; • Persons covered by the policy (some or all employees and any different provisions for different categories of employees, contractors etc); • Policy compliance with international and national laws and regulations, and trade Section Two and/or union agreements; and • How the policy will be applied. General considerations • Statement regarding the intent of the company to have an HIV/AIDS policy for application to company operations; Section Three • Statement of the goal and objectives of the HIV/AIDS policy; • Statement as to whether the policy is specific to HIV/AIDS or whether it incorporates HIV/AIDS into existing sections on life-threatening illnesses. Principles Section Four Policies entrench principles as part of an organisation’s ethos. A workplace HIV/AIDS policy must reflect a set of principles that are consistent with national and international laws and that describe the organisation’s stated position on a range of issues. Typically these are statements that every employee has the right to: • Equality – in terms of pre-employment practices, promotion, training and access to benefits; Section Five • Non-discrimination and acceptance regardless of HIV status; • Privacy and confidentiality of medical information; and • Protection from unfair dismissal. Structure Appendices This should describe the governance structure that the company will put in place to plan, co-ordinate, implement and monitor the HIV/AIDS response. Roles and responsibilities The roles and responsibilities that should be defined in the policy include that: • HIV/AIDS prevention is the responsibility of all employees, including senior Acknowledgements management, supervisors and unions, and that everyone has responsibilities for maintaining an environment that reinforces safe sexual behaviours; • Managers and employee representatives should play a leadership role in addressing HIV/AIDS, both in the company and in the wider community; • The company and union/s have responsibilities for providing all employees with timely, accurate, clear and adequate information about HIV prevention, community support services, treatment options and changes in company HIV/AIDS activities; and • Partners and stakeholders have a responsibility to support and/or participate in achieving the goals of the policy and programmes. Page 47 Programme elements The policy should reflect the framework of interventions that will constitute the organisational response. Typically these will fall into three main categories: • Management strategies, including employment and personnel issues; • Workplace or internal activities – prevention, treatment, care and support for employees; and • Outreach or external activities. 1. Management of the HIV/AIDS epidemic within the company 1.1 The policy should include provision for assessing the impact of the HIV/AIDS epidemic on the company – the human resource, productivity and cost impli- cations – and then procedures to plan prevention and mitigation strategies in response to this evidence. 1.2 The policy should cover all personnel issues, such as: • Job access; • Job security; • HIV testing (no screening for HIV as a condition of recruitment, continued Workplace HIV/AIDS Policy employment, training or promotion); • Confidentiality and disclosure; • Protection against discrimination; • Employee benefits (pension/provident, medical, compassionate leave, death benefits; • Access to training, promotion, benefits; • Performance management; • Grievance procedures; and Management Strategies • Reasonable accommodation. 2. Workplace programme The policy should define the parameters of the workplace programme, which should contain (i) prevention activities and (ii) treatment, care and support activities. 2.1 HIV/AIDS prevention activities should include: • Awareness activities and support for behaviour change, including condom promotion and distribution; • Training around prevention, across all levels and from induction to in-service training; • Peer education; • VCT; • STI management; and • A safe working environment and compensation if infected with HIV as a result of an injury at work 2.2 Treatment, care and support for HIV infected and affected employees should cover: • Wellness management, including provision of or assistance in gaining access to life-saving treatments and drugs for HIV and opportunistic infections; • Counselling and related social and psychological support services for HIV infected and affected employees (and dependents), including support groups and post-test clubs; Page 48 • Legal support services for employees (in-house or contracted out) to access legal advice for assistance in safeguarding dependents through the preparation of wills, transfer of property and leveraging of social services (eg grants); • Links with other workplace programmes; and • Links with and referrals to other agencies. 3. External/community outreach activities Section One The policy should cover external activities such as: • Partnerships to enhance broader HIV/AIDS responses; • Participation in networks of stakeholders responsible for HIV/AIDS-related activities, projects and programmes; and • Participation with external stakeholders in the common goals of preventing new infections and mitigating the impact of the epidemic. Section Two Red Flags and Special Challenges Section Three The following questions are commonly asked regarding workplace HIV/AIDS policies. What sort of workplace HIV/AIDS policy should I select? The decision as to whether your workplace HIV/AIDS policy should be a stand-alone HIV/AIDS policy or integrated into a broader life-threatening illness or disability policy, Section Four or a short and succinct statement of intent that is referenced to other organisational policies are decisions that are context-specific, and depend primarily on the precedents that have been set for your organisation in the past. Having said that, most organisations opt for a stand-alone workplace HIV/AIDS policy. This allows for specific issues, such as non-discrimination, to be directly addressed. Section Five Policy or programme – which comes first? There are no specific rules about sequence, both are necessary and both are not set in stone and should change over time. The recommendation is that initiating a workplace programme should not wait on the completion of a policy development Appendices process, which may take many months. Should the policy be restricted to the workplace, or should it be broader, covering customers, suppliers, partners, surrounding communities? No organisation is an island and workplace HIV/AIDS policies should also define the Acknowledgements context for your organisation’s commitment to and involvement in broader external or outreach HIV/AIDS activities. NOTE: Some policies are sector-wide, binding all organisations belonging to the sector. Should the policy be accompanied by operational or implementation guidelines? Yes, policies, by their nature are not detailed. A policy is the WHAT and the guidelines will provide the HOW. The guidelines will facilitate implementation, and can also be useful when developing annual work plans and preparing budgets for the activities. Page 49 It’s overwhelming, where does one start? It is not necessary, in fact probably not possible, to implement all aspects of a workplace HIV/AIDS policy immediately. Start with the obvious and easier elements and add on others over time. What will it cost? Many companies delay embarking on their workplace HIV/AIDS policy process, because of fears of what the cost implications will be. Whilst it is true that there will be costs associated with implementing the policy, there are many cost benefits to early, proactive action, whereas delaying the process can have the opposite effect. Tool: A workplace HIV/AIDS policy development process Instructions The process undertaken to develop a workplace HIV/AIDS policy is arguably as Workplace HIV/AIDS Policy important as the policy itself. If your organisation has a well-developed and tested policy development and implementation process – that involves the unions at every stage – use that process to develop your workplace HIV/AIDS policy, but refer to the one detailed below to check if any steps in your process can be improved. Management Strategies If, on the other hand, your organisation does not have an established policy development and implementation process, follow the steps described below. Step Six Monitor the policy • Include policy performance measures in 6 the JDs of staff with HIV/AIDS related roles • Track indicators and report regularly • Periodically review the policy Step Five Implement the policy • Launch the policy officially 5 • Disseminate copies to all employees (and possibly to other stakeholders as well) • Commence implementation Step Four Finalise the policy • Define the indicators by which 4 policy implementation will be monitored • Develop an implementation strategy Step Three Consult and negotiate • Define and implement a process that 3 ensures consultation with all constituencies • Redraft the policy, addressing all comments received Step Two Draft the policy • Call on technical inputs where necessary 2 • Gather information to inform the policy • Reach consensus on the policy goal, objectives, principles and key response elements Step One Establish a policy task team • Provide training/capacity building 1 (if required) to task team members • Develop TOR for the task team Page 50 Score Card: Workplace HIV/AIDS policy 10/10 Instructions Review the actions in the score card, where the sections are indicative of a minimal (1 red ribbon), good (3 red ribbons) and “blue-chip” (5 red ribbons) response. Assess your organisation’s level of competence in each. Then decide on future actions to Section One improve your organisation’s rating. Score Card Description Rating Future Actions • Statement on HIV/AIDS included in  Section Two Minimal Response occupational health and safety policy • Peer educators distribute the statement during their sessions  • Multi-disciplinary team develop Section Three Good Response HIV/AIDS policy • Policy adopted jointly by management and unions • Policy launched and copies distributed to all employees • Policy makes provision for HIV/AIDS Section Four budget • Policy shared with sectoral partners,  suppliers and customers Blue-chip Response • Policy reviewed annually and amended in line with latest developments in the Section Five HIV/AIDS field • Policy implementation measured accordingly to selected indicators Appendices Costs There may be cost implications to the development of a workplace HIV/AIDS policy if technical experts, such as legal experts, need to be retained at points during the Acknowledgements development. There will be implications in terms of personnel time, and there will be costs associated with printing the policy, if distribution to employees and others is planned, and if a launch function is scheduled. Establishing a cost centre for the organisational HIV/AIDS response is a good way of formalising and being able to track all aspects of the policy implementation. Page 51 Case Study: Workplace HIV/AIDS policy CASE STUDY The following is an extract from the South Deep Mine HIV/AIDS policy – sometimes called an agreement in the mining sector. It was signed into practice by the National Union of Mineworkers (NUM), the United Association of South Africa and the Placer Dome Western Areas Joint Venture in 2002. Policy statement South Africa is facing an HIV/AIDS epidemic of severe proportions. HIV targets the reproductive age group and hence those of working age. The workplace therefore becomes the target of the epidemic. South Deep acknowledges the seriousness of HIV/AIDS as a reality and fully recognises the tragic social implications associated with this illness as well as the impact thereof upon our operations. The philosophy of South Deep is that it should act in the best interest of all its employees by treating employees infected with HIV/AIDS in the same manner as those employees affected by any other serious or life threatening illness. Workplace HIV/AIDS Policy Policy principles 1. Individual’s HIV/AIDS related information will be dealt with on a strictly confi- dential basis. Breaches of confidentiality will be seen in a serious light and will be dealt with accordingly. 2. Information about the HIV status of an individual will be managed within the Management Strategies clinical environment according to standard medical guidelines. • Employees will not be dismissed or discriminated against on the grounds of being HIV positive. Any necessary termination of service on the grounds of medical incapacity will be dealt with in terms of established medical separation procedures. • Where applicable employees who are clinically ill will continue to receive medical treatment or benefits in accordance with the rules of the relevant medical scheme or medical service in which they participate. • Once an employee becomes incapable of executing his or her normal duties due to ill health, the provisions of the relevant provident or pension fund will be applicable with regard to the payment of benefits. • Appropriate training and protective equipment will be provided to those employees who are employed in occupations which may expose them to the risk of possible infection. • Information and education programmes on HIV/AIDS will be provided to employees to make them aware of the dangers of HIV/AIDS and which preventative steps should be taken to avoid being infected. • HIV/AIDS testing - HIV testing on a voluntary basis will be made available to employees with informed consent. HIV testing is not allowed by the EEA (Employment Equity Act). - HIV testing in a clinical environment for diagnostic purposes will be per medical ethical guidelines where practically possible. Page 52 • All employment practices that are applied to HIV/AIDS should be consistent with ethical guidelines for good medical and occupational health practice, taking cognisance of prudent policies and relevant international best practices. Operational guidelines The company will develop an HIV/AIDS programme with due regard to: • Statistical surveillance; Section One • Communication, education, voluntary counselling and testing (VCT) and wellness programmes; • Effective services for the treatment of STIs; • Provision of appropriate medical care; and • Involvement of all stakeholders in programmes and the development of initiatives. Section Two Additional Information Section Three For the full South Deep HIV/AIDS policy, go to www.weforum.org/ globalhealth/cases. Other company policies are also available on www.weforum.org/globalhealth/ cases or in the ILO document entitled Implementing the ILO Code of Practice on HIV/AIDS and the world of work: an education and training Section Four manual (2002); available on www.ilo.org. The IFC; Good Practice Note: HIV/AIDS in the workplace, available on www.ifc.org/ifcagainstaids situates an HIV/AIDS policy within the other elements of a workplace response. Section Five Information on the development of workplace HIV/AIDS policies is available in the South African Department of Labour’s HIV/AIDS Technical Assistance Guidelines, available on www.labour.gov.za. Appendices Acknowledgements Footnotes 1 Most organisations will be familiar with the way in which policy is a major component of management systems, such as environmental management systems. This model – which consists of policy, planning, implementation and operation, checking and corrective action, and management review – can apply equally well to HIV/AIDS Page 53 Section Two Co-ordinator and Workplace HIV/AIDS Structure Co-ordinator and Workplace HIV/AIDS Structure INFO Briefing Note A workplace HIV/AIDS response needs to be spearheaded, directed and co-ordinated. For this reason it is necessary to appoint a co-ordinator and to establish an HIV/AIDS structure, or set of structures – all with well-defined mandates and clear lines of communication and accountability. Appointing a staff person or committee to Contractors may not be in a position to appoint a dedicated HIV/AIDS Co-ordinator, serve as a focal point for handing all company but they should formally nominate a person to lead their HIV/AIDS response. Similarly, HIV/AIDS-related activities brings accountability they may not create a formal in-house HIV/AIDS structure, but may well be able to and focus to the process. … it is important participate in existing structures at sites where they are operating. Management Strategies that they be vested with authority over activities and given a direct line of commu- A useful model for how structures with different HIV/AIDS-related responsibilities nication with senior management. and competencies should operate and be linked together has been developed by Extract from IFC; the IFC. Good Practice Note: HIV/AIDS in the workplace IFC framework for co-ordinated action Maximizing the chances of success through action in four spheres Due to the complexity of the problem and the pervasive nature of the disease, a company acting alone may be unsuccessful in controlling the impact of AIDS on its workforce as a result of external factors. IFC’s experience in working with companies through its “IFC Against AIDS Program” shows that the most succesful interventions often involve coordinated action among four seperate but interrelated spheres: Operational, Medical, Managerial, and Community. Within each of these spheres lie particular skills and resources which need to be identified and leveraged if the fight against HIV/AIDS is to be won in the company’s area of operations. Page 54 Operational: Representatives from this sphere include individuals The Operational Committee can identify: from the operational level of a company. In addition to (i) risks that they see at the working level; company employees it may also include peer eductors, (ii) opportunities that exist for promoting on-the- staff from human resources, contractors, and union job education and prevention; and representatives. (iii) specific needs of employees in terms of health programs and services. Section One Medical: Community: al Commit The medical sphere tion tee Representatives drawn pera comprises dinical staff O from the local community from the company as may include prominent Section Two well as from public munity citizens such as village l Com hospitals, NGOs or ca chiefs, religious leaders, di local health offices. or school representatives e M The Committee can as well as community identify the general organizations, women’s Section Three F oint Focal Point health trends in al groups and NGO’s. i er the area, prioritize Members from this ag Man concerns and committee can serve coordinate medical as a liaison between programmes and the company and services. community, strenghtening Section Four communication and cooperation on efforts to combat HIV/AIDS Managerial: Section Five Committed leadership is essential for companies to address HIV/AIDS effectively. The Managerial Committee may include senior management representatives and Board members, whose responsibilities include championing the program, allocating budgetary and staff resources and undertaking a periodic review of the various activities. What are the core competencies of an HIV/AIDS Co-ordinator? Appendices The person appointed to lead an organisation’s HIV/AIDS response should have as many of the following skills as possible: Acknowledgements • HIV/AIDS training and experience; • Skills in advocacy, networking and co-ordination; • HR and financial management experience; • Project management and planning skills; • Strong communication skills; and • Report writing skills, and monitoring and evaluation experience. Page 55 What should the composition be of a workplace HIV/AIDS structure? A workplace HIV/AIDS structure should include: • Those who will be involved in the development, implementation, and monitoring and evaluation of the HIV/AIDS policy and programme; • Representatives from all divisions within the organisation, and, where relevant, from different geographic areas as well; • Special “interest” groups, such as unions, women and people living with HIV/AIDS; and • People who have relevant skills that the programme requires. Example from Gold Fields HIV/AIDS workforce policy (2001) It is recorded that a joint Management/Union Plenary Working Group has Co-ordinator and Workplace HIV/AIDS Structure been established at Group level. HIV/AIDS structures will be established on the operations and the parties commit themselves to support these structures. Representation will be agreed upon at operational level. HIV/AIDS co-ordinators will be appointed in consultation with the agreed structures and shall be trained so as to be competent in their work. Red Flags and Special Challenges Management Strategies Amongst the challenges that face an organisation when appointing an HIV/AIDS Co-ordinator and setting up a workplace HIV/AIDS structure are: • The need to identify and appoint an experienced and skilled person to lead the organisation’s HIV/AIDS response; • Adequate representation on the structure and support from all stakeholders in the organisation; • Locating the HIV/AIDS Co-ordinator within the unit or section where he/she will be most effective, and defining communication channels that allow for access to management, unions and the general workforce; • Defining the strategic and operational functions of the HIV/AIDS structure; • Providing an adequate budget for implementation; • Obtaining clear commitment and support from management for participation by nominated employees on the HIV/AIDS structure; • Ensuring that union representatives are included on the HIV/AIDS structure; and • Establishing clear lines of communication between the HIV/AIDS structure and all relevant units within the organisation. Employees with responsibility for their organisation’s HIV/AIDS response almost always describe the multiple barriers that they experience in getting started. Page 56 These barriers include: • Denial, at all levels of the problem; • OR, the problem is too big for us, so leave it alone; • A lack of commitment from top management; • A lack of support from organised labour; • No common vision of what the needs to be done; • The lack of a uniform approach to the problem by management and organised Section One labour; • Apathy from employees; • Inappropriate attitudes, particularly to PLWHAs; • Competing demands on their time – the HIV/AIDS portfolio is just one of many; • The lack of a formal mandate for the HIV/AIDS work that they are expected to Section Two do; • HIV/AIDS is not part of their job description or a key performance area against which their performance will be evaluated; • Inadequate resources (financial and material) for HIV/AIDS related activities; and Section Three • Inadequate information about supportive community services. These barriers lead to feelings of frustration and isolation and are the reason why many initial efforts falter and fail. To prevent or deal with them: • Define the problem – only then can you begin to do something about it; Section Four • Test the environment to assess its receptiveness to change; • Identify the things that you can do about the problem – have goals and a plan; • Find supporters and change agents and build a coalition or team to support you; • Lobby others whose support you need; • Identify and understand the opposition – what makes them “tick’’; Section Five • Identify WHO decides, WHAT they decide and HOW it is decided; • Don’t be overambitious; start where you have some chance of success; • Never doubt the power of numbers – collect them and use them; • Select your messages and communicate, communicate, communicate; • Act – actions speak louder than words; Appendices • Monitor and record – this too can be a powerful advocacy tool; and • Celebrate your successes and let others share in them too. This all relates to the need for advocacy. Advocacy is action which aims to change policies, positions or programmes – it puts a problem onto an agenda, provides a solution and builds support for action. Acknowledgements Tool: Checklist of questions relating to the HIV/AIDS Co-ordinator and structure Instructions Use the following questions to guide discussions and decisions regarding the appointment of an HIV/AIDS Co-ordinator and the establishment of a workplace HIV/AIDS structure: Page 57 HIV/AIDS Co-ordinator • What skills and experience does the HIV/AIDS co-ordinator need to have? • Should the person be appointed solely to deal with HIV/AIDS? • Where will this person best be placed within the organisational structure? HIV/AIDS structure • What are the functions of the structure and to whom will it report? • What skills and expertise are required on the structure? • What capacity building will members of the structure require to fulfil their roles? • How can the organisation ensure that unions, women and PLWHAs have a voice on the structure? • What links will the structure have with other structures and what partnerships Co-ordinator and Workplace HIV/AIDS Structure should it form to fulfil its functions? Score Card: HIV/AIDS Co-ordinator and 10/10 workplace structure Instructions Review the actions in the score card, where the sections are indicative of a minimal (1 red ribbon), good (3 red ribbons) and “blue-chip” (5 red ribbons) response. Assess your organisation’s level of competence in each. Then decide on future actions to improve your organisation’s rating. Management Strategies Score Card Description Rating Future Actions • Occupational Health Nurse is appointed  as HIV/AIDS Co-ordinator Minimal Response • HIV/AIDS Task Team is a sub-committee of the Health and Safety Committee • HIV/AIDS is an agenda item at Health and Safety meetings • HR Director is appointed as HIV/AIDS  Co-ordinator Good Response • HIV/AIDS Task Team meets monthly and reports are submitted to management quarterly • Peer educators are represented on the Task Team • Dedicated HIV/AIDS Co-ordinator  appointed, with relevant skills, and Blue-chip Response reporting to the CEO • Members of the HIV/AIDS Task Team receive training on HIV/AIDS, advocacy and programme management • HIV/AIDS budget, which is 1% of payroll, is managed by the HIV/AIDS Task Team Page 58 Costs There may be significant costs related to appointing an HIV/AIDS Co-ordinator, if it is a dedicated position, and if the person is at a senior level. The costs related to a functioning HIV/AIDS Task Team are primarily in terms of staff Section One time and HIV/AIDS competency training. Case Study: Terms of reference (TOR) for a workplace HIV/AIDS Task Team CASE STUDY Section Two The following TOR, which were originally developed for government departments in South Africa, have been adapted slightly to be relevant for organisations operating in the mining sector. Section Three 1. Proposed structure Representative(s) from each of the following: • Employee assistance programme; • Human resources; • Trade unions (all trade unions to be represented); Section Four • Labour relations; • Occupational health and medical services; • Occupational safety • People living with HIV/AIDS; • Divisional and site representatives; Section Five 2. Administrative arrangements • Cost centre for the HIV/AIDS response; • Monthly meetings, convened and chaired by the responsible senior manager; • Secretariat to be provided by the senior manager; and • Monthly reports to be submitted to management; Appendices 3. Terms of reference for the Task Team The Task Team will be a co-ordinating structure, facilitating implementation and with the following responsibilities: • Policy development and review: this involves developing policies that enable the Acknowledgements company to deal with HIV/AIDS in the workplace and within the community within which the company operates; • Situational analysis of the HIV/AIDS workplace programme, and identification of priorities and needs; • Development of an implementation plan for the company, which includes clear objectives and indicators for measurement; • Development of a system of regular monitoring and evaluation of programmes; • Implementation of a comprehensive package of HIV/AIDS prevention, treatment, care and support for employees; • Implementation and/or facilitation of and/or participation in community-based programmes that reduce the spread of HIV infection within the community, and mitigate the impact of HIV/AIDS on individuals, families, and the community at large. Page 59 4. Details of the Task Team’s role and function Advocacy • Support the HIV/AIDS Co-ordinator; • Provide a focal point for advocacy across the company. Co-ordination • Co-ordinate the implementation of both the workplace and community-based HIV/AIDS programmes; • Enable integration of HIV/AIDS programmes into all other programmes in the company. Communication • Provide a regular link with business units/sites and allow for two-way Co-ordinator and Workplace HIV/AIDS Structure communication on all issues relating to HIV/AIDS; • Initiate and maintain an HIV/AIDS communication strategy, in association with the PR section and others. Facilitation • Form a link between the HIV/AIDS Co-ordinator and management; • Influence management to ensure implementation of the HIV/AIDS implementation plan; • Facilitate management decision-making on HIV/AIDS programmes; • Facilitate the allocation of budgets and other resources to the HIV/AIDS programme. Management Strategies Advisory • Advise management on HIV/AIDS issues in general and those related to the company in particular; • Support the HIV/AIDS Co-ordinator with strategic advice; • Provide management with current information on programme implementation. Monitoring and reporting • Monitor and report on the HIV/AIDS policy and programme. Additional Information The NOSA AMS defines the standards for an HIV/AIDS management committee, available on www.nosa.co.za, see section 4.4.1.1. The IFC model is available in the Good Practice Note: HIV/AIDS in the workplace, which can be accessed on www.ifc.org/ifcagainstaids. Page 60 Section Two HIV/AIDS Leadership and Management Section One Commitment Section Two INFO Briefing Note Section Three What is HIV/AIDS leadership and management commitment? HIV/AIDS leadership and management commitment refers to the visible and vocal presence of decision-makers in leading and supporting all aspects of an organisation’s response to HIV/AIDS. Why is leadership and management commitment important for an Section Four organisation’s HIV/AIDS response? Strong leadership at all levels of society One of the most consistently identified factors that is critical for a successful HIV/AIDS is essential for an effective response to response is leadership and commitment from leaders, be they political, government, the epidemic. business, labour or civil society leaders. Leadership by governments in com- bating HIV/AIDS is essential and their What has been less clear is what this leadership and commitment actually is, and Section Five efforts should be complemented by what form leadership can take in the workplace. As a starting point, areas in which the full and active participation of civil HIV/AIDS leadership could and should emerge are: society, the business community and • Corporate citizenship; and the private sector. • Worker welfare. Leadership involves personal commitment Appendices and concrete actions. Contractors, like big corporations, also have opportunities to demonstrate leadership Declaration of commitment on HIV/AIDS and management commitment on HIV/AIDS within their particular spheres of UN General Assembly Special Session on HIV/AIDS influence. June 2001 What are the elements of HIV/AIDS leadership and management Acknowledgements commitment? In a workplace context, HIV/AIDS leadership and management commitment should be evident in three areas: • Internally – leadership on HIV/AIDS issues within the organisation; • Externally – leadership with other stakeholders; and • At a personal level – by acting as a role model, for example by demonstrating solidarity with people living with HIV/AIDS (PLWHAs). In all three spheres this leadership and commitment has the potential to: • Minimise the stigma and discrimination that is so frequently associated with HIV/AIDS; • Shape the debate about HIV/AIDS; • Exert influence and change the pace of action; and • Mobilise resources. Page 61 Leadership on HIV/AIDS can occur among peers within a sector (company to company, or union to union) and in conjunction with leaders in other sectors. There are multiple benefits to leadership and management commitment, including: • A positive public image and publicity for the company; • Access to concerned decision-makers in other sectors; • A satisfied and supportive workforce; and • Greater involvement with communities. Red Flags and Special Challenges HIV/AIDS Leadership and Management Commitment Leadership challenges include that: • Verbal commitment is not synonymous with implementation; • Often commitment is event-based, but not sustained over time; • Top-level leadership on HIV/AIDS is frequently not mirrored at middle- management level; • Managers may not have the requisite knowledge or skills to provide meaningful leadership on HIV/AIDS; • As long as HIV/AIDS is not mainstreamed as a core management function, it is not perceived as important; and • There are usually no accountability checks in place, against which to measure leadership and management commitment. Management Strategies Gold Fields, lessons learned Essential to success are an involved and committed Board, executive and top management, combined with all employees and their representative organisations, and committed to achieving results. Tool: Menu of HIV/AIDS leadership and management commitment actions Instructions Review the following for appropriate and feasible actions that can be employed in your organisation to demonstrate HIV/AIDS leadership and management commitment. • Educate yourself and your fellow managers about HIV/AIDS; • Participate actively and visibly in HIV/AIDS events; • Use public platforms to speak about HIV/AIDS; • Wear a red ribbon, as a symbol of awareness and solidarity; • Promote cross-sector HIV/AIDS partnerships; • Act as a catalyst to bring different organisations together to work on joint HIV/AIDS projects; • Facilitate the transfer of innovative solutions on HIV/AIDS problems within the organisation and to other stakeholders; Page 62 • Prioritise the resourcing and delivery of HIV/AIDS workplace programmes; • Encourage support for community HIV/AIDS projects within your organisation’s corporate social investment (CSI) programme; • Demonstrate support for infected or affected employees and their families; • Support employees who wish to volunteer their time and services to community HIV/AIDS projects; • Take an open and principled stance on human rights and gender issues; Section One • Participate in meetings of the HIV/AIDS workplace structure; • Ensure transparency on HIV/AIDS issues and build trust across all divisions in the workplace; and • Support the implementation of the workplace HIV/AIDS programme. Section Two Score Card: HIV/AIDS leadership and 10/10 management commitment Instructions Section Three Review the actions in the score card, where the sections are indicative of a minimal (1 red ribbon), good (3 red ribbons) and “blue-chip” (5 red ribbons) response. Assess your organisation’s level of competence in each. Then decide on future actions to improve your organisation’s rating. Score Card Description Rating Future Actions Section Four • CEO participates in World AIDS Day  event Minimal Response • HIV/AIDS features in management/union negotiations • CEO attends sector-wide meetings at Section Five which HIV/AIDS is discussed • HIV/AIDS programme reported on in  Annual Report Good Response • Senior manager chairs HIV/AIDS Appendices workplace structure • HIV/AIDS KPAs included in JDs and performance appraisals of all managers • Organisation receives an award for its  HIV/AIDS programme Blue-chip Response Acknowledgements • CEO serves on Board of community HIV/AIDS project • Organisation represented by management at HIV/AIDS conferences Costs There are few costs of HIV/AIDS leadership and management commitment, except where this commitment translates into additional resources for HIV/AIDS workplace programmes or for community projects. Page 63 Case Study: HIV/AIDS leadership and CASE STUDY management commitment Anglovaal has attempted to institutionalise leadership and management commitment in their policy guidelines, by defining governance responsibilities as follows: At the centre: • Overall responsibility for the implementation of the required interventions lies with the Board. • The Strategy and Policy Task Team will meet quarterly to set policy and review progress. • Each divisional Vice President will quarterly submit a progress report to the above HIV/AIDS Leadership and Management Commitment Task Team for review. • The Group Project Co-ordination Team will meet monthly to review the key indicators of the group intervention programmes. At the operations: • General Managers will convene an HIV/AIDS Action Committee to implement the HIV/AIDS programme. • This committee will include as broad a representation of stakeholders as possible. • A monthly progress report will be submitted through the General Manager to the responsible VP. Additional Information Management Strategies FHI’s publication entitled Workplace HIV/AIDS programs: an action guide for managers (2002) has a chapter on “Company leadership in HIV/AIDS prevention and care”. The document is available on www.fhi.org. Page 64 Section Two HIV/AIDS Legal Compliance Section One Section Two INFO Briefing Note What is an HIV/AIDS legal compliance review? Section Three An HIV/AIDS legal compliance review is a formal process undertaken on a regular basis to ensure that company policies and procedures with HIV/AIDS implications comply with national and international laws and agreements; and, where deviations are found in any policies or procedures, that appropriate modifications are made. Why does an organisation need to conduct an HIV/AIDS legal Section Four compliance review? Employees with HIV should be treated The HIV/AIDS epidemic has, too frequently, resulted in discriminatory and unfair in the same way as any other employee. labour practices. These include testing employees for HIV and then denying those Employees with HIV-related illness, who test HIV positive equal opportunities in terms of benefits, promotion or training; including AIDS, should be treated the discharging employees who are HIV positive; and disclosing confidential information Section Five same as any other employee with a life- about an employee’s HIV status to others within the organisation. threatening illness. Extract from the Code on HIV/AIDS and Often these practices, which may be entrenched in one or more company policies, Employment in the Southern African are in breach of the laws of the country, and may result in costly and time-consuming Development Community disputes. Conducting an HIV/AIDS legal compliance review, on the other hand, and Appendices ensuring that policies and practices comply with the law, will not only prevent such disputes, but will also create an enabling and supportive environment for workplace HIV/AIDS interventions. Contractors, like all other businesses are bound by the laws of the country/ies within which they operate. They therefore have responsibilities to ensure that their policies Acknowledgements and procedures comply and that any HIV/AIDS-related decisions are taken with due regard to these laws. Embarking on a process to ensure compliance is likely to be much less costly than trying to resolve a dispute would be. Page 65 What should an HIV/AIDS legal compliance review consist of? Step One: The identification of a senior staff member, with suitable qualifications, or with access to legal expertise, who is tasked to conduct the review. Step Two: Collection of all relevant national laws, agreements and codes and international agreements that have been signed by the country. Typically this list would include: • The Constitution – which is the supreme law in any country; • The Bill of Rights – which sets out the rights of all citizens, such as rights to equality and non-discrimination, privacy, fair labour practices and access to information; • Common law protections – which typically include the right to privacy and bodily integrity; • National labour legislation – which covers equality and non-discrimination in the workplace through anti-dis- crimination measures and, in some instances, affirmative HIV/AIDS Legal Compliance action, a safe working environment and compensation for occupationally acquired injuries or diseases; • International agreements, such as the International Labour Organisation (ILO) Convention 111 on Discrimina- tion (Employment and Occupation) (1958), and the ILO Code of Practice on HIV/AIDS and the World of Work (2001); and • Regional agreements, such as the South African Develop- Management Strategies ment Community (SADC) Code on AIDS and Employ- ment which was approved by the Council of Ministers in September 1997. Collection of all company policies, including those dealing Step Three: with health and safety and employment practices, as well as all union agreements. Analysis of company policies in light of national and Step Four: international provisions. Preparation and submission of report to management and Step Five: unions, identifying any changes that need to be made. Amendment of policies, ensuring meaningful consultation Step Six: with all role players, and adoption of amended policies. Identification of indicators to monitor legal compliance. Step Seven: Possible indicators could be: • Inclusion of a paralegal module in selected training programmes; • Regular checks of policies, protocols and procedures against a checklist developed for the purpose, and particularly following the promulgation of any new legislation with employment implications; and • Regular reports on compliance to an appropriate manage- ment forum and to a management/union forum. Page 66 Red Flags and Special Challenges Ensuring legal compliance is particularly challenging in situations where the relationships with workers are informal, where workers are not unionised, or where workers “sell” their labour, such as in the construction industry. Ensuring legal compliance is just one way of addressing the problem of stigma and Section One discrimination. This is a challenge that cuts across every aspect of a workplace HIV/AIDS response, and that needs to be recognised and vigorously addressed, whenever and wherever it occurs. In order to create an enabling environment where there is zero tolerance for stigma and discrimination, it may be necessary to embark on the following: Section Two • Dissemination of information; • Coping-skills acquisition for PLWHAs; • Refining counselling approaches; • Programmes promoting the greater involvement of people living with HIV/AIDS; Stigma is the unfair, uneducated and • Monitoring violations of human rights; Section Three unholy disgrace we have allowed to • Creating institutional and legal support to enable people to challenge develop around the disease. … Stigma discrimination; destroys self-esteem, destroys families, • Legal reform/legal action/public interest litigation; disrupts communities and takes away • Community mobilisation; all hope for future generations. • Community education; Section Four Njongonkulu Ndungane • Institutional policy responses; Anglican Archbishop of Cape Town • The development of administrative and professional guidelines; • Research; and • Advocacy. Section Five Tool: Checklist for HIV/AIDS legal compliance Appendices Instructions Use the following questions as a guide when undertaking a review of company policies. Do any recruitment procedures, advertising practices and selection criteria exclude, directly or indirectly, job applicants on the basis of Acknowledgements their HIV status? In many countries a job applicant is included in the definition of an employee, and the non-discrimination laws that apply to employees in service also apply to job applicants. Is any HIV testing currently taking place in the workplace and, if so, is such testing prohibited in terms of any laws? In many countries medical testing of an employee (including HIV testing) is prohibited except in circumscribed circumstances. The prohibition may even cover questionnaires and other forms of inquiry about possible risk behaviour or HIV status. Page 67 Is any HIV testing required as a qualification for benefits or loans, or as a requirement for travel and, if so, is such testing legal? A number of benefits, eg a housing loan, require that the employee take out life assurance, acceptance for which is contingent on a negative HIV test result. Many employees are unclear about the implications of these sorts of procedures and require clear, unambiguous information upon which to make their decisions. Is medical information about employees, including HIV status, kept confidential? Because employees have privacy rights, they may not be legally required to disclose their HIV status to their employer or to other employees. Are any employees living with HIV being unfairly discriminated against, or denied equal opportunities in terms of any laws? There should be no discrimination in job classification and grading, remuneration, benefits, and terms and conditions of employment, job assignments, access to facilities at work, training and development, promotion and performance evaluation systems, HIV/AIDS Legal Compliance transfers, and dismissals. There are usually provisions in labour laws that state that it is not unfair discrimination to distinguish, exclude or prefer any person on the basis of an inherent requirement of a job. Have basic conditions/minimum standards of employment – working hours, leave, sick leave, compassionate and family leave – been reviewed in light of the likely demands of the HIV/AIDS epidemic? These could include extended sick leave at a reduced rate of pay, leave to attend Management Strategies funerals, and so on. Have any employees been dismissed because they were HIV positive? If disputed, a dismissal solely because an employee is HIV positive or has AIDS is likely to found to be unfair if it is a dismissal based on discriminatory conduct by the employer. However if an employee with AIDS is dismissed for incapacity it will in all likelihood be found to be fair, provided the correct dismissal procedures have been followed. Can the organisation’s grievance and disciplinary procedures be applied to HIV-related disputes? The remedies available to employees living with HIV/AIDS should be integrated into existing grievance and disciplinary procedures. This may involve special measures to ensure confidentiality. Have all reasonably, practicable measures been taken to create and maintain a safe working environment, where the risk of HIV exposure and transmission is minimised? Employers generally have a legal duty to ensure that: • Steps are taken to assess health and safety risk, including the risk of occupational HIV infection; • The risk of possible HIV infection is minimised; • Staff training is undertaken on safety steps to be taken following an accident; • Universal infection control procedures are used in any situation where there is possible exposure to blood or blood products; • Universal infection control equipment is available for employees at the site of any accident; and • Protocols exist for the management of occupational exposure to potentially infected blood or body fluids. Page 68 What provision is there for compensation for employees who are injured in the course and scope of their employment, is HIV transmission included in the definition of an occupational injury, and are there procedures in place to adequately prove the cause? Compensation should be possible, in accordance with the law, where an employee becomes HIV infected following an occupational exposure to infected blood or Section One blood products. The success of a claim for compensation is likely to be reliant on the procedures which are followed immediately following an accident as it will be necessary to show that the occupational accident was the direct cause of the person sero-converting (i.e. becoming HIV positive). Section Two Score Card: HIV/AIDS legal compliance 10/10 Instructions Review the actions in the score card, where the sections are indicative of a minimal (1 red ribbon), good (3 red ribbons) and “blue-chip” (5 red ribbons) response. Assess Section Three your organisation’s level of competence in each. Then decide on future actions to improve your organisation’s rating. Score Card Description Rating Future Actions Section Four • HR department responsible for ensuring  that the company complies with the Minimal Response laws of the land • Ad hoc discussions at management meetings about new legislation that is promulgated Section Five • Legal and human rights training included  in training conducted for managers and Good Response supervisors • Process to ensure legal compliance is Appendices discussed at management/union meetings • Procedures to ensure confidentiality are instituted, such as not linking medical records to employee payroll numbers Acknowledgements • HIV/AIDS legal compliance is included  as a KPA for selected managers Blue-chip Response • Legal compliance review is a annual requirement by the Board and shareholders Costs The costs involved in assuring legal compliance will include the time of the employee nominated to conduct the review and to monitor compliance. In addition, there may be costs associated with “buying-in” legal expertise. Page 69 Case Study: HIV/AIDS legal compliance CASE STUDY In 1999, the South African Department of Labour introduced a new law on employment equity. This law was one of the first to address the problem of discrimination on the basis of HIV status. Since this is a new labour matter, the Minister, after consultation with NEDLAC and the Commission for Employment Equity, issued a Code of Good Practice on key aspects of HIV/AIDS and employment. The Code is based on five key principles: • Equality and non-discrimination between individuals with HIV infection and those without; and between HIV/AIDS and other comparable illnesses; • The creation of a supportive environment so that employees with HIV or AIDS can continue working for as long as possible; • Protection of human rights; • Ensuring that the rights and needs of women are addressed in all policies and programmes; and HIV/AIDS Legal Compliance • Consultation, inclusiveness and participation of all stakeholders in all policies and programmes. The following extract from the Code defines the measures that must be taken to ensure that there is no discrimination based on HIV status in workplaces. A non-discriminatory workplace in which people living with HIV or AIDS are able Management Strategies to be open about their HIV status without fear of stigma should be promoted. All recruitment procedures from the advertising and selection processes to the actual appointment need to be carefully screened. Remuneration packages, including employee benefits and terms and conditions of employment should be consistent among all employees. Training and development programmes, performance evaluation systems and promotion, transfer and demotion should be completely devoid of any differentiation between those who are either infected or affected by HIV or AIDS. In 2002, the Department of Labour published HIV/AIDS Technical Assistance Guidelines to complement the Code of Good Practice on key aspects of HIV/AIDS and employment. Additional Information The Code and Technical Assistance Guidelines are available on the South African Department of Labour’s website, at www.labour.gov.za. Other important references are: • UNAIDS; HIV/AIDS and human rights international guidelines, available on www.unaids.org; • ILO; Code of good practice on HIV/AIDS and the world of work, available on www.ilo.org; and • SADC; Code of good practice on HIV/AIDS, available on www.hri.ca/ partners/alp/resource/thesadc/shtml. Page 70 Section Two Behavioural Surveillance – the Section One KAP Survey Section Two INFO Briefing Note One of the most commonly used methods used to survey behaviour is the knowledge, Section Three attitudes and practices (or KAP) survey. What is an HIV/AIDS KAP survey? A KAP survey (sometimes called a KABP survey – knowledge, attitudes, behaviours and practices) is a tool to track trends in key behavioural indicators over time and to Section Four inform HIV/AIDS prevention activities. It is a simple way of gathering standardised information from a large number of people. In some instances KAP surveys are done in conjunction with biological surveillance, i.e. anonymous testing for HIV, to establish the prevalence of infection in the workforce. Section Five Why does an organisation need to conduct KAP surveys? In order to develop effective workplace responses to HIV/AIDS, reliable information is needed about the attitudes, beliefs and practices of employees, particularly about Appendices the sexual behaviours that can spread HIV. Monitoring changes over time in these behaviours and attitudes, by repeating the KAP survey (eg every 5 years), is essential to maintaining appropriately designed programmes. Contractors, with employees on site at mines, may be invited to participate in the mining company’s KAP survey. In such instances, the survey tool should capture Acknowledgements information related to the contractor’s employees, and this should then be used to target information and prevention messages. What are the features and elements of a KAP survey? In the past many people were deeply sceptical about the validity of self-reported data on sexual behaviour, but there is growing experience that indicates that people do not generally lie when completing KAP questionnaires. KAP surveys take many different forms, from a simple one-page questionnaire that is administered to participants before and after an HIV/AIDS workshop, to a tool used by peer educators, to focus groups and PRA-type methodologies, to very complex, multifaceted surveys that require specific design and interpretation skills. Page 71 Typically the objectives of a KAP survey are: • To gather information on the knowledge, attitudes and behaviours in respect to HIV/AIDS, STIs and TB of employees; • To identify specific attitudes and risk behaviours which may be associated with the transmission of HIV; • To gain relevant information to inform and guide the development of a compre- hensive HIV/AIDS strategy in a company and to ensure that any implemented strategies and interventions are appropriate for their intended audiences; • To identify sources of information, means of communication and different health-seeking behaviours; • To assist in identifying the strengths and any weaknesses, shortfalls or deficiencies in the existing HIV/AIDS initiatives and to then convey these to management and employees. This in turn is aimed at promoting more commitment to the programme by management and employees; • To determine to what extent managers and supervisors are equipped to deal Behavioural Surveillance – the KAP Survey with HIV/AIDS-related issues at the workplace – on a personal, ethical and legal level; • To identify if there are any major differences in the KAP profile of various job categories, ages and sexes of employees, in order to better target future interventions; and • To obtain base line information against which to measure and monitor the efficacy and impact of the company’s HIV/AIDS programme in the future. A typical KAP survey methodology and design process consists of the following activities: • Developing the protocol; Management Strategies • Negotiating with employee representatives to create an optimal environment for the survey; • Defining the sample; • Developing the research instrument; • Piloting the research instrument; • Training those who will administer the research instrument; • Informing employees of their participation; • Administering the survey; • Capturing and interpreting the data; • Reporting on the findings; and • Using the findings to inform workplace programmes. A cornerstone of successful KAP surveys is a consistent sampling strategy in repeated surveys. The sample should be selected from across the various job-bands and should be stratified by job grade and/or category. Not only should there be a consistent sampling methodology, but also consistent data collection methods and established indicators in order to track trends in behaviour over time. Page 72 Typically the research instrument is a questionnaire that is completed anonymously. Face-to-face administration by an interviewer is sometimes selected as the means of implementation where the respondents have low levels of literacy or where probing and clarification is important. The questionnaire can comprise a mix of qualitative-type questions, quantitative, fixed-choice (closed) questions, scales and open-ended questions. Section One The use of standardised questionnaires has many advantages, not only because questionnaire development is a difficult process, but also to allow for comparisons to be made across companies and contexts. It is however still essential to pre-test and adapt the survey instrument for every local setting. This involves translating the instrument into local languages and using the appropriate local terminology to Section Two ensure that the original meaning of the question is not lost. Where this is the selected methology it is useful to develop a guide for the person/s administering the questionnaire, which goes through the questionnaire one question at a time, explaining in full the rationale behind each question and its intended Section Three meaning. This guide can be used in training and during the survey itself, to clarify any ambiguities or misunderstandings that may arise. A baseline survey provides a “snapshot” of worker knowledge, attitudes and practices, before any intervention strategies are initiated. It also serves to benchmark the impact of a long-term comprehensive workplace response, allowing for comparisons with Section Four future surveys. Ethical considerations are very important. Surveys cannot take place without the informed consent of the respondent. Special efforts must be made to ensure that the potential respondents understand their rights, in terms of the research process, Section Five the measures in place to ensure confidentiality and any risks involved. Using the findings – there is no point collecting KAP data unless they are used, and used for the benefit of the people from whom they were collected. It is always best to think about how the findings will be used from the very beginning of the process. Appendices Indicators related to behaviour change can be linked to KAP surveys, such as: • Knowledge of HIV prevention methods; • No incorrect beliefs about HIV transmission; • Reduction in the number of non-regular partners in the last year; • Condom use at last sex with a non-regular partner; and Acknowledgements • Consistent condom use with non-regular partners. Page 73 Red Flags and Special Challenges • Especially for the baseline survey, be sure to include all the aspects about which you require information. For example, do you want to explore employees’ perceptions about the company’s HIV/AIDS programme, or do you want information about alcohol and drug use practices that may influence risk taking sexual behaviour? This will mean that comparisons can be made on a wide range of issues, when repeat KAP surveys are conducted. • Negotiation with trade unions and employee representatives, and agreement from them to participate in a KAP survey, is a fundamental requirement and should never be short-circuited. Tool: Checklist of elements to include in a Behavioural Surveillance – the KAP Survey KAP questionnaire Instructions When developing or adopting a research instrument for your KAP survey, decide which of the following elements you want to cover and then check that they are all in the KAP instrument/questionnaire. • Biographical details, age, sex, marital status, job grade/category, etc; • Sexual history and practices (including past and current condom use1 and history of STI infections); Management Strategies • Knowledge regarding HIV/AIDS, STIs and TB – both prevention and treatment; • Common myths and misconceptions (such as transmission via mosquitoes); • Attitudes to people infected with and affected by HIV/AIDS – personal and work- related; • Awareness of any persons living with HIV/AIDS – in the community or at work; • Knowledge of basic human and employment rights; • Knowledge of HIV/AIDS-related services – at work and in the community; • Access to supplies, eg condoms; • Awareness of HIV/AIDS-related policies, practices and programmes at work; • Awareness of the impact of the HIV/AIDS epidemic on the company – current and future; • Knowledge of HIV status (of themselves – a yes or no answer might be preferable to the actual result); • Perceptions of risk; • Perceptions of self-efficacy; • Information seeking behaviour and main sources of information on HIV/AIDS, STIs and TB; • Communication about HIV/AIDS – with whom, when and about what; and • Health seeking behaviour. Page 74 Score Card: Knowledge, attitudes and 10/10 practices Instructions Review the actions in the score card, where the sections are indicative of a minimal (1 red ribbon), good (3 red ribbons) and “blue-chip” (5 red ribbons) response. Assess Section One your organisation’s level of competence in each. Then decide on future actions to improve your organisation’s rating. Score Card Description Rating Future Actions Section Two • Peer educators complete a pre- and  post-workshop questionnaire during Minimal Response their training • Some information leaflets are translated into local languages Section Three • Base-line KAP survey conducted and  results used to draw up a set of key Good Response messages for the workplace prevention programme • Results presented to employees, with the Section Four opportunity to interact with them • KAP surveys commissioned on a regular  basis. Blue-chip Response • Workplace HIV/AIDS programme reviewed annually in light of KAP survey Section Five results and trends over time • Company supports KAP survey in the community • KAP survey results used in advocacy and awareness campaigns Costs Appendices Conducting and interpreting a KAP survey requires special skills and experience. Acknowledgements They should, in most instances, be outsourced to suitably qualified persons or institutions. The cost of a KAP survey will vary greatly from context to context and depends on whether it is done in-house or outsourced, the number of respondents, the geographic coverage of the survey, the sampling design, and the frequency and methods of data collection. An indicative cost of a KAP survey that was outsourced, for a company with 5 000 employees, was about $19 0002. To limit the costs of a KAP survey, staff can be used to distribute and collect completed forms, which are then sent for coding and interpretation. Page 75 Case Study: KAP survey CASE STUDY Placer Dome conducted a KAP survey in 2001, which played an influential role in shaping and reorienting the direction of the HIV/AIDS programme. The survey assessed 170 general workers and 16 supervisors, which corresponds to 4% of all workers. This process led to key recommendations for the future of the HIV/AIDS programme at South Deep and included; • Expansion of the existing condom distribution programme especially the access for women to improve availability in terms of time and location; • Re-emphasizing the correct use and safety of condoms; • Re-emphasizing confidentiality and the clearly defined disciplinary procedures for dealing with infractions; • Implementing an aggressive STI programme supported by a dynamic education programme aimed at; Behavioural Surveillance – the KAP Survey - Addressing myths and misconceptions based on cultural and gender beliefs; and - Emphasizing the implications of maternal transmission. Building upon lessons and experiences to date, combined with insights that have been gathered through monitoring and assessment, South Deep will be focusing on the following issues in the future: • Intensifying education; • Training and deploying peer educators; • Increasing VCT uptake; • Providing antiretrovirals to prevent mother to child transmission; and Management Strategies • Providing a sustainable wellness programme. Additional Information Other case studies of KAP surveys are available on www.weforum.org/ globalhealth/cases. Additional information on behavioural surveillance and KAP surveys can be found in the UNAIDS publication; Guidelines for second generation HIV surveillance, which is available on www.unaids.org. Footnotes 1 Male and female condoms 2 Calculation based on breakdown of AVMIN’s HIV/AIDS budget, where the KAP survey constituted 8% of the budget. Page 76 Section Two Biological HIV Surveillance Section One Section Two INFO Briefing Note Section Three What is biological HIV surveillance? In the workplace context, HIV surveillance refers to the periodic anonymous, unlinked testing of a representative sample of the workforce, to establish the pattern of HIV prevalence in the workforce – the magnitude and distribution of HIV infection in a company. Section Four Example from DaimlerChrysler South Africa The results from the HIV sero-prevalence study are currently being used to make projections on future HIV prevalence levels, to estimate the economic and other impacts of HIV on the company and as a baseline against which Section Five to evaluate the DCSA HIV/AIDS programme in the future. At a more national level, HIV surveillance can also be done in other ways, such as: • Sentinel surveillance in defined sub-populations, eg HIV testing of women Appendices attending antenatal clinics; and • Regular screening of donated blood; In addition, information on HIV prevalence can be estimated from: • Targeted research studies of HIV infection rates; Acknowledgements • HIV and AIDS case reporting; • STI and TB case reporting; and • Death registration. Whilst these sources can provide useful information to an organisation, and can be used as proxies, there are always a number of adjustments and assumptions that have to be made when using this data that can be, and often are challenged. The groups tested may be high risk (STI clients), antenatal clients (young, sexually active women), or not necessarily representative of the general population (blood donors or TB patients). As a rule extrapolating these results requires the services of an experienced epidemiologist, and even then the data may not be complete enough for an accurate estimate. Page 77 Important adjustments that would need to be made to national data would include: • That antenatal data, which is the most frequently selected form of sentinel surveil- lance, is confined to women, usually in the 15-40 year age group and mainly in the 20-35 year bracket. Mining workforces are mainly men and are typically in a wider age range; • That mining employees are likely to have higher and more stable incomes than the general population; and • That, if employees live apart from the families for long periods, they may have a higher risk of infection as a result of casual or commercial sexual contacts. Traditional surveillance typically tracked HIV or STIs, but did not track the sexual practices that lead to HIV/STI transmission. This made it difficult to corroborate and explain HIV/STI trends. More recently, so-called second generation surveillance has evolved, which seeks to combine biological and behavioural data. This allows for a more meaningful interpretation of the surveillance results. Why does an organisation need to conduct surveys of HIV prevalence? Biological HIV Surveillance The information from regular or serial HIV surveys allows an organisation to: • Develop an accurate understanding of the profile of the HIV/AIDS epidemic within the workforce, and its age, gender, job grade, department/section, employee benefit fund, and residence and geographic distribution; • Plan, using this information, and to generate models of the epidemic and its likely impact on the organisation in the future; • Track changes, even small changes, in prevalence, and understand the factors responsible for these changes; Management Strategies • Plan for programmes and services – prevention and care – and target these appropriately; and • Monitor its HIV/AIDS programme, and measure any successes. Contractors may not be in a position to commission an HIV prevalence survey. Should they do so, and if their numbers of employees are small, this could create problems with the anonymity of the survey. A possible compromise would be for the contractor to participate in the survey of a larger organisation to which they are providing services. What are the features and elements of a workplace HIV prevalence survey? Many of the features of behavioural surveillance are relevant also for biological surveillance. These include: • Developing the protocol; • Negotiating with employee representatives to create an optimal environment for the survey; • Defining the sample; • Informing employees of the survey and how they may participate; • Administering the survey; • Analysing the results; • Reporting on the findings, which can constitute an important “wake-up call”; and • Using the findings to inform workplace programmes. Page 78 In addition, HIV prevalence surveys provide information for: • Human resource planning; • Critical job analysis; • Establishing trends in the epidemic in each strata (age, job band etc); • Employee benefit fund management; • Budgeting for health care costs; and • The assessment of utilisation of ART and VCT programmes. Section One There are important ethical considerations associated with conducting HIV surveillance. These include obtaining approval from the ethics committee of a local academic institution that the protocol is ethically sound, and ensuring that participants give free and full consent to participate. Section Two These requirements become clear when HIV surveillance is placed within the context of other HIV testing. Unlinked anonymous testing (without informed consent) • Testing of unlinked specimens collected for other purposes; Section Three • No personal identifiers or names obtained, no informed consent, no counselling required; • Coded specimen. Unlinked anonymous testing (with informed consent) • Testing of unlinked specimens collected solely for surveillance purposes; Section Four • Informed consent required; • No personal identifiers or names obtained (usually only age, sex and job grade information is collected), no counselling required; • Coded specimen. Section Five Linked confidential testing (with informed consent) • Informed consent and pre-test and post-test counselling required; • Personal identifiers or names obtained; • Coded specimen; code linked to personal identifying information. Appendices Linked anonymous testing (with informed consent) • Informed consent and pre-test and post-test counselling required; Anonymous and unlinked surveillance • No personal identifiers or names obtained; or epidemiological testing is defined • Coded specimen; code given to client so that only client can link himself in the Code1 as anonymous, unlinked or herself to the result. testing which is done in order to determine Acknowledgements the prevalence and possibly incidence of In addition, HIV surveillance should only be undertaken by professionals with disease within a particular community or qualifications in epidemiology or public health. The tests should be done by group to provide information to control, qualified and experienced laboratory technicians and the tests utilised should have prevent and manage the disease. The high sensitivity and specificity and be suitable for such surveillance. Code states further that such testing will not be considered anonymous if there is Many types of specimens can be used for HIV biological surveillance: whole blood, a reasonable possibility that a person’s plasma, serum, oral fluids/saliva and urine. The choice of specimen depends on HIV status could be deduced in any way factors such as logistics, staff (availability and competency) and sites. Saliva tests are from the survey results. usually selected for workplace HIV surveillance, because of the ease of specimen collection. Page 79 Specimens must be collected, stored and tested in an appropriate manner in order to obtain accurate and reliable results. Information that can be obtained from an HIV surveillance exercise includes: • Prevalence according to: - Sex: male or female - Age: eg <35; 35–49; >49 years - Race - Job: unskilled; skilled;management - Province/region/site; • Projected prevalence; • Projected incidence; and • Projected mortality. Red Flags and Special Challenges HIV sero-prevalence studies should never be the first, or even one of the first Biological HIV Surveillance HIV/AIDS interventions, and participation should never be mandatory, as this could send problematic messages to the employees and the community. Conducting an HIV prevalence survey is easier in a large organisation than in a small one, as the assurance of anonymity is more credible in larger organisations. The most difficult aspect of conducting HIV surveillance in the workplace is to obtain the co-operation of workers and to get high participation rates. Failure to obtain Management Strategies participation levels of over 70% will result in the data being biased, unreliable and of limited value. It is also important to assess employee participation by age, job etc to understand possible biases. • The survey is unlikely to be supported if employees cannot understand how the results will be of any benefit to them; and • Surveys tend to raise suspicions that management is trying, through the survey, to identify HIV infected employees. Epidemiological testing 1. Testing programmes for epidemio- logical purposes will be the subject of Participation in workplace HIV surveillance can be enhanced if: appropriate consultation with recognised • Management launches awareness campaigns about the survey; employee organisations and will be subject • Employees, trade unions and staff associations are involved in to independent and objective evaluation planning the survey; and scrutiny. • The survey is conducted by an independent third party; and 2. The statistical results of testing pro- • Results are shared with all employees. grammes will be shared with employees and Unlinked anonymous studies are not considered ethical unless potential participants recognised employee organisations. have independent access to voluntary HIV testing and counselling. 3. The results of epidemiological studies will not be used as a basis for discriminat- A single prevalence survey is of little use, whereas a sequence of surveys over a ing against any class of employee in the number of years will allow for trends to emerge. workplace. Extract from the agreement between Experience has shown that it is difficult to organise and conduct both an HIV prevalence the National Union of Mineworkers and the survey and a KAP survey at the same time, despite the temptation to use the same Chamber of Mines sample and to be able to link the results. Page 80 Tool: Checklist for an HIV prevalence survey Instructions When embarking on an HIV prevalence survey in your company, use the following checklist as a guide to ensure that you have considered all the important issues: • There should be an established HIV/AIDS programme in the company and a Section One multidisciplinary task group/committee to oversee the survey; • The company should know why it wants to do a survey and how it will use the data. The company should list the benefits of doing the survey, both to the company and to its workforce; • The survey must have ethics approval from an established medical research ethics committee (usually a local medical school); Section Two • The company must decide which strata it would like to capture in the survey i.e. age bands, job bands, department, gender etc; • Employee representatives must be consulted and agree to the survey in writing; • Employees must be informed about the survey and its benefits; • The consultant doing the survey should be experienced in research methodology Section Three and have appropriate qualifications (in epidemiology or public health); • The measurement tool, i.e. the HIV antibody test, should have high sensitivity and specificity and be shown to match well with blood testing studies; • The team collecting specimens needs to be experienced in research methodology; • The laboratory investigation should be done by experienced laboratory Section Four technicians who have experience with the HIV antibody test selected; • A strategy should be in place to communicate the survey results to the workforce, and the results must be given to management and labour simultaneously; • A personal and confidential HIV test with pre- and post test counselling must be available to any employee who wants to have an HIV test; • Essential bio statistical analysis must be done; Section Five • An appropriate sample size should be determined prior to the survey; and • A financial costing for the survey and the expected outcomes must be decided and agreed upon prior to the survey. Appendices Acknowledgements Page 81 10/10 Score Card: HIV surveillance Instructions Review the actions in the score card, where the sections are indicative of a minimal (1 red ribbon), good (3 red ribbons) and “blue-chip” (5 red ribbons) response. Assess your organisation’s level of competence in each. Then decide on future actions to improve your organisation’s rating. Score Card Description Rating Future Actions • National data, such as antenatal data,  used to develop a best and worst case Minimal Response scenario of the impact of HIV/AIDS on the company • Once-off surveillance conducted, and  results used to plan for future technical Good Response Biological HIV Surveillance needs • Results shared with pension and medical aid providers • Surveillance repeated every 2-3 years  and results considered for all aspects of Blue-chip Response strategic and operational planning • Biological and behavioural surveillance Management Strategies linked and results used to target HIV/AIDS prevention programmes Costs Like a KAP survey, an HIV surveillance exercise requires specialist skills and will, in most cases, be contracted out. The cost of the survey will depend on the cost of the tests usually US$ 3-5 per employee tested and an administrative fee (which will depend on the size of the workforce, number of employees to be surveyed, geographical location etc). Case Study: HIV surveillance study CASE STUDY The following case study describes the process undertaken by a large mining company to conduct an HIV prevalence survey. It does not include information on the benefits to the company that resulted from the process, or the way in which the survey results may have been used to inform the HIV/AIDS programme. In 1999, Aurum Health Research (AHR) used an anonymous unlinked survey to estimate an HIV prevalence of 24% in employees in the lower pay scales in the Free State region. The employees in these pay scales represent 85% of the workforce in the region. Page 82 In 2001, a follow-up anonymous unlinked survey of employees in the same lower pay scales estimated an HIV prevalence of 29%. The second survey was done in collaboration with the London School of Hygiene and Tropical Medicine. Between June 2000 and April 2001, the research team, using a stratified random sampling method, selected employees visiting the occupational health centre for their mandatory annual medical examination. The survey invited 6 100 employees Section One from both the Free State region and the Vaal River region to participate and had an 87% response rate. Participants were informed using a video available in two local languages followed by a question and answer session with a nurse. HIV testing was done by means of a urine test. Section Two The study protocol was approved by two independent ethics committees of which one had local labour representation. Based on the surveys, antenatal data, and extrapolation from comparable reference Section Three groups, AngloGold estimated a 2001-2002 company-wide prevalence rate of 25 to 30%. The number of deaths per 1 000 workers had decreased from 13 per 1 000 in 2001 to 4 per 1 000 in 2002. Likewise, the number of ill-health retirements per 1 000 workers had dropped from 19 per 1 000 to 6 per 1 000 in 2000 and 2002 respectively. It is assumed that this apparent paradox can be explained by the increased uptake of voluntary separation packages offered routinely during Section Four downsizing and through AIDS-sick employees not returning to the workplace and being dismissed in absentia. Additional Information Section Five The full AngloGold and DaimlerChrysler case studies are available at www.weforum.org/globalhealth/cases. Appendices The full Chamber of Mines and NUM policy is contained in the ILO manual which is available on www.ilo.org. Additional information on biological HIV surveillance can be found in the UNAIDS publication; Guidelines for second generation HIV surveillance, which is available on www.unaids.org. Acknowledgements Footnotes 1 The Code referred to is the South African Department of Labour’s Code of good practice on key aspects of HIV/AIDS and employment Page 83 Section Two HIV/AIDS Risk and Impact Assessment INFO Briefing Note HIV/AIDS Risk and Impact Assessment What is an HIV/AIDS risk and impact assessment? An impact assessment, often referred to as a risk assessment, is an exercise to describe the potential or likely impact of the epidemic on an organisation by describing the current situation and modelling scenarios into the future. An impact assessment typically includes costing the impact of the epidemic on all functions of the organisation. It may also cost out various interventions and their cost benefits compared to the cost of doing nothing. Myth Management Strategies HIV/AIDS is a soft business issue best handled by the human resource function Why does an organisation need to conduct an HIV/AIDS impact in the company. assessment? All organisations operating in the mining sector in Southern Africa are more or less Reality vulnerable to the impact of the epidemic. The impact may be on the company itself HIV/AIDS is going to have a significant or on its business or consumers. Typically the HIV/AIDS epidemic results in1: impact on bottom-line profits and needs to be part and parcel of line Workplace impacts management’s strategic thinking and • Reduced supply of labour; decision-making. • Loss of skilled and experienced workers; Whiteside, A and Sunter, C • Absenteeism and early retirement; AIDS, the challenge • Stigmatisation of and discrimination against workers with HIV/AIDS; and for South Africa (2000) • Increased labour costs for employers; from health benefits to retraining. Societal impacts • Reduced productivity, contracting tax base and negative impact on economic growth; • Changing consumer behaviour/spending; • Falling demand, investment discouraged and enterprise development undermined; • A threat to food security (and agricultural production) as rural workers are increasingly affected; • Increased demands for health care; • Additional demands on pension, provident, death and funeral benefits; • Social protection systems and health services under pressure; and • Pressure on higher purchase or bank loans and life insurance. Page 84 Family and community impacts • Increased burden on women to combine care and productive work; • Loss of family income and household productivity, which, in turn exacerbates poverty; • Orphans and other affected children forced out of school and into child labour; and • Pressure on women and young people to survive by providing sexual services. Section One It is much better for organisations to understand how these factors will impact on their operations and to plan accordingly than to wait for the impact of the epidemic to become really obvious and then to try and respond. Conducting an impact assessment therefore allows for a much more proactive response, in particular relating to those factors that can be influenced or manipulated to minimise their impact. In Section Two addition, organisations can use the platform created by an impact assessment to initiate interventions – such as HIV/AIDS prevention programmes for employees and contractors, or nutrition and treatment provision for HIV infected employees – that have the potential to significantly change the epidemic’s impact. Section Three NOSA HIV/AIDS specification The NOSA AMS2 requires an HIV/AIDS determinant identification and risk assessment as a starting point and important input into the planning of an HIV/AIDS management system and subsequent implementation, Section Four evaluation, corrective and preventive action, and review. The intent is stated as follows: Identify and assess HIV/AIDS risks through a dynamic and holistic process to facilitate effective risk reduction plans and actions. Importantly the risk assessment includes “socio-immigration and migrant Section Five labour, single-sex hostels, overcrowded housing, poor access to health services, lack of recreation facilities, lack of accurate information, culture, high unemployment, exploitation of women and poverty factors such as TB” Appendices Contractors, whilst they may not formally commission a risk and impact assessment, should attempt to identify and quantify risk factors, and should build this understanding into their planning – not only for their HIV/AIDS programme, but also in relation to their services, markets, suppliers and so on. Acknowledgements What are the elements of an HIV/AIDS impact assessment? An HIV/AIDS impact assessment consists of: • Collecting and analysing data; • Creating models of the impact of epidemic on the organisation and its structures; and • Conducting a cost analysis, and monitoring cost impacts. 1. Collecting and analysing data The data that is available will vary in different organisations, but most companies will be able to provide data on: • The number of employees, by age, gender, grade and education level; • The salaries and benefits of contract and permanent staff; • The rate of sick leave and compassionate leave usage; Page 85 • Medical aid claims; • Clinic utilisation; • Early retirements for health reasons; • Deaths in service; • Staff turnover; and • Measures of productivity. Example of data analysis Those who terminated due to HIV/AIDS took between 11 and 68 more days leave in their final year of service than did employees who were still in the workforce3. They were 22-63% less productive in their final year of service. Supervisors reported spending 7-25 days of time per employee with HIV/AIDS, in the employee’s last year of service. HIV/AIDS Risk and Impact Assessment It is important to remember the oft quoted statements that no data = no decisions; rubbish in, rubbish out; what is measured is managed; and manage HIV, don’t let HIV manage you; all of which highlight the critical importance of reliable data for impact assessments. 2. Creating models of the impact of epidemic on the organisation and its structures As demonstrated in the following diagram, a model is a conceptual framework that attempts to describe reality, and to provide answers to questions about the real Management Strategies world. Process for using a model of the HIV/AIDS epidemic Reality Model (hypothesis) Assumptions Modelling tool Parameters and data Scenarios Analysis Action Page 86 Most models have concentrated on predicting the path of the epidemic, though there are some that attempt to measure the impact of certain interventions. These may assist in answering questions such as: • Is it better to invest resources in one intervention rather than another? • Which service or combination of services gives the best value for the budget available? • How should resources be allocated within the competing needs of the HIV/AIDS Section One programme? • How can an extra investment best improve a programme’s performance? It is important to keep adding real data (such as deaths, costs, known HIV/AIDS cases etc) to the model so that, eventually, an organisation will have a data set and epidemic Section Two curve of real events and, in time, will no longer need to model the epidemic. Finally, apart from providing information for planning, models are also a useful advocacy tool. Section Three All models, however, must be used with caution. They are mathematical constructs, not crystal balls, and, apart from their dependence on quality data, they also require a number of assumptions. In addition, the further into the future the model projects, the more these cautions need to be stressed. 3. Conducting a cost analysis and monitoring cost impacts Section Four Costing the human resource implications of the epidemic is only one aspect of a cost analysis. It should also consider the goods and services flowing into and out of a sector, the markets, and indeed macro-economic changes that will impact on the organisation. Section Five Appendices Acknowledgements The following diagram illustrates the human resource costs of HIV/AIDS to an organisation at different points4. Similar flowcharts could be developed to assist in costing the other elements. Page 87 Analysis of the human resource costs of HIV/AIDS to an organisation Progression of HIV/AIDS Economic impact of Economic impact of in the workforce individual case all cases 1. Employee becomes • No costs to the company • No costs to the company infected with HIV at this stage at this stage 2. HIV/AIDS-related • Sick leave and other • Overall productivity of morbidity begins absenteeism increase workforce declines • Work performance declines due • Overall labour costs increase to employee illness • Additional use of medical aid • Overtime and/or contractors' benefits causes premiums to HIV/AIDS Risk and Impact Assessment wages increase to compensate increase for absenteeism • Managers begin to spend time • Use of health/medical aid and resources on HIV-related benefits increases issues • Employee requires attention of • HIV/AIDS interventions are human resource and employee designed and implemented assistance personnel 3. Employee leaves • Payout from death benefit or life • Payouts from pension fund workforce due to insurance scheme is claimed cause employer and/or death, medical • Pension benefits are claimed by employee contributions to boarding, or employee or dependants increase voluntary resignation • Returns to training investments Management Strategies • Other employees are absent to attend funeral are reduced • Funeral expenses are incurred • Morale, discipline, and concentration of other • Loans eg housing are not repaid employees are disrupted by • Co-workers are demoralised by frequent deaths of colleagues loss of colleague 4. Company recruits a 4 • Company incurs costs of • Additional recruiting staff and replacement recruitment resources must be brought in employee • Position is vacant until new • Wages for skilled (and possibly employee is hired semi-skilled) employees • Cost of overtime wages increase as labour markets increases to compensate for respond to the loss of workers vacant positions 5. Company trains the • Company incurs costs of pre- • Additional training staff and new employee employment training resources must be brought in (induction etc) • Company incurs costs of in- service training to bring new employee up to level of old one • Salary is paid to employee during training 6. New employee joins • Performance is low while new • There is an overall reduction in the workforce employee comes up to speed the experience, skill, • Other employees spend time institutional memory and providing on-the-job training performance of the workforce • Work unit productivity is disrupted due to increased staff turnover Page 88 Red Flags and Special Challenges When conducting an impact assessment it is best to use consultants who have a range of epidemiological, actuarial and modelling experience. Often the information that is available in an organisation is not in a format that can Section One be used in an HIV/AIDS impact assessment. Organisations need to develop systems that will capture information in appropriate forms. Validation of the findings of an impact assessment is an important step to ensuring ownership at company level. This should take the form of consultative briefings, which will assist in ensuring that the results are used optimally in planning and Section Two programming. It is often difficult to make comparisons of costs, across organisations, or across time, due to the fact that different elements are either factored in, or excluded, such as recruitment costs, the cost of supervisors’ time and so on. Section Three Tool: Impact assessment checklist Section Four Instructions Use the following checklist when defining the parameters of your organisation’s impact assessment. Bear in mind that not all organisations will have access to all this information. Organisational profile Section Five • Structure of organisation – management/human resource structure (organogram); • Number of staff – by gender, age, grade, type of employment and type of contract (explain the grading system); • Number of contractors by gender, age, and type of work; Appendices • Operations, functions and services; and • Age of organisation (and organisational history). Nature of work/employee information • For different types of work in the organisation, how much experience/ Acknowledgements training is needed? • Do some types of work require experience gained on the job? • How easy is it to train or replace individuals in different categories of work? • Are there key personnel whom it will be particularly difficult to replace? • Are there key personnel on whom a certain process or activity depends? • Does any of the work demand travel? • Are certain employees/contractors at greater risk of exposure to HIV/AIDS (such as those who travel or who are based away from home)? Page 89 Employee benefits (include grade differentials where applicable) • What type of the following are provided, to whom, and at what cost: - Medical services or medical aid - Death benefits - Insurance - Pension for dependants - Other benefits (eg housing, transport) especially those affected by illness/ death? • Is there sick leave provision? How much? • Is there compassionate leave? How much? • What type of HIV/AIDS prevention programmes are in place? Management information system • How does the organisation record: - Absence from work? - Lateness for work? HIV/AIDS Risk and Impact Assessment - People leaving work early? • Does the organisation maintain records of reasons for employees’ absence? • Does the organisation keep records of compassionate leave? • What is this data used for? • Where is the data collected and collated? By whom? For how long? Absenteeism • Rates or numbers of absences per month, by grade, gender, and age; • Rates of short-term and extended absenteeism; and Management Strategies • Reasons for absenteeism. Sick leave • Absence by grade and age; • Diagnosis; • Number of employees (per month); and • Number of work days lost per month. Ill-health retirements • Numbers per month by: - Age - Grade - Gender - Engagement date - Level of training - Diagnosis at time of departure – i.e. reason for leaving; and • Were any of these key personnel who were difficult to replace? • Did any workers receive “continuation health care” or support on retirement, and at what cost? Page 90 Death data • Numbers per month by: - Age - Grade - Gender - Engagement date - Level of training Section One - Cause (diagnosis); and • Were any of these key personnel who were difficult to replace? Other/undefined turnover • Numbers of employee departures per month; Section Two • Reasons for departures; • Do departures correlate with absenteeism – do people leave after extended absenteeism? • Were any of these key personnel who were difficult to replace? Section Three Replacement hiring • How long are posts vacant? • Is it difficult to find replacement personnel? • How costly is recruitment, hiring, and training? Effect on daily operations Section Four • What is the effect on the organisation’s daily operations of illness, absenteeism, and turnover of staff and volunteers? • Are there frequently vacant posts? Are there holes in the management hierarchy or chain of production? • What is the impact of the loss of experience and need for training? Section Five • Are there problems with a lack of cohesion, or loss of morale? • What is the impact on the ability of staff and volunteers to perform their duties? • What is the impact on the organisation’s ability to meet its targets? Appendices Acknowledgements Page 91 10/10 Score Card: HIV/AIDS impact assessment Instructions Review the actions in the score card, where the sections are indicative of a minimal (1 red ribbon), good (3 red ribbons) and “blue-chip” (5 red ribbons) response. Assess your organisation’s level of competence in each. Then decide on future actions to improve your organisation’s rating. Score Card Description Rating Future Actions • HR data reviewed and analysed annually  for any trends that may indicate Minimal Response HIV/AIDS-related impact • MIS reviewed and adjusted to ensure  HIV/AIDS Risk and Impact Assessment Good Response optimal data collection for tracking and monitoring HIV/AIDS-related trends • Monthly collection of data and quarterly analysis • Impact assessment commissioned and results presented to management • Impact assessment linked to behavioural  and biological surveillance, and Blue-chip Response composite results fed into strategic Management Strategies and operational planning and budgeting Costs Impact assessments are costly exercises, but can easily be justified in terms of the information for planning that they provide to an organisation. Case Study: HIV/AIDS impact assessment CASE STUDY Anglovaal Mining Ltd. (AVMIN) is a company that develops copper, cobalt, nickel, ferrous and precious metals. The company has 8 mining and plant operations in South Africa, Zambia and Namibia. The company has 7 500 workers (5 300 employees and 2 200 contractors). AVMIN generated US$ 369 million revenue and US$ 37 million earnings in 2001. As part of an annual risk assessment, the present value of the average cost of a newly infected HIV employee was estimated in all divisions except for headquarters and Zambia (85% of employees were assessed) in a study with the Boston University School of Public Health. The results were as follows: Page 92 Salary class Present value of one infection (US$) Tier I (unskilled) $ 5 774 Tier II (skilled and artisans) $ 10 091 Section One Tier III-VI (supervisors and managers) $ 32 433 Company average $ 8 170 Section Two The average cost breakdown was: death and disability (38.1%), productivity losses (41.9%), supervisory time (7.1%), sick leave (6.5%), medical aid premiums (4.5%), recruitment and training (1.9%). In 2002, AVMIN estimated a future HIV/AIDS liability of US$ 6.1 million for all HIV infected employees. This assumes an estimated 2002 prevalence of 14.1%; present Section Three value per infection of US$ 8,170; 5 300 employees; and that all infections started in 2002. Additionally, AVMIN estimated that US$805 000 of that liability was assumed through the estimated 99 HIV infections that were acquired in 2002. Section Four Additional Information The full Anglovaal case study is available at www.weforum.org/globalhealth/ cases. Section Five Information on impact assessments and modelling techniques is available in a publication edited by Prof. Alan Whiteside and entitled Implications of AIDS for demography and policy in Southern Africa (1998). The Futures Group International has developed a number of modelling Appendices techniques. Their AIDS Impact Model for Business is available on www.futuresgroup.com/aim. Data sets and sources are described in the UNAIDS publication, Guidelines for studies of the social and economic impact of HIV/AIDS (2000), available on www.unaids.org. Acknowledgements The NOSA AMS 16001: 2003 documents: Standard for HIV/AIDS Management System specification document and guideline document are available on www.nosa.co.za. Footnotes 1 See also the information on the HIV/AIDS epidemic and the workplace, in Section One of the Guide 2 The AMS is available on www.nosa.co.za 3 Other sources quote an average of 55 days in the last 2 years of service 4 Adapted from The response of African businesses to HIV/AIDS, in HIV/AIDS in the Commonwealth and quoted in Whiteside, A and Sunter, C; AIDS the challenge for South Africa (2000) Page 93 Section Two Managing the Human Resource Implications of Managing the Human Resource Implications of the HIV/AIDS Epidemic the HIV/AIDS Epidemic INFO Briefing Note What is meant by the human resource implications of the HIV/AIDS epidemic? Because HIV/AIDS affects the economically active age groups, there are implications for the world of work unlike those associated with any other disease. In addition, the fact that the disease, in an infected employee, remains “invisible” for years and then follows an often unpredictable pattern from symptomatic HIV disease to death means that it is very difficult to plan for an organisation’s human resource needs. Management Strategies In addition to the predictable effects of large numbers of infected employees – such as increased absenteeism, reduced productivity, and increased demand on benefits, there are systemic effects, such as the loss of valuable, and sometimes irreplaceable institutional memory; factors which are often neglected when considering the implications of the epidemic on human resources. There are potentially profound effects related to the stigma and discrimination which are associated with HIV/AIDS and which are still pervasive in many workplaces, even in situations where the epidemic has been well-established for a decade or more. These effects can translate into all forms of workplace disruption, reduced morale and even conflicts – problems that require time and attention if they are to be resolved. Finally, outside of the workplace, but with significant implications for employees from affected families and communities are the consequences for those who are forced to assume ever increasing social burdens, in the form of supporting orphans or caring for sick family members. Eskom example When ESKOM observed that there were twice as many deaths in service as previously; and that 50% of ill-health retirements were as a result of HIV/AIDS, they tripled their bursary scheme to ensure a consistent supply of suitably qualified technical staff. Page 94 Why does an organisation need to manage the human resource implications of HIV/AIDS? In order to function, organisations need the right number of people, with the right competencies, in the right places. The HIV/AIDS epidemic poses a threat to demand, supply and quality of human resources that must be managed appropriately. Contractors are no different, in fact they may be more vulnerable than larger organisations Section One to the loss of a highly skilled employee. They should therefore identify these critical positions and institute plans to ensure that the skills necessary for their operation are retained, should the employees in these positions be lost to the organisation. Red Flags and Special Challenges Section Two 1. Succession plans Many organisations fail to identify critical posts, nor do they have succession plans in place to replace workers in these critical posts who fall ill, are retired early on Section Three medical grounds, or who die. Several mining companies are investigating innovative methods to reduce the impact of HIV/AIDS on the families of mineworkers who are unable to continue working. Section Four At Lonmin’s Western Platinum Operation1, HIV-positive employees who are faced with medical boarding can nominate candidates as possible replacements. This provides an important opportunity for employment benefits to remain within the immediate or extended family of the affected person. The impact of the loss of income is therefore mitigated. This solution is, however, only likely to be practical for jobs that do not require high levels of skills. Section Five 2. Confidentiality Every person has the right to personal privacy and dignity. Every person has the Appendices In a world where there is still preju- dice and misunderstanding about right to decide what aspects of his or her life are private and what can be made HIV/AIDS, confidentiality is a right public. Unfortunately this right is frequently abused when it concerns a person’s that protects other rights. Failure to HIV status. defend the right to confidentiality will drive HIV/AIDS underground, Express and informed consent must be obtained from a person before information Acknowledgements with drastic consequences . 1 about their HIV status is passed on to anyone else. This means that the person living with HIV or AIDS must be informed about the intended use of the information, including who is going to be told. Page 95 Tool: HR HIV/AIDS management checklist Instructions Review your human resource systems and procedures to ensure that they adequately integrate the following actions: 1. Succession and skills planning Managing the Human Resource Implications of the HIV/AIDS Epidemic • Look at your organisation’s long-term workforce and succession needs, given that HIV/AIDS will result in high staff turnover, reduced skills levels, declining quality of available recruits, and high competition for skilled personnel. • Draft plans for ensuring the organisation’s medium- and long-term ability to fill positions with quality, skilled individuals; these should include hiring plans, systematic induction processes, and skills development. • Consider ways to replicate skills and knowledge among multiple employees, so that the absence or loss of any individual can be more easily absorbed. This can be accomplished through co-operative and team-based work processes, multi-tasking, training and effective information exchange. • Record institutional knowledge and important processes in a formalised manner, such as through a manual for each position, so that this knowledge is not lost with the loss of an individual employee. 2. HR information systems • Evaluate and find ways to improve your human resource information systems, so you can monitor the impacts of HIV/AIDS on your organisation. This is Management Strategies particularly important for large or decentralised organisations, where people in management positions may not be aware of how the epidemic is impacting staff and contractors. 3. Benefits • Review and, where necessary, remodel benefit schemes; • Review and, where necessary, amend the services of the medical aid scheme; • Enhance the process for management of death benefit allocations; and • Enhance the capacity for managing ill health and early retirement cases. 4. HR policies and practices Review HR policies, such as sick leave and incapacity policies to ensure that they adequately cater for HIV/AIDS. Develop systems and programmes to manage: • Increased absenteeism; • Reduced productivity; • Higher labour turnover; and • Loss of skills. 5. Reasonable accommodation Review existing measures and, where feasible, create opportunities for: • Job modifications; • Flexible scheduling; • Job sharing; • Leaves of absence; • Transfers; Page 96 • Computer terminals at home; • Ease of access (eg wheelchair ramps); and • Technological alternatives. 6. Training Develop an HIV/AIDS training plan that includes: • Managers, supervisors and personnel officers; Section One • Employee representatives; • Peer educators; • Health and safety officers; and • Employees who may come into contact with blood and other body fluids. Section Two Score Card: HR HIV/AIDS management 10/10 Instructions Review the actions in the score card, where the sections are indicative of a minimal Section Three (1 red ribbon), good (3 red ribbons) and “blue-chip” (5 red ribbons) response. Assess your organisation’s level of competence in each. Then decide on future actions to improve your organisation’s rating. Score Card Description Rating Future Actions Section Four • HIV/AIDS module included in induction  and re-induction courses Minimal Response • Critical positions identified  • Succession plan developed, in light of Section Five Good Response results from impact assessment • 2 or more successors trained for every  critical position Blue-chip Response • Bursaries provided for training in key Appendices technologies • Early warning system in place to identify HIV/AIDS cases and to provide back-up to ensure that functions and productivity are not affected Acknowledgements Costs There will be costs associated with many of the HR HIV/AIDS management activities. These include training costs, costs associated with implementing a skills succession plan, the costs of reasonable accommodation, and so on. Page 97 Case Study: HR data collection CASE STUDY Debswana collects a range of HR data on a monthly basis, which they analyse and compile into an HIV/AIDS Fact Sheet for submission to management on a quarterly basis. The following is a consolidation of the information which they have found to be of use in tracking the HIV/AIDS epidemic at their various operations. Managing the Human Resource Implications of the HIV/AIDS Epidemic Workforce demographics – by age bracket, gender, job grade and location Average workforce Average mandays worked No. on Medical Aid Medical retirement – by age bracket, gender, job grade and cause (accidental, HIV/AIDS or other) Turnover and separation – by age bracket, gender, job grade and cause (normal retirment, transfer within the group, medical retirement, death, resignation, dismissal, localisation and end of contract) Turnover (no. of separations) Management Strategies Turnover rate Total ill health retirements ARC ill health retirements Death data – in-service and out-of-service – by age bracket, gender, job grade and cause (accidental, HIV/AIDS or other) Leave – by age bracket, gender, job grade and cause and type (sick leave, unpaid leave, compassionate leave and absenteeism) Productive % time lost due to illness % no. of days lost to leave over the total no. of mandays Total no. of days Total no. of people Recruitment costs – local and international – and by age bracket, gender, job grade Advertising costs Relocation costs Permits and licences Agency fees Settling in/upset allowance Travel and accommodation Labour/staff costs Page 98 Training costs – apprenticeships and on the job training – and by age bracket, gender, job grade Labour/staff costs General expenses (travel and accommodation, training materials, equipment, tuition/course fees, apprenticeship allowances etc) Section One HIV/AIDS-related data Sero-prevalence – 2001 Estimated no. HIV+ Employees registered on AfA (Aid for AIDS disease management programme) Section Two % HIV+ employees registered Spouses registered on AfA Trained counsellors No. of employees counselled No. of employees tested (voluntary) Section Three No. of employees tested HIV+ Trained peer educators Peer educator master trainers Contributions into the Trust Fund Section Four ART claims from the Trust Fund Condoms distributed Condoms distributed per employee/month STI cases TB cases Section Five Additional Information Appendices Whiteside and Sunter detail the direct, indirect and systemic HR costs, in their book entitled; AIDS, the challenge for South Africa (2000). Information on personnel profiling, critical post analysis and various strategies such as out-sourcing and multi-skilling can be found in the UNAIDS publication; Acknowledgements Guidelines for studies of the social and economic impact of HIV/AIDS (2000), available on www.unaids.org. Footnotes 1 Elias et al from the MMSD report (2002) 2 From Positive development: setting up self-help groups and advocating for change. A manual for people living with HIV – developed by GNP+ (1998) Page 99 Section Two HIV/AIDS Corporate Social Investment INFO Briefing Note HIV/AIDS Corporate Social Investment What is corporate social investment (CSI)? CSI means achieving commercial success in ways that honour ethical values and respect people, communities, and the natural environment. It also means addressing the legal, ethical, commercial and other expectations society has of organisations, “The aim of this Group is, and will remain, and making decisions that fairly balance the claims of all key stakeholders. to make profits for our shareholders, but to do it in such a way as to make a real CSI is thus the way a company achieves a balance or integration of economic, and lasting contribution to the communi- environmental and social imperatives while at the same time addressing shareholder Management Strategies ties in which we operate.” and stakeholder expectations – in effect CSI serves as a strategic framework to guide Anglo American founder, a company’s behaviour by taking into consideration the social, environmental and Sir Ernest Oppenheimer ethical dimensions of their business practice. Different terms are used to reflect this (or aspects of this) important function; these include corporate social responsibility, corporate citizenship, business ethics, socially responsible investment, sustainable development, good stewardship and so on. CSI implies partnerships. Establishing good relationships between corporations, communities, civil society organisations, government authorities and even international donor agencies is not new. What is new is strengthening these relationships to the point where all parties ‘pool’ their knowledge, resources and skills to address complex social problems. Companies in the extractive industries have traditionally come under pressure from advocacy groups and financial institutions to demonstrate corporate responsibility and accountability through a combination of policy and action. As part of a growing movement towards becoming more open and transparent, a large number of companies are preparing sustainability reports that review a company’s social and environmental performance against established goals and objectives. In its simplest terms CSI revolves around: “what you do, how you do it, and when and what you say.” Page 100 Why is it important for an organisation to mainstream HIV/AIDS into its CSI programme? By having in place a CSI strategy a company is demonstrating that it understands the far-reaching influence of its operations. It is also taking a pro-active stance to identify and assess its social and environmental risks and put in place a strategy to manage their corporate activities that will help to strengthen their reputation as a good corporate citizen. Without a strategy in place to manage and report on the Section One company’s contribution to sustainable development, business can become an easy target for high profile campaigns launched by advocacy groups, often on behalf of affected communities. These campaigns typically attract negative media coverage and trigger strong reactions from consumer groups, analysts and regulators, while placing companies in a defensive position in an attempt to avert further damage to their reputation and impact on their bottom line. Section Two Across Southern Africa, companies are engaged in serious efforts to define and integrate CSI into all aspects of their business, with their experiences being bolstered by a growing body of evidence that CSI has a positive impact on business economic performance. Stakeholders – including shareholders, analysts, regulators, activists, labour unions, Section Three employees, community organisations and the news media – are asking companies to be accountable not only for their own performance but for the performance of their entire supply chain, and for an ever-changing set of CSI issues. The issues that represent a company’s CSI focus vary by business, by size, by sector and even by geographic region. In its broadest categories, CSI typically includes Section Four issues related to: business ethics, community investment, environment, governance, social development, marketplace and workplace. HIV/AIDS, as arguably the pivotal development issue in the region, must be one such issue. Contractors may, or may not, have formal CSI programmes, but all will be approached Section Five from time to time to provide support to community initiatives. An appreciation of where and how this support can benefit HIV/AIDS initiatives can make a significant difference to projects that rely on local business for funding and other forms of assistance. Appendices What are the elements of mainstreaming HIV/AIDS into CSI grant programmes? When evaluating grant applications, the following are sample criteria to ensure that HIV/AIDS is mainstreamed into this particular CSI function. Note: some are generic criteria; others are HIV/AIDS specific1. • Does the proposed project fit within the objectives of the national HIV/AIDS Acknowledgements strategy and programmes? • Will the project benefit HIV/AIDS efforts? • How does the project rate in terms of coverage, quality and cost? • Are the HIV/AIDS mitigation measures feasible? • Is the project consistent with the priorities of the community? • Are the community and civil society organisations (CSOs) involved in or contributing to the project? To what extent have the community and CSOs made efforts to address HIV/AIDS in their ongoing activities? • Does the proposal indicate that various groups in the community participated in identifying the HIV/AIDS problems and prioritising the proposed solutions? • Can the project be conducted within the time period specified? • Are HIV/AIDS competent, skilled or trained personnel available, and, if not, does the proposal include provision for these individuals to be trained? Page 101 • Are the roles and responsibilities of parties (including families, institutions, community groups etc) clearly delineated – for implementing, supervising and monitoring the HIV/AIDS components? • Is there a reasonable plan for sustaining HIV/AIDS activities at community level? • Are staff salaries based on local wages? • Will procurement procedures interfere with implementation of the project? • How will on-going operational and maintenance costs be covered to ensure that services are maintained throughout the project? • Is there a well-defined plan and approach for monitoring and evaluating performance? Red Flags and Special Challenges HIV/AIDS Corporate Social Investment Sometimes, within the ambit of CSI, companies find themselves under pressure to deliver community services or benefits that are more properly the responsibility of government. Often CSI-related decisions are taken independently of a company’s main HIV/AIDS priorities, which can result in the effect being less than optimal. Tool: Mainstreaming HIV/AIDS into CSI Management Strategies functions Instructions A CSI strategy ensures that a company’s social investment programme is strategically aligned with their core business interests and that it provides a performance measurement framework for gauging progress towards the goals and priorities they have established for themselves. There are many aspects of corporate behaviour that can be enhanced with a comprehensive CSI strategy including corporate governance, environmental management, stakeholder relations and community development, which all contribute to the company’ ability to retain their social license to operate. Consider each of the following strategies, which constitute areas where CSI should feature and define how your company will mainstream HIV/AIDS into them. • Mission, vision and values statements CSI merits a prominent place in a company’s core mission, vision and values documents, and HIV/AIDS-related philosophies and commitments should also be reflected in these. • Corporate governance Many companies have established ethics and/or social responsibility committees of their Boards to review strategic plans, assess progress and offer guidance about emerging CSI issues of importance. These committees should be HIV/AIDS competent, if HIV/AIDS is to feature appropriately as a CSI issue. Page 102 • Strategic planning A number of companies are beginning to incorporate CSI into their long-term planning processes. The plans should feature all CSI priorities, including HIV/AIDS. • General accountability In some companies, in addition to the efforts to establish corporate and divisional Section One social investment goals, there are similar attempts to address these issues in the job descriptions and performance objectives of as many managers and employees as possible. This helps everyone understand how each person can contribute to the company’s overall efforts to be more socially responsible, eg in terms of contributing to national HIV/AIDS-related targets. Section Two • Communications, education and training When publicising the importance of corporate social investment internally, include the issues that will be the focus of the CSI programme. This is a good opportunity to generate awareness about HIV/AIDS, and to improve knowledge about com- munity HIV/AIDS projects. Section Three • CSI reporting Annual CSI reports can build trust with stakeholders and encourage internal efforts to comply with a company’s CSI goals. The best reports demonstrate CEO and senior leadership support; provide verified performance data against indicators; share “good” and “bad” news; set goals for improvement; include stakeholder Section Four feedback; and many times are verified by outside auditors. Including HIV/AIDS in reporting processes will create opportunities for debate and will begin to subject this issue to the sort of rigour that is currently missing in most companies. • Use of influence Section Five Socially responsible companies recognise that they can play a leadership and catalyst role in influencing the behaviour of others, from business partners to industry colleagues to neighbouring businesses. This influence can extend to profiling HIV/AIDS in CSI programmes and can promote more considered approaches and support for projects and activities that are developmental and Appendices sustainable. • Use of existing opportunities In CSI programmes, education projects are probably the most commonly supported projects, often receiving the greatest “slice” of CSI budgets. These projects, with a little creativity, can also serve as foundations for HIV/AIDS prevention and/or Acknowledgements care and support activities. For example, by integrating life skills into education activities for young people, or utilising schools as centres of support for orphans and vulnerable children. • Corporate giving This could include the CSI budget, as well as employee giving schemes, providing gifts or resources in kind, or staff secondments to community projects. Each of these could have a strong HIV/AIDS emphasis. Page 103 Score Card: Corporate social investment 10/10 and HIV/AIDS Instructions Review the actions in the score card, where the sections are indicative of a minimal (1 red ribbon), good (3 red ribbons) and “blue-chip” (5 red ribbons) response. Assess your organisation’s level of competence in each. Then decide on future actions to improve your organisation’s rating. Score Card Description Rating Future Actions • Grants to HIV/AIDS projects constitute  10% of the CSI budget Minimal Response • Annual CSI report mentions funded HIV/AIDS Corporate Social Investment HIV/AIDS projects • HIV/AIDS – as part of CSI – included in corporate communications materials • CSI HIV/AIDS priorities linked to  national and local priorities Good Response • HIV/AIDS included as topic during CSI consultations with stakeholders • Employees can name the company’s CSI priorities Management Strategies • Employees receive accolades for  participating in CSI-funded projects Blue-chip Response • HIV/AIDS is priority CSI issue and features in annual audited sustainability report • Local HIV/AIDS project is the company’s “flagship” CSI project Costs HIV/AIDS-related CSI costs must be considered within the broad CSI budget, and there will often be situations where trade-offs must happen; which will sometimes benefit HIV/AIDS-related activities and sometimes not. Page 104 Case Studies: Corporate social investment CASE STUDY and HIV/AIDS The following case studies, either explicitly or implicitly, contribute to efforts to prevent new HIV infections or mitigate the impact of the epidemic on individuals, families and communities. Section One Anglo American has a long tradition of social investment and, together with its independently managed subsidiaries, currently allocates some $ 7 million per annum in supporting community initiatives. These include funding education, income generation, small and micro-business development, health care provision, housing, Section Two general development and welfare, in the process making a positive contribution to addressing the factors that drive the HIV/AIDS epidemic. Individual operations contribute to activities that are intended to directly benefit employees and the immediate surrounding communities. Section Three Richards Bay Minerals (RBM) was established in a largely underdeveloped area, with inadequate infrastructure and facilities, especially in neighbouring rural areas. This led to the formation of a number of community partnerships, with support from RBM, focusing on the provision of schooling, health services, job creation and community development. Section Four These partnerships are based on five principles: • Meaningful community involvement, adopting a bottom-up approach; • Partnerships rather than benevolence; • Development at the pace dictated by the community; • Skills transference; and Section Five • Ownership and self-sufficiency. This is an example in which, by addressing development priorities, in a developmental manner, the company is addressing the causative factors of the HIV/AIDS epidemic in the area. Appendices The ESKOM Development Foundation has dedicated some R 30 million (over $ 4 million) to the South African AIDS Vaccine Initiative (SAAVI). “It makes absolute sense that the utility company that powers South Africa should be a power behind the quest for a vaccine.” Acknowledgements This example represents a conscious decision to fund and support a specific HIV/AIDS priority, one that hopefully offers a long-term solution to the epidemic. Page 105 Additional Information A number of useful documents on CSI can be found on the Business Partners for Development (BDP) website, at www.bpd-naturalresources.org/ html/pub_working.html. Generic information on corporate social investment can be found on www.bsr.org/BSRResources/IssueBriefDetail.cfm?DocumentID=48809. For more information and access to tools on CSI refer to the following sources: • World Business Council for Sustainable Development; • Business for Social Responsibility; • CSR Europe; • Conference Board of Canada; HIV/AIDS Corporate Social Investment • Canadian Business for Social Responsibility; • Global Reporting Initiative; • OECD Guidelines for Multinational Enterprises; • OECD Guidelines for Corporate Governance; • http://strategis.ic.gc.ca/ - Industry Canada; • United Nations Global Compact; and • www.ftse.com/ftse4good/index.jsp#. Management Strategies Footnotes 1 Adapted from UNICEF, UNAIDS and World Bank; Draft operational guidelines for supporting early child development (ECD) in multisectoral HIV/AIDS programmes in Africa (2003) Page 106 Section Three Workplace HIV/AIDS Programme Section Three contains all the elements of a comprehensive workplace HIV/AIDS programme. The goal of the workplace programme is to prevent new HIV infections and provide care and support for infected and affected employees. The elements are: • Prevention through behaviour change communication; • Peer education; • Condom promotion and distribution; • Sexually transmitted infection (STI) management; We have lit candles as a signal of hope and • A safe working environment; memory of our relatives, family members • Voluntary counselling and testing (VCT); and comrades who have died of HIV and AIDS; and for ourselves who are • Prevention of mother to child transmission (of HIV) (PMTCT); and all infected or affected by this epidemic. • A wellness programme consisting of: All of us are involved and we must fight - Nutritional advice and support; together. But our message is of hope, not despair. - Lifestyle education; With education, access to safe sex, counselling - Treatment of minor ailments; and voluntary testing, decent food and - Treatment of STIs; treatment for those with HIV, and, above all, openness and mutual support, we - Reproductive health services for women; will together gain victory. - Prevention of opportunistic infections; Congress of South African - Treatment of opportunistic infections; Trade Unions (COSATU) - Highly active antiretroviral therapy (HAART); - Psychosocial support; - Family support; and - Referral networks and partnerships. Page 107 Section Three Prevention Through Behaviour Change Communication Prevention Through Behaviour Change Communication INFO Briefing Note What is behaviour change communication? Behaviour change communication (BCC) is a multi-level tool for promoting and sustaining risk-reducing behaviour change in individuals and communities by means of tailored messages and using a variety of communication channels. Why does an organisation need a prevention programme with behaviour change activities? Even in situations where HIV prevalence is high, the majority of employees are still Workplace HIV/AIDS Programme uninfected, and prevention efforts should always remain an important component of workplace responses to HIV/AIDS. But before employees, or indeed any individuals, can reduce their risk and vulnerability to HIV, they must be given basic facts about HIV/AIDS, taught a set of protective skills and offered access to appropriate services and products. They must also perceive their environment to be supportive of changing or maintaining safe behaviours. Contractors, who have HIV/AIDS programmes in place, will typically have a strong focus on prevention. Rarely, however are the prevention activities based on behavioural theory, or linked to measurable outcomes. Existing prevention programmes should therefore be reviewed, strengthened and integrated into broader HIV/AIDS responses What are the objectives of behaviour change and the elements of behaviour change? BCC strategies in HIV/AIDS aim to create a demand for information and services relevant to preventing HIV transmission, and to facilitating and promoting access to care and support services. Some specific BCC objectives include: • Increasing the adoption and continued use of safer sex practices; • Promoting visits to clinics treating STIs and opportunistic infections, including tuberculosis; Page 108 • Increasing the demand for VCT, for mother to child transmission (MTCT) prevention services, orphans and vulnerable children (OVC) care and support, sup- port groups for people living with HIV/AIDS, and social and economic support; • Stimulating dialogue and discussion on risk, risk behaviour, risk settings and local solutions; and • Reducing stigma and discrimination for those living with HIV/AIDS. Section One The following diagram describes the complexities involved in initiating and then sustaining behaviour change. It is important to appreciate these factors when designing HIV/AIDS prevention programmes. Factors influencing and contributing to behaviour change1 Section Two The person is aware of the positive The person understands how non- or protective benefits of the performance of the behaviour will behaviour affect his/her life (vulnerability) Section Three There are no environmental constraints making it impossible for the behaviour to occur The person forms a strong positive The person possesses the skills intention, or makes a commitment necessary to perform the behaviour to perform a behaviour Section Four The person believes the advantage The person feels more social of performing the behaviour is more pressure to perform the behaviour positive than negative than not to perform the behaviour Section Five The person's emotional reaction to The person perceives that the performing the behaviour is more behaviour is more consistent than positive than negative inconsistent with their self-image Appendices The person believes that he or she has the capabilities to perform the behaviour (self-efficacy) Acknowledgements POSITIVE BEHAVIOUR CHANGE Behaviour change is thus influenced by a multiplicity of factors – personal, infrastructural, regulatory and societal – to name but a few. Page 109 Red Flags and Special Challenges When conducting BCC activities it is important to reflect on these challenges: Are the education strategies user-friendly? Do participants feel comfortable engaging in the sessions and talking about HIV/AIDS-related issues? Do the educational materials look good and attract people’s attention? Is the design and colour attractive? Are they culturally sensitive? Can the participants identify with the materials? Does the educational material avoid discrimination? Does the material show people Prevention Through Behaviour Change Communication of similar racial origin, age, and sexual orientation? Do the illustrations foster stigma or fear? For example, showing a person dying of AIDS might lead some people to believe that all people living with HIV/AIDS are about to die. Does the educational material generate feelings of fear? Messages such as “AIDS kills” might scare people away, and such scare tactics rarely help promote effective behavioural change. Positive messages often promote changes in attitude and behaviour. However, some illustrations that catch people’s attention, even negative illustrations, can be effective in raising people’s awareness. The key is to know the target group well and choose your messages accordingly. Does the educational material avoid moralising and preaching? People resist listening to someone telling them what they should and should not do. Such practices often lead the learners to become silent and less likely to engage in open and productive Workplace HIV/AIDS Programme discussions. The best materials provide information in a clear, respectful way and enable people to make their own decisions. Do the educational strategies build upon already acquired skills, and promote confidence? It is important to build on the expertise of the target group. What do they already feel confident in doing? How can that confidence be translated to other circumstances? Does it help to build a supportive environment? People learn best when they feel cared for and supported. If people work together toward the same ends, much can be achieved. Does the learning session provide an opportunity for ongoing support for one another? Do the sessions take place during working hours, and is attendance a part of work obligations? Who conducts the sessions, is it done in-house, or outsourced? What is the role of the trade unions? If sessions are principally conducted by the trade unions, does this potentially miss non-trade union members? What methods of evaluation of the educational sessions have been considered? Evaluation of participant learning can be done through conducting pre- and post testing. Observation of practice, and observation or anecdotal reports of behaviour change are other forms of evidence. Have the participants been asked to evaluate the facilitator, and the sessions? What will be done with the evaluation information? Page 110 Tools: Principles and rules for behaviour change programmes Instructions When developing your organisation’s HIV/AIDS prevention programme, ensure that you follow the principles and rules that research and experience has taught us2. Section One Principle 1: Promote non-discrimination and openness around HIV/AIDS. Principle 2: Because HIV/AIDS is a preventable disease it makes sense to offer prevention education to all workers and to specifically invest in targeting situations of high risk. Section Two Principle 3: HIV/AIDS prevention works – we can change behaviour. But, information alone is not enough to change behaviour. Behaviour change is only possible if we reach solutions by developing our own responses and people need to be taught skills to enable them to put the information into practice. Section Three Principle 4: Education needs to be complemented by supportive services. Principle 5: HIV/AIDS programmes in the workplace can help control the epidemic and reduce the impact on businesses. Principle 6: Effective HIV/AIDS prevention yields enormous savings in averted Section Four costs. Principle 7: The most powerful change agents are our friends and peers. Principle 8: The involvement of people living with HIV/AIDS is central to an effective workplace programme. Principle 9: HIV/AIDS programmes must be simple, specific, concrete and Section Five verifiable. Use core management principles (simplicity, focus, precise targets, strong performance monitoring) and an explicit results chain (required inputs, outputs, outcomes and impacts). Management buy-in will assist at all stages of implementation. Principle 10: Strategies and projects in areas of economic and social develop- Appendices ment which address poverty, income inequality, the bargaining power of women, housing, migrancy and so on will address the underlying factors which fuel the epidemic. Research shows that: Acknowledgements • Those who plan and implement HIV/AIDS programmes should develop strategic approaches that view BCC not as a collection of different, isolated communication tactics, but as a framework of linked approaches that function as part of an integrated, ongoing process. • BCC should be integrated with overall programme goals and specific objectives. BCC is an essential element of HIV/AIDS prevention, care and support programmes, providing critical links with other programme components. BCC should be linked to policy initiatives and service provision. • BCC should encourage individual behaviour change and also help create environmental conditions that facilitate personal risk reduction. • Formative assessment or audience research must be conducted to better understand the needs of the target population and the barriers to behaviour change that its members face. Page 111 • All BCC in HIV/AIDS should contribute to stigma reduction. • The target population should participate in every phase of BCC development. • Using a variety of communication channels is more effective than relying on any one. For example, peer education should be accompanied by mass media, small media, campaigns and other approaches. • Pre-testing is essential for developing effective BCC materials. • Monitoring and evaluation should be incorporated at the start of any BCC pro- gramme. Evaluation results must be fed back into the programme, to keep it relevant. • Objectives for change after exposure to the communication should be specified. These may be changes in actual behaviour or shifts in the precursors to behaviour change, such as in knowledge, attitudes or concepts. Prevention Through Behaviour Change Communication • Fear campaigns do not work. They contribute to an environment of stigma and discrimination. • Because society-wide change is slow, changes achieved through BCC will not be seen overnight. Score Card: Behaviour change 10/10 communication Instructions Review the actions in the score card, where the sections are indicative of a minimal (1 red ribbon), good (3 red ribbons) and “blue-chip” (5 red ribbons) response. Assess your organisation’s level of competence in each. Then decide on future actions to Workplace HIV/AIDS Programme improve your organisation’s rating. Score Card Description Rating Future Actions • HIV/AIDS prevention messages  included in induction courses. Minimal Response • HIV/AIDS posters displayed in the clinic waiting room. • HIV/AIDS videos screened during lunch break in the canteen. • HIV/AIDS prevention strategy  developed and implemented, in line Good Response with KAP survey results. • BCC programme evaluation includes feedback from employees. • BCC messages complement VCT and wellness programme. • BCC specialist in advisory capacity to  team designing the BCC strategy. Blue-chip Response • Sector-specific BCC materials developed and tested, then distributed in different languages Page 112 Costs There are costs associated with a BCC programme; however research has shown that investments in prevention are cost effective in terms of HIV infections prevented. Case study of behaviour change activities Section One CASE STUDY AngloGold has a comprehensive behaviour change and HIV/AIDS prevention programme. Each business unit plans a campaign of mass awareness events it will pursue each Section Two year. Some of the events used in 2002 included: mass meetings to demonstrate VCT, drumming sessions with HIV/AIDS themes, industrial theatre acts, candle-lighting ceremonies, workshops, seminars, mass e-mails, newsletters, pamphlets, etc. All new employees and employees returning from annual leave undergo induction Section Three training which includes an HIV/AIDS component. The HIV/AIDS component is taught by qualified training officers and covers the following topics: (1) basic facts about HIV/AIDS; (2) national and company policies and programmes; and (3) referral resources. In the first six months of 2002, the programme trained 15 623 employees, which Section Four corresponds to 36% of employees. Supervisors and management also go through specialised training which covers the same topics as induction training, as well as: (1) a review of performance management processes; (2) the legal framework supporting confidentiality and grievance procedures if it is breached; and (3) incapacitation processes. Section Five 317 peer educators (139:1 ratio) are currently active. 182 have been certified and trained internally through a three-day course. The remaining 135 peer educators were trained by various external providers and require an internal refresher course to obtain certification. The goal is to achieve a 100:1 ratio of certified peer educators by the end of the year. The training teaches the following topics and skills: (1) Appendices intensive AIDS education; and (2) participative methods, such as picture coding and role playing in generating peer-driven behaviour change. The peer educators focus on the following activities: (1) providing informal peer education; (2) acting as a resource for other HIV/AIDS training and referrals; and (3) Acknowledgements replenishing condom dispensers. The peer educators meet monthly and AngloGold is evaluating methods to monitor performance. Page 113 Additional Information For the full AngloGold case study, go to: www.weforum.org/globalhealth/ cases. ILO; Implementing the ILO Code of Practice on HIV/AIDS and the world of work: an education and training manual (2002), available on www.ilo.org, details (in Module 6) the prevention activities that should be carried out to comply with the Code. Additional BCC information is available on the following websites: Prevention Through Behaviour Change Communication • Family Health International at http://www.FHI.org/en/HIVAIDS/FactSheets/ bcchiv.htm; and • UNAIDS at www.unaids.org and search for the Fact sheets on HIV/AIDS for nurses and midwives. Workplace HIV/AIDS Programme Footnotes 1 Adapted from Save the Children; Learning to live: monitoring and evaluating HIV/AIDS programmes for young people (2000) 2 Adapted from the Project Support Group’s work Page 114 Section Three Peer Education Section One Section Two INFO Briefing Note What is peer education? Section Three Peer education, in its broadest sense, refers to a programme designed to train select members of any group of equals, (office, factory, etc) to effect change among members of that same group. Peer education is a means whereby the effectiveness of a single trained educator can be multiplied. Section Four In the workplace peers are people who are similar to one another in age, background, job roles, status, experience and interests. A peer educator is someone who belongs to a group as an equal participating member, but who receives special training and information so that this person may bring about or sustain positive behaviour change among group members. Section Five In general, peer education is based on behavioural theory which asserts that people make changes not because of scientific evidence or testimony but because of the subjective judgement of close, trusted peers who have adopted changes and who act as persuasive role models for change. Appendices Why does an organisation need a peer education programme? Peer educators are ready-made experts in communicating with their peers and work colleagues. People are more likely to listen to and follow the advice of their peers, and peers also have a greater influence on co-workers than non-peers, which is a significant factor lending credibility to behaviour change messages. Acknowledgements Peer education example The companies chose peer educators from among their workers, approximately one for every 20 workers on the site. The selection process focused on workers who were team leaders or key workers who were respected by their co-workers and who had at least a secondary school education, an interest in helping fellow workers and good communication skills. Contractors can, and often do, have a peer education programme as one of the pillars of their HIV/AIDS response. This may involve finding a suitable training institution to train the peer educators, and providing them with on-going support and possibly also resources for their activities. Page 115 What should an HIV/AIDS peer education programme consist of? With specific training and support, peer educators can effectively carry out a range The Compass Group is the largest of HIV/AIDS education and other activities with their co-workers. foodservice company in the world, operating in 90 countries, with over Peer educators should possess good communication skills that will be enhanced 375 000 employees. through training. They must be able to see and understand the issues at hand through CHAPS, the Compass HIV/AIDS Peer the perspectives of the group. Society, is a dedicated peer support group, consisting mainly of catering Peer education is not a uniform approach, and it is useful to distinguish between managers and training officers. peer information, peer education and peer counselling1. CHAPS is dedicated to providing HIV/AIDS education and support, and to continuously uplifting the staff of Compass Group SA. Different peer education approaches Peer Peer Peer information education counselling Objectives Awareness Awareness Information Information Information Attitude change Attitude change Attitude change Self-esteem Peer Education Self-esteem Prevention skills Prevention skills Coping skills Psycho-social support Problem-solving Workplace HIV/AIDS Programme Coverage High Medium Low Intensity Low Medium/high High Confidentiality None Important Essential Focus Large groups Small groups Individual Workforce Community Training required Briefing Structured workshops Intense and long Refreshers Relative cost Low Medium High Examples of Drama, special events Repeated group events With people living activities Material distribution based on a curriculum with AIDS Mobile vans Clinic-based World AIDS Day counselling activities Page 116 Red Flags and Special Challenges • For a peer education programme to succeed, it needs the support of management, supervisors and employees. • Peer educators should be appointed from across the entire spectrum of the workforce, including from management. • A ratio of 1 peer educator to 200 employees is simply not workable. A ratio of Section One 1:20 is probably ideal, and the distribution of peer educators should cover all sections of the workplace. • The recruitment and training of peer educators takes time. It also takes time to monitor and supervise them once the training period is over. • A good peer education programme should build in a regimen of continuous Section Two training for peer educators to sustain them and help remind them about what they are trying to accomplish, while enhancing their skills to aid them on the way. In addition, they need new materials, methods and messages in order to sustain the interest and involvement of their work colleagues. • Assumptions that employees who are peer educators are themselves HIV positive need to be guarded against, as these can jeopardise the programme. Section Three • Peer education programmes typically experience a turnover rate of peer educators, so it is usually necessary for the recruitment and initial training phases to be undertaken continuously. • It is important to use feedback and evaluation results to continuously inform the programme. Section Four A recent project co-ordinated by UNAIDS and the Horizons Project2, and implemented with the Jamaican Ministry of Health, PATH, AIDSMark/PSI, IMPACT/FHI, and USAID identified nine priorities for successful peer education programmes. Section Five 1. Integration of HIV/AIDS peer education with other interventions Peer education generates demands for services in the intended audience. Therefore, it should be integrated with or linked to services that provide access to condoms, medical care, voluntary counselling and HIV testing, and STI management. Peer education should also be integrated, where Appendices possible, with community health and development initiatives. 2. Finding and keeping peer educators. 3. Training and supervising peer educators. 4. Gender, sexuality, and the socio-cultural context Peer education programmes must address gender inequalities that Acknowledgements affect sexuality and HIV/AIDS transmission and mitigation. 5. Programme activities to foster behaviour change. 6. Care for people living with HIV/AIDS. 7. Stakeholders and gatekeepers, since they are key to the success and the sustainability of the programme, should be involved from the design phase onward in order to address their concerns, needs, and priorities, and to instil a sense of ownership of the programme. 8. Programme sustainability. 9. Evaluation and operations research. Page 117 Tool: Peer education guidelines Instructions Use the following guidelines when developing your HIV/AIDS peer education programme. 1. Planning a peer education programme3 • Begin with a clearly defined target population. Consider job grade, age, gender, race/ethnicity, sexual orientation, socio-economic factors, etc. • Include members of the defined population from the beginning of the planning process. Their participation will ensure that the programme is owned by them rather than that it has been foisted upon them by management. • Set a clearly defined programme with realistic goals and objectives. A time period and the number of people to be reached for each objective will help define the programme and target population, and ensure measurable goals and objectives. • Plan realistically for evaluation in the time line and budget. Whether a detailed process evaluation or a long-term impact evaluation, it must be planned from the beginning, or data gathered will be partial and inconclusive. Changes in knowledge can be measured by pre- and post testing peer educators and participants. Process evaluation data may include numbers and characteristics Peer Education of programme activity and participants and post-workshop satisfaction measures, and peer educator journal entries recording activities and referrals. • Find the right person or people to co-ordinate the programme. 2. Recruiting and training the peer educator team Workplace HIV/AIDS Programme • Recruit peer educators from a broad base of potential candidates. Consider opinion leaders, but look also for those who strongly believe in the programme’s goals and objectives and want to help achieve them. • The criteria used in selecting peer educators vary from workplace to workplace. Of course, characteristics that place the peer educator as a member of the target group are always taken into account. Other criteria considered should be: - Must have time and energy to devote to this work; - Should have enough education to implement the activities of a peer educator; - Should have good listening skills, ability to form relationships and encourage others to learn about STIs/HIV/AIDS and change behaviours; - Should be enthusiastic and self-confident, exhibit leadership potential; and a demonstrated interest in working with peers; - Should be respectful, non-judgmental, and committed to maintaining client confidentiality; - Should be acceptable to the workers who they will serve; - Should be able to establish good relations with both individuals and the group as a whole; and - Should serve as a role model and to exercise leadership. • Decide what incentives the programme will provide for the peer educators. • Provide sufficient training for the peer educators. Skills development is as crucial as knowledge. Training empowers peer educators to recognise when to refer a peer to a service or to a professional person. • In addition to factual information, eg HIV/AIDS transmission and prevention, peer education training should address sexuality and gender, interpersonal and group communication skills, and legal and ethical issues. Page 118 • Successful programmes will have ongoing training for the peer educators, times to practise existing skills and to develop new ones. • Training should be competency-based and include initial and ongoing evaluation of competencies. • Training should take into account the personal development of the peer educator. • Supervision of peer educators’ performance should include both actual peer Section One group sessions and office-based supervisory sessions. • Staff supervising peer educators must be technically competent, as well as motivational and supportive. 3. Implementing the peer education programme • Select a curriculum to maximise interactive and experiential learning. Bear in Section Two mind that peer educators will gain ownership of the programme when they play a role in deciding which activities and materials to use, or in adapting a curriculum or designing new ways to present the information. • A schedule of topics that peer educators should cover would include: - Transmission of HIV; Section Three - Prevention of HIV transmission; - STIs and TB; - How to assess personal risk and formulate behaviour change plans; - Safer sex and condom use; - HIV testing facilities and processes; - The rights of infected and affected employees (including rights to Section Four confidentiality); - How to treat a co-worker with HIV/AIDS; - Treatment, care and support for infected employees; - HIV/AIDS, as part of broad-based wellness programmes; - Infection control in the workplace; Section Five - The workplace HIV/AIDS policy and current programmes; - Non-discrimination and equality (in terms of benefits etc); and - Referral sources and services. • Research shows peer education to be most effective when part of a comprehensive initiative, so link peer educators with referral resources, community agencies, and Appendices programmes with similar goals. • Monitor the peer educators’ work. After the initial training, peer educators will need ongoing supervision of their work and training. Peer educators should keep a log of informal activities. Monitoring will highlight skills or knowledge that need strengthening. Feedback will also help them become more skilful and effective educators. Acknowledgements • Provide ongoing encouragement and support. Their work is not always easy. Positive feedback and support will help keep them involved, as will encouraging them to support each other. • Expect attrition and have a formal structure for recruiting and training new peer educators. Exit interviews will help gauge whether their reasons are personal or programmatic. Involving current peer educators in the recruitment and training of new peer educators will also empower them and help them develop new skills. • Provide opportunities for peer educators to give feedback about the programme, its activities, and their own performance. The peer educators usually know what they need to become more effective and to enjoy their work more. • Finally, promote the programme. Develop literature showcasing services and highlighting accomplishments. Positive stories from the peer educators and feedback from fellow employees will enliven data-based reports. Page 119 Score Card: Peer education 10/10 Instructions Review the actions in the score card, where the sections are indicative of a minimal (1 red ribbon), good (3 red ribbons) and “blue-chip” (5 red ribbons) response. Assess your organisation’s level of competence in each. Then decide on future actions to improve your organisation’s rating. Score Card Description Rating Future Actions • 1 peer educator trained for every 200  employees Minimal Response • Peer educators use interactive teaching and learning techniques (such as role plays and group discussions) • Essential HIV/AIDS prevention messages are repeated in peer education sessions • Peer education programme is based on a  comprehensive curriculum Good Response • Peer educators participate in defining Peer Education their roles and responsibilities • Peer educators are encouraged to run peer education activities in their communities Workplace HIV/AIDS Programme • Peer educators refer to various service  providers (eg for HIV testing) Blue-chip Response • Peer educators are identifiable (eg through badges, T-shirts or some form of uniform) • Peer educators receive creative rewards/ incentives • Peer educators go on exchange visits to peer educators from other companies • Community members are trained with peer educators and involved in the programme Costs It is generally assumed that peer education is one of the least expensive strategies to effectively reach a target population. The costs that should be quantified would include the: • Cost of training, initial and top-up training; • Cost of time allocated to peer education activities; • Cost of incentives or uniforms for the peer educators; • Cost of peer group meetings/sessions; and • Cost of educational material and condoms distributed. Page 120 Case Study: Peer education CASE STUDY One of the persistent problems faced by HIV/AIDS communication programmes is keeping material interesting and relevant to participants over many months. Too frequently, information is repeated to a point where audiences “tune out.” NAMDEB’s peer educators recognised this potential problem and employees’ need for a wide range of health information. Section One Although most Namibians know that HIV is transmitted mainly through unprotected sex, many workers are unaware of other health issues and how their own behaviours influence their health. As the workforce showed interest in learning more about other health issues, the peer education programme incorporated these health topics. Section Two The programme annually addresses 10 health topics, making each the focus of discussion for one month. In addition to updates on HIV/AIDS and STIs, topics have included malaria, TB, family planning, healthy lifestyles, child abuse, alcohol and drug abuse, stress and child care. As the topics are known in advance, relevant materials are compiled for distribution to participants. Section Three Peer educators feel confident in this approach, since it maintains the attention of their colleagues, provides them with the opportunity to learn and convey new information and sustains an important programme. The variety of topics also broadens the context of discussing HIV and AIDS, since most of the topics relate to or are affected by the epidemic. Section Four The comprehensive programme has had a positive impact on controlling HIV/AIDS and STIs. Condom distribution, which was said to be minimal before, rose from 6.7 per 1 000 workers in 1990 to 20.7 per 1 000 workers in 1995. For company management, these results indicated that the impact of HIV/AIDS could be contained Section Five and managed. Programmes must be sustained over several years before any impact can be noticed. Thus, there is good reason for peer education components of a prevention programme to remain relevant to the changing and broadening needs of workers. Appendices After the initial success, NAMDEB began to assist other mining companies in establishing similar programmes. The company hired a full-time co-ordinator and enlisted the participation of a dozen other companies, including gold and copper mines, the port authorities and fishing industries. In 1999, the Chamber of Mines assumed support to the other mines and interested companies. One of the mining companies, Okurugu Acknowledgements (Fluospar/Solvay), supports the full-time co-ordinator; the Chamber of Mines provides office space and contributes to operating costs. Individual companies contribute to the costs of the co-ordinator and select staff for peer educator training. Condoms are usually provided by the government. Most companies have also reached out to surrounding communities, assisting in educational events, providing STI treatment for partners of employees, distributing condoms in the community and supporting local women’s organisations or school clubs. In one case, peer educators were given a week off to organise a tour to perform an educational theatre programme for all secondary schools in a remote area. Page 121 Additional Information Most workplace HIV/AIDS references include information on peer education, eg the ILO publication entitled; Implementing the ILO Code of Practice on HIV/AIDS and the world of work: an education and training manual (2002), available on www.ilo.org. An informative article on peer education for young people appeared in the AIDS Bulletin, Vol.12, No.2 (August 2003). It refers to tools and checklists that are available on www.hsph.harvard.edu/peereducation. Peer Education Workplace HIV/AIDS Programme Footnotes 1 Adapted from Save the Children; Learning to live: monitoring and evaluating HIV/AIDS programmes for young people (2000) 2 For the full report entitled Peer education and HIV/AIDS: past experience, future directions, go to www.popcouncil/horizons/horizonsreports 3 Adapted from UNESCO; Peer approach in adolescent reproductive health education: some lessons learned Page 122 Section Three Condom Promotion and Distribution Section One Section Two INFO Briefing Note Section Three What is condom promotion and distribution? Condom promotion and distribution aims at encouraging safer sexual practices through raising awareness and opening the debate about safer sex and condom use; and then ensuring that supplies of condoms are readily accessible, when and where they are needed. Section Four Why is it important to have a workplace condom promotion and distribution programme? Since the earliest days of the HIV/AIDS pandemic, the use of male condoms has been a central component of prevention initiatives. Male and (more recently) female condoms – when used consistently and correctly – are Section Five an effective means of preventing HIV infections, other STIs and unplanned pregnancies among people who are sexually active and need to protect themselves. When incorporated into a comprehensive set of prevention messages – including reducing the number of sexual partners, practicing mutual monogamy, delaying onset Appendices and reducing frequency of penetrative sex and getting treatment for STIs – condom use has resulted in decreases of HIV incidence. And, in various settings, promotion of 100% condom use has contributed to marked reductions in STI rates. Contractors can usually incorporate condom promotion and distribution activities into Acknowledgements their HIV/AIDS programme. Supplies can sometimes be sourced from government (the Ministry of Health). Where these need to be purchased, contractors should explore options of procurement in partnership with bigger companies, in order to benefit from bulk prices. Page 123 What are the elements of a successful condom promotion and distribution programme? Successful condom programmes are characterised by: • The promotion of both male and female condoms; • Choices, such as a choice between free condoms and branded subsidised ones; • Linking condom distribution to education on condom use, and joint decision making between partners on sexual health issues; • The involvement of peer educators in promoting condom use, incorporating “how to use condoms” in their sessions, and serving as distribution points; • Well-known, and creative and diverse distribution points; • IEC materials that support the condom programme; and • Regular monitoring of condom uptake. Accurate messages about condoms must build on (and not substitute for) a wide range of HIV and STI risk-avoidance and risk-reduction approaches. Condom Promotion and Distribution Because of the non-clinical nature of condoms, distribution points can include non- traditional sites, such as toilets, canteens, tuck-shops, and clocking stations. One of the best established methods of condom distribution is what is known as “social marketing” (CSM). This is the marketing of public health goods or ideas through conventional marketing channels. The main objective of CSM projects is to increase the availability and use of good quality, low cost condoms and hence contribute to preventing the transmission of HIV infection. The strategy usually promotes condom use in general and use of the social marketing organisation’s own Workplace HIV/AIDS Programme condom brand in particular. The strategy also aims to disseminate messages concerning HIV prevention, safe sexual behaviour and correct condom use. These objectives are achieved through fairly standard marketing techniques with the main activities being to conduct market research; to acquire and package condoms; to advertise and promote the product; to train retailers; and to distribute the product. Other barrier methods Microbicides, which come in a gel, cream, sponge, suppository or film, are showing promise as effective against STI and HIV transmission. Their role in a workplace HIV/AIDS programme has not been tested. Red Flags and Special Challenges Condom distribution is often one of the first strategies implemented by companies, as part of their workplace HIV/AIDS response. The start-up problems they may experience are in relation to: • Deciding on the location of the distribution points; • Keeping these stocked; and • Establishing a system to monitor condom uptake. Page 124 Many companies have been disappointed at the lack of condom uptake, following the implementation of a condom distribution programme. This is typically due to the absence of any associated strategies to promote condom use. In monitoring a condom promotion and distribution programme, it is generally not possible to use indicators such as increased condom use, as this is impossible to measure directly. Proxies for this can however be used, such as decreased incidence Section One of STIs, which implies safer sexual practices, including condom use. Tool: Model for condom use Section Two Instructions Consider the following model when developing your condom promotion and distribution programme. What is the behaviour to be changed; what are the determinants (individual and environmental) of the behaviours; and then decide what programme activities – at an individual and environmental level – can be designed to change Section Three each selected determinant? Model for condom promotion and distribution Individual level Environmental level intervention Section Four Behaviour intervention areas areas Increase protection, Reduce belief that using condoms Expand media and folk messages by increasing the use affects pleasure promoting condom use of condoms Section Five Increase belief that most sexually Enhance social norms against active men are using condoms unprotected sex Increase self-efficacy to say “no” Establish or expand workplace and to unprotected sex community-based condom Appendices distribution Increase beliefs that having unprotected sex is against Improve access to condoms at clinics personal standards Develop user-friendly health services Acknowledgements Increase self-efficacy to use a condom properly Provide information on safe sex through health services Increase feelings of safety when using condoms Implement programme for effective prevention of alcohol use Increase ability to refuse alcohol or drugs Increase peer educators ability and willingness to teach effective sexuality/ STI/HIV education Increase parent-child communication about sexuality and condoms Page 125 10/10 Score Card: Condom promotion and distribution Instructions Review the actions in the score card, where the sections are indicative of a minimal (1 red ribbon), good (3 red ribbons) and “blue-chip” (5 red ribbons) response. Assess your organisation’s level of competence in each. Then decide on future actions to improve your organisation’s rating. Score Card Description Rating Future Actions • Free condoms available in the clinic  • Peer educators demonstrate condom use Minimal Response during sessions Condom Promotion and Distribution  • Male condoms – free and subsidised Good Response – available from multiple points within the workplace • Social marketing awareness materials displayed and distributed • Peer educators monitor condom uptake and report this in their monthly reports • Regular condom promotion campaigns  Workplace HIV/AIDS Programme Blue-chip Response conducted • In addition to male condoms, female condoms available from the clinic and in female toilets • STI statistics analysed and compared to condom uptake trends • Reduction in condom uptake investigated and strategies implemented to address the causes Costs Many organisations can get free supplies of male condoms from government Health Ministries/Departments. Where this is not possible, or where subsidised condoms are made available as well as free government-issue condoms, there would need to be a budget to purchase these. Plan for about 12 condoms per sexually active male per month, and then adjust in line with uptake. Female condoms are significantly more expensive than male condoms. There are also costs associated with condom promotion, such as posters and pamphlets. Page 126 Case Study: Condom promotion and distribution CASE STUDY FB Vending is a company that has been active in the vending industry for over 15 years1. For the past 5 years FB Vending has also manufactured a specially designed and registered high quality 3-column condom dispenser and distributed Section One these, together with high quality condoms, into the workplaces of South Africa and bordering countries. FB Vending provides guidance to companies in establishing their condom programmes. The guidance covers the following elements: Section Two 1. Establish what your needs are • Do you need only male condoms? • Do you need only female condoms? • Do you need male and female condoms? • Do you need only condom dispensers? Section Three • Do you need condom dispensers with condoms? • Do you need to outsource the condom distribution to a specialist company? 2. Quantity and placement • How many male toilets are there per floor level, building and in total? • How many female toilets are there per floor level, building and in total? Section Four • How many recreation rooms are there per building and in total? • How many smoking rooms are there per building and in total? • C a n d is p e n s e rs b e fix e d to d e s ig n a te d s p a c e s o n th e w a lls o f th e a b o v e rooms? You should install a condom dispenser in at least one male and one female toilet per Section Five floor or if your staff compliment is small (less than 30), a dispenser in one male and one female toilet for your workplace. To get to a total of the number of condom dispensers required, work on 20 staff per dispenser (this way you can fill dispensers once or twice per month). Appendices • Work on 13 condoms per staff member per month; • Gather gender information on your staff; and • Include contractors visiting your premises on a regular basis. 3. Dispenser installation • In s ta ll y o u r c o n d o m d is p e n s e rs to c o in c id e w ith y o u r p la n n e d H IV /A ID S Acknowledgements awareness programme; • The dispensers must be installed for maximum visibility and for easy access; and • Get authorisation beforehand from your maintenance team, architect and/or landlord for your planned installations. 4. Refilling condom dispensers • Staff such as cleaning staff, maintenance staff, peer educators or specially appointed staff, who will be responsible for filling condom dispensers and collecting condom usage data, must be identified and instructed before condom dispensers are installed and used. Page 127 5. Storage of condoms • Identify suitable storage space for condom supplies. Condoms must be stored in a cool dry place away from any direct sunlight or other weather conditions; • T h e c o n d o m b o x e s m u s t b e p ro te c te d fro m th e flo o r b y s to rin g th e c o n d o m boxes on wooden pallets or similar; and • C o n d o m s m u s t n o t b e s to re d w ith d a n g e ro u s a n d h a z a rd o u s m a te ria ls o r liquids. 6. Condom management • Condom uptake and distribution can be monitored and controlled manually or with the help of a computer programme. 7. Budget • Make sure that management is informed of the financial implications of the condom distribution programme. Condom Promotion and Distribution 8. Implementation schedule • Confirm the procurement process as this will have an impact on your delivery time and on the installation date for the condom dispensers and condoms. • Set delivery and installation dates in order to keep up with your planned awareness programme and to ensure that promises are kept. • The installation team must also be confirmed and be made aware of dates and deadlines. 9. Integration into the HIV/AIDS programme • Integrating the condom programme into an existing or planned HIV/AIDS Workplace HIV/AIDS Programme programme is very important; • One idea is to brand the condom dispensers with your company or programme colours, logos and slogans; • Ensure that your entire staff is aware of the condom distribution programme; and • Trainers and educators must be well trained on the “how and why” of condom and dispenser use, and they, in turn, must be able to train staff on how to use the dispensers and condoms. Additional Information For additional information on barrier methods, go to the Family Health International website at http://www.fhi.org/training/en/modules/ADOL/ goals.htm. Contact details for PSI and SFH, the organisations providing condom social marketing services in most Southern African countries, can be found in Appendix Four. Footnotes 1 For more information, contact FB Vending at sales@mrwilly.co.za Page 128 Section Three Sexually Transmitted Infection (STI) Section One Management Section Two INFO Briefing Note Section Three What is STI management? STI management is the comprehensive care of a person with an STI-related syndrome or with a positive test for one or more STIs. Sexually transmitted infections or STIs are diseases such as syphilis, gonorrhoea, chancroid, herpes, chlamydia, trichomoniasis and Hepatitis B. Symptoms of STIs include ulcers or sores, discharge, burning or pain on passing urine, lower abdominal pain (in women), testicular pain or swelling Section Four in men and swelling of the lymph nodes in the groin. Why is it important to have a workplace STI management programme? Sexually transmitted infections are among the most common causes of illness in adults in the world and have far-reaching health, social and economic consequences for many countries. In South Africa 15% of adults have an STI in any one year! Section Five The same risk behaviours are involved in both HIV and STI transmission. The presence of an untreated STI, particularly an ulcerative STI, can multiply the risk of HIV transmission during unprotected sex up to ten-fold. Appendices The risk of HIV transmission in the presence or absence of other STIs No condom, no STI • Female to male spread 1 : 1 000 Acknowledgements • Male to female spread 2 : 1 000 • Male to male spread 1 : 100 No condom, inflammatory STI (discharge) • Female to male spread 1 : 100 • Male to female spread 2 : 100 • Male to male spread 1 : 100 No condom, ulcerative STI (sore) • Female to male spread 6 : 100 • Male to female spread 6 : 100 • Male to male spread 3 : 10 Page 129 Effective management of STIs is one of the cornerstones of STI control, as it prevents the development of complications and sequelae, decreases the spread of these diseases in the community, and offers a unique opportunity for targeted education about HIV prevention. Contractors that do not have on-site health services should establish links with STI services in the community, and should promote early health seeking behaviour for employees with or at risk of STIs, as well as for their partners. Where workers have access to and utilise the health services of the companies where they are providing services, the data available from the clinic (# of clients treated, trends in infections seen, etc) should be captured and analysed to inform broader HIV/AIDS prevention programmes. Sexually Transmitted Infection (STI) Management What are the elements of an STI programme? Few developing country health facilities have the laboratory equipment or skills required for aetiological diagnosis of STIs. To overcome this, a syndrome-based approach to the management of STI patients has been developed and promoted. Syndromic management is based on the identification of consistent groups of symptoms and easily recognised signs (syndromes), and the provision of treatment, according to standardised protocols, that will deal with the majority and the most serious organisms responsible for producing a syndrome. The elements of STI management include: history taking, examination, correct diagnosis, early and effective treatment, advice on sexual behaviour, promotion and/or provision of condoms, contact tracing and partner treatment, case reporting and clinical follow-up as appropriate. Thus, effective case management consists Workplace HIV/AIDS Programme not only of antimicrobial therapy to obtain a cure and reduce infectivity, but also comprehensive and confidential care of the client’s needs for reproductive health. Appropriate treatment of STI clients at their first encounter with a health care provider is an important public health measure. Ideally the encounter should be in a user- friendly environment, as described below. Characteristics of user-friendly STI services Provider Health facility Programme design Other possible characteristics characteristics characteristics characteristics • Specially trained • Convenient hours; • Client involvement in design • Education materials staff; • Convenient location; and continuing feedback; available on site and • Respect for clients; • Adequate space and • Drop-in clients welcomed to take away; • Privacy and sufficient privacy; and appointments arranged • Group discussions confidentiality; and rapidly; available; and • Adequate time for • Comfortable • No overcrowding; • Alternative ways to client and provider surroundings. • Short waiting times; access information, interaction; and • Free service or affordable fees; counselling and • Peer counsellors • Publicity to inform and services. available. reassure clients; • Men and women welcome and served; • Wide range of services available; and • Necessary referrals available. Page 130 Red Flags and Special Challenges Employees with STIs are often concerned about confidentiality of their medical records at work and will opt to visit a private practitioner for treatment. There is significant evidence that the STI treatment provided in the private sector (eg GPs and traditional healers), is often not optimal and may not fully treat – and cure – the STI. Indeed, in some Southern African countries public sector STI management also falls far short of Section One the ideal. And yet the treatment is standardised, simple, cheap, effective and safe, and can be provided by nurse clinicians. Contact tracing and partner treatment has always represented a challenge. Treatment of a client with an STI will be of little benefit if his/her partner is also infected, but Section Two not treated. Re-infection is then a real possibility. Many STI symptoms are very mild or asymptomatic and active medical surveillance is required to detect disease in these clients. In particular women may get used to these symptoms, and not seek treatment for them. Section Three Tool: STI prevention and care: essential components checklist Section Four Instructions Check that your STI programme contains all the elements of a comprehensive prevention and care package. • Promotion of safer sex behaviour; • Condom programming – encompassing a full range of activities from condom Section Five promotion to the planning and management of supplies and distribution; • Promotion of health-seeking and safer sex behaviours – and the education of individuals at risk on modes of disease transmission and means of reducing the risk of transmission; • Treatment and education of the sexual partners of infected individuals; Appendices • Integration of STI prevention and care into primary health care and reproductive health care services; • Specific services for populations at risk – such as sex workers and long-distance truck drivers; • Syndromic management of STIs; • Early detection of symptomatic and asymptomatic infections; Acknowledgements • Access to counselling and testing for HIV; and • Monitoring trends, using clinic and hospital records. Page 131 10/10 Score Card: STI management Instructions Review the actions in the score card, where the sections are indicative of a minimal (1 red ribbon), good (3 red ribbons) and “blue-chip” (5 red ribbons) response. Assess your organisation’s level of competence in each. Then decide on future actions to improve your organisation’s rating. Score Card Description Rating Future Actions • Peer educators mention STIs as a risk  factor for HIV transmission Minimal Response • Public health clinics offer free STI Sexually Transmitted Infection (STI) Management treatment, and employees are given time off to seek medical treatment • Free STI services offered on site  • Occupational health nurse is trained to Good Response provide syndromic management • All STI clients receive a stock of free condoms • STI health-seeking campaigns conducted  annually Blue-chip Response • All STI clients encouraged to have HIV tests – which are offered as a free service Workplace HIV/AIDS Programme and are accompanied by pre- and post-test counselling Costs An on-site STI management service implies the existence of an occupational health clinic. Where such a clinic exists, treatment of STIs is likely to be one of the services available. Costs associated with such a service would include staffing, and possibly training for the staff, equipment and supplies (including drugs, condoms and information). The alternative, which is treatment at public or private health facilities, could represent considerable costs in terms of time off work for those employees seeking this care. This is an instance where STI prevention – and the costs associated with prevention – will be much less than those associated with treatment of STIs and the risk of HIV infection. Page 132 Case Study: Successful STI management CASE STUDY Supported by Harmony Gold Mining Company, USAID/AIDSCAP , the National Reference Centre for STDs (South African Institute for Medical Research), the Institute of Tropical Medicine, Antwerp, Pfizer Pharmaceuticals, the South African National HIV/AIDS and STD Programme, and the provincial and local health departments, the Lesedi Project began in 1996 around Virginia, a town in the Free State Province of South Section One Africa, with a population of approximately 80 000 people including a workforce of 13 000 miners (90% of whom lived in single-sex hostels). The project ensured that miners who had symptoms of an STI were treated promptly Periodic presumptive treatment (PPT) using the syndromic approach. Additionally, women at high risk of STIs, most of whom Section Two refers to regular (periodic) treatment with were sex workers, were given periodic presumptive treatment. Both had access to an antibiotic which is known to be ef- sexual health advice, counselling and male and female condoms. fective against many different STIs. It is presumptive since the patients have not The results from the first stage of the project were impressive. In mineworkers, been diagnosed with an STI. On the basis gonorrhoea and chlamydia were reduced by 42% and a 77% reduction in genital ulcers of previous research showing that the ma- Section Three was observed. Among the women, similar dramatic declines in STIs were seen. jority of the group have curative STIs, it is presumed that they have STIs requiring A cost-effectiveness assessment was conducted using a computer model to estimate treatment. the number of HIV infections that would have occurred in the community. It was estimated that 235 HIV infections were averted (40 women and 195 men), i.e. a 46% decrease in estimated HIV infections. In terms of averted HIV/STI-related Section Four medical costs, an estimated US$ 316 216 (ZAR 2.34 million) was saved. This was a massive saving compared with the relatively small cost of the intervention – US$ 36 216 (ZAR 268 000). Section Five Additional Information In 1998, DFID published a Health and Population Occasional Paper entitled Sexually transmitted infections: guidelines for prevention and treatment, Appendices which details the components of a comprehensive STI programme. Chapter 12, in Clive Evian’s book, Primary AIDS Care, deals with STIs in the context of HIV/AIDS treatment and care. A publication on the diagnosis and management of STIs in Southern Africa Acknowledgements is available from the STD Reference Centre at the South African Institute for Medical Research, Box 1038, Johannesburg, 2000. Other useful documents on STIs can be found on the following websites: • UNAIDS; at www.unaids.org; • WHO; at www.who.org; and • CDC; at www.cdc.gov. Page 133 Section Three Safe Working Environment INFO Briefing Note To prevent the transmission of HIV in any work environment, the central strategy is Safe Working Environment the adoption of universal infection control precautions. What is universal infection control? Universal infection control is a simple standard of infection control practice used in the care of any person to minimise the risk of transmission of blood-borne pathogens. Where there may be an occupational These practices were originally devised in 1985 by the United States Centers for Workplace HIV/AIDS Programme risk of acquiring or transmitting HIV Disease Control and Prevention (CDC), largely due to the HIV/AIDS epidemic and infection, appropriate precautionary the urgent need for new strategies to protect hospital personnel from blood-borne measures should be taken to reduce infections. The new approach places emphasis on applying blood and body fluid such risk, including clear and accurate precautions universally to all persons regardless of their HIV status. information and training on the hazards and procedures for safe work. Why does an organisation need to implement universal infection Extract from the SADC Code on control precautions to ensure a safe working environment? HIV/AIDS and employment HIV and other blood-borne infections (like hepatitis B) can be transmitted in an accident situation where there is contact with blood. HIV is a fragile virus, meaning it is vulnerable to changes in temperature and other environmental factors, and has been shown not to be viable in dried blood for more than an hour. The risk of a person becoming infected with HIV in such a situation is dependent on factors such as the extent of the contact or the sort of injury that allows blood to enter another person’s body. The average risk of transmission is however low; approximately 0.3% following a needlestick-type injury1. Preventing occupational exposure to potentially infectious blood and blood products and managing occupational exposures that do occur are important elements of any workplace safety programme. In most countries, labour legislation requires that employers take measures to ensure that, as far as is reasonably practicable, the working environment is safe and healthy. This could imply that: • Employers have a legal duty to apply universal infection control measures in the workplace; Page 134 • There must be a clear position on HIV testing following an occupational accident; and • There should be a protocol in place covering the steps to be followed after an occupational accident, possibly including the provision of post-exposure prophylaxis. Contractors, like all other employers, are obliged to meet certain requirements in Section One terms of safety (including infection control) in the workplace. Contractors should have protocols for the management of accidental occupational exposure, and whilst these may not include the provision of post-exposure prophylaxis, they should include processes to assist employees to access these services elsewhere, eg in public sector hospitals. Section Two What should a universal infection control programme consist of? Measures that should be in place are: • The education of employees about occupational risks, methods of prevention of HIV transmission, and procedures for reporting exposures; Section Three • The provision of equipment and supplies such as gloves and disinfectants to clean up blood spills; and • The provision of post-exposure counselling, treatment, follow-up and care. These measures should apply not only within the operations of the company, but also to any health care facilities – hospitals, clinics, medical posts – that are operated Section Four by the company. Red Flags and Special Challenges Section Five Universal infection control procedures are rarely followed consistently outside of the health care profession. Workplace safety risk assessments do not routinely include the risk of HIV transmission Appendices within the workplace. Tool: Universal infection control guidelines Acknowledgements Instructions Adapt the following infection control guidelines for use in your workplace. 1. Prevention of occupational exposure • Create a safe working environment by identifying any risk situations and minimising such risks; • Assume that everyone is HIV positive and always take precautions in an accident situation; and • Ensure that personal protective first aid equipment (such as gloves) is available and that personnel (such as first aiders and health and safety personnel) have been trained about infection risks, infection control procedures and how to use the equipment. Page 135 2. Minimising the risk of HIV transmission as a result of occupational exposures • In the event of accidental contact with blood, follow standard first aid procedures: - Wash hands before and after any procedure; - Use protective equipment such as gloves; - Immediately wash the wound or affected area well; - Clean with an antiseptic agent (mucous membrane and eye exposures should be flushed extensively with water); - Handle contaminated sharp objects carefully and disinfect them properly; and - Make sure that any contaminated materials are disposed of safely. • Comply with health and safety regulations in terms of recording and reporting incidences. 3. Post-exposure procedures • Conduct a rapid assessment of the exposure (high or low risk). High risk is usually needle-stick injuries with a hollow bore needle, low risk is usually from Safe Working Environment blood splashes; • If there is no record of the HIV status of the source person, an attempt should be made to obtain blood for this purpose – this should be done in accordance with existing guidelines for counselling and testing. Also, check his/her clinical condition for signs of HIV infection or immune deficiency; • If the source person’s HIV status is not known or cannot be established, initiating post-exposure prophylaxis (PEP) should be decided on a case by case basis – depending on the assessment of the risk; Workplace HIV/AIDS Programme • Initiate PEP with antiretroviral agents, such as AZT and 3TC, as soon as possible after the incident – preferably within 1-2 hours, and definitely within 24 hours. PEP is recommended for any high risk exposure; • Continue PEP for 4 weeks unless serious toxicities or intolerances occur; • Provide supportive counselling for the exposed employee, including safer sex counselling and pregnancy avoidance advice for female employees; • Injured employees should establish their own HIV status at the time of the injury and at 3 months, 6 months and one year later. If HIV positive at the time of the injury then PEP is not indicated; and • Keep good records of all processes and results, whilst maintaining confidentiality as far as is practically possible. 4. Compensation for occupationally acquired HIV infection • Occupationally acquired HIV infection from an injury in the workplace is a compensable injury in most countries; • In the pre-sero-conversion phase, it is usually the duty of the employer to provide for the necessary procedures and costs, such as HIV tests, medical consultations, PEP and counselling; • If sero-conversion occurs, the infected employee should receive appropriate counselling and treatment; • Compensation claims should be initiated. For compensation claims to be successful, it is necessary to prove a link between the injury on duty and the HIV infection, i.e. the employee must be able to demonstrate an HIV negative status at the time of the incident (and, ideally, an HIV positive status in the source person). Page 136 Travel tips If you must travel to areas of the world where the safety of the blood supply is not guaranteed, you should follow these measures: • Before you travel, identify sources of reliable medical help in your destination country; • Carry sterile disposable needles and syringes for use in the event of a Section One medical emergency; • Be aware of emergency medical evacuation procedures; • Reduce your risk of injury by following safety precautions such as using seatbelts and driving carefully; and • If you are injured and lose blood, consider using a plasma substitute instead of blood. If severe or acute blood loss has occurred, efforts Section Two should be made to ensure that the blood has been screened for HIV and hepatitis B virus. Section Three Score Card: A universal infection control 10/10 programme Instructions Section Four Review the actions in the score card, where the sections are indicative of a minimal (1 red ribbon), good (3 red ribbons) and “blue-chip” (5 red ribbons) response. Assess your organisation’s level of competence in each. Then decide on future actions to improve your organisation’s rating. Section Five Score Card Description Rating Future Actions • First aid kits in every unit  • First aid kits restocked regularly Minimal Response Appendices • First aiders trained in universal infection control procedures • Accident recording and reporting systems in place • Awareness campaign conducted  Acknowledgements Good Response • Risk assessments include risks of exposure to blood and blood-borne pathogens • Confidential reporting system in place for occupational exposures • Infection control protocol includes  provision for counselling, HIV testing, Blue-chip Response PEP , and medical monitoring • Starter pack of recommended drugs for PEP available on site Page 137 Costs Many of the costs of a universal infection control programme are costs that an organisation is legally bound to incur – first aid and safety costs. The cost of managing occupational exposures to blood and blood-borne pathogens – assuming that this involves testing, counselling and PEP, although significant is yet another case of prevention being much cheaper than “cure”! Case Study: Universal infection control CASE STUDY precautions as part of a workplace (HIV/AIDS) programme In South Africa, the “Working for Water” programme is a national poverty initiative of the Department of Water Affairs and Forestry (DWAF). As part of their HIV/AIDS Safe Working Environment programme, they have trained safety and first aid officers who take responsibility for ensuring the safety of employees in universal infection control procedures. In support of their HIV/AIDS programme, they have developed and distributed a number of information pamphlets for employees and other stakeholders, one of which deals with universal infection control precautions. It details: • Why it is important that these precautions are followed; Workplace HIV/AIDS Programme • The responsibilities of employers; and • The first aid steps to follow in the event of a workplace accident. Additional Information For detailed notes and a flow diagram on managing occupational exposures see Chapter 15 in Evian, C; Primary AIDS Care (2002). For information on universal precautions (particularly within the health care setting) go to the UNAIDS website at www.unaids.org and search for the Fact sheets on HIV/AIDS for nurses and midwives. See also the IFC occupational health and safety guidelines, on www.ifc.org. Footnotes 1 Approximately 1 in 300-330 such exposures will result in an established HIV infection Page 138 Section Three Voluntary Counselling and Testing (VCT) Section One Section Two INFO Briefing Note Section Three What is VCT? Voluntary counselling and testing (VCT) refers to confidential HIV testing done on an individual to establish his/her HIV status, and who, after having undergone pre-test counselling, voluntarily consents to the test. VCT also implies that post-test counselling will be provided when the person receives his/her test result. Section Four Sishen Mine example In 2002, Sishen management received approval to conduct a Know Your Status Campaign as part of their ongoing HIV/AIDS response. The results were as follows: Section Five Category Number Percentage Tested 1 723 52% of workforce Collected results 1 156 67% of those tested Over 25 years of age 1 504 87.3% of those tested Appendices Under 25 years of age 219 12.7% of those tested Employees tested negative 1 611 93.5% of those tested Employees tested positive 112 6.5% of those tested Acknowledgements Why does an organisation need a VCT programme? Data indicates that the majority of at-risk persons have not been tested for HIV antibodies and a large population of individuals with HIV infection are unaware of their status. Failed early detection of HIV infection prevents any possible early educational interventions or behaviour modification and precludes pre-AIDS treatment with highly active antiretroviral therapy (HAART). Aggressive antiretroviral treatment can significantly improve clinical and health status and reduce viral load, which may diminish patient infectivity and potentially interrupt any future transmission. Continued high-risk behaviour among persons with unrecognised and untreated HIV infection promotes transmission of the virus. Page 139 VCT is acknowledged within the international arena as an efficacious and pivotal strategy for both HIV/AIDS prevention and care. It is also an invaluable link between prevention and care. • VCT is more than drawing and testing blood and offering a few counselling sessions. It is a vital point of entry to other HIV/AIDS services including prevention of mother to child transmission; prevention and clinical management of HIV-related illnesses, tuberculosis control, and psychosocial and legal support. • VCT provides benefits for those who test positive as well as those who test nega- tive. VCT alleviates anxiety, increases a client’s perception of their vulnerability to HIV, promotes behavioural change, facilitates early referral into a wellness programme for treatment, care and support including access to antiretroviral therapy and assists in the reduction of stigma in the community. • On-site VCT services can enable companies to track employee responses to the HIV/AIDS programme, by monitoring their uptake of the VCT services. Voluntary Counselling and Testing (VCT) Contractors will rarely be in a position to establish and run a VCT service. They could, however ensure that “knowing your status” is an important message within their HIV/AIDS programme, and that there is support for employees to wish to be tested at services in the community. Some companies will even pay for VCT by means of a voucher system, where the service is not free in the community. What should a VCT programme consist of?1 VCT is a service that can be offered by government, non-government, community and private sector facilities. VCT services need to be accessible and acceptable, which may mean being open after working hours. Workplace HIV/AIDS Programme Debswana example Tebelopele is a Setswana word that literally means “forward looking”. The Tebelopele VCT initiative in Botswana is a collaborative multi-stakeholder project, established to create a network of free, anonymous, voluntary HIV counselling and testing centres throughout Botswana. The centres have been set up by the BOTUSA project which is a partnership between the Botswana government and the US government. Three years ago, in view of Debswana’s urgent need for VCT centres to complement the mine facilities, and to give employees a choice of service provider (which is really crucial in small communities), a company house was leased, at no rental cost, to the BOTUSA project in Jwaneng; and an eight-man park home was donated for Letlhakane and partitioned to suit the purposes of a VCT service. The Letlhakane service is utilised by both the Orapa and Letlhakane mines and communities. This is an example of a public-private partnership that benefits not just Debswana but also the communities in which they operate. The gold standard for VCT follows a regimen of pre-test counselling, testing (as desired by the client and after informed consent is provided), and post test counselling (which may involve one or more sessions depending on the client’s needs). Individual risk assessment and risk reduction planning are integral components of pre- and post test counselling. Page 140 VCT must be accessible and affordable for those at highest risk of HIV infection or those suspected to have HIV-related illness. Sites must be adequately staffed by individuals with high quality training in counselling and testing practices. Management of sites must support staff to sustain high quality service provision, retain skilled staff, and prevent burnout of the counsellors. Section One A counsellor’s role is to: • Ensure complete confidentiality; • Provide accurate and relevant information so that the client can make informed choices; • Give and explore options; Section Two • Recognise and respect the uniqueness of the client; • Be aware of his/her own beliefs and values; and • Know when to refer the client for specialised interventions. Counsellors, to do their work well, need support, such as: Section Three • Back-up support and personal protection, when facing angry clients or potentially violent spouses or relatives; • Incentives, such as acknowledgement for their role and work; • Psychological and emotional support, such as debriefing and counselling sessions; • Retreats (time away) to allow them to replenish their energy; Section Four • Adequate logistic support, such as a counselling room with privacy; • Professional development and training to keep up-to-date on emerging issues and findings; and • Networking, exchange visits and counsellor support groups, to keep in touch with their peers. Section Five HIV testing is not easy to administer or interpret, and requires specialised training, and rigorous quality control. Most workplaces will elect to send specimens to a recognised laboratory for testing, however, large companies with well-developed health facilities, may elect to use rapid tests that can be interpreted on-site. It is, however, important to stress that confirmatory testing of positive specimens is the Appendices recognised standard, and this may involve using a second, different, rapid test or sending the specimen to a laboratory for confirmatory testing (particularly if a second rapid test is negative, i.e. discrepant results). VCT design must include identifying or strengthening other care and support services, Acknowledgements community and hospital referral networks. Integrated approaches can facilitate family planning, STI management, TB referral etc. In developing new VCT sites it is crucial to ensure a standardisation of services in terms of quality of care and support offered to clients. The design and establishment of VCT services must be tailored to take into account stigma reduction and demand creation. Marketing VCT services is critical. This implies raising awareness of the benefits of VCT, and promoting these services, with appropriate messages for specific target groups, such as migrant workers. Post test clubs have proven very successful in many contexts. Admittance is linked to having had an HIV test, not to whether the result was positive or negative. Post test club activities aim at providing support for members, and information on a range of HIV/AIDS-related issues. Page 141 Monitoring and evaluation systems should be established from the onset for both counselling and testing components to determine whether it is provided in accordance with a predetermined protocol and that the service satisfies client needs. Red Flags and Special Challenges There are many challenges to a successful VCT programme: • Widespread fear of taking an HIV test; • Fears about breaches of confidentiality; • Potential for discrimination and isolation as a result of sharing information about HIV sero-positivity; • Lack of readily accessible testing opportunities; • Time delay in receiving results (a problem especially with blood tests); Voluntary Counselling and Testing (VCT) • The attitudes of health care workers; and • Lack of access to drug therapies, psychosocial support and clinical care. The following forms of HIV testing constitute discriminatory practices: • During an application for employment; • As a condition of employment; • During procedures related to termination of employment; • As an access requirement to obtain employee benefits; and • As an eligibility requirement for training for staff development programmes. Workplace HIV/AIDS Programme The following forms of testing are not discriminatory provided they take place in accordance with national standards and policies: • Within a health care worker/patient relationship (even if it is on the company premises and funded by the employer); • As part of a voluntary HIV testing and counselling programme; • Within an unlinked and anonymous surveillance programme; and • Testing after an occupational accident. Tool: Voluntary counselling and testing Instructions When setting up a VCT service, consider the following checklist of requirements. • Convince decision makers of the need and value of a VCT service; • Consider the pros and cons of establishing an on-site service, versus outsourcing the service (which is often perceived as making it more accessible and accept- able); • Select counsellor trainees who have warm and caring personalities, are good listeners, are respected by others, and are motivated and resilient; • Train them, and follow up the training with supervised practice and ongoing, in-service training; • Provide regular and structured psychological support to the counsellors; • Be sensitive to the location and time of services, in terms of accessibility and ensuring that the services do not become stigmatised; • Have adequate supplies of information materials and condoms; • Run campaigns to promote the VCT services; Page 142 • Provide counsellors with adequate referral services – to other counsellors, and for treatment, antenatal care, family planning, social support and orphan care; • Set up clear counselling standards and protocols, including mechanisms to ensure confidentiality; and • Set up clear testing standards and protocols, including provision for confirmation of HIV positive tests, and quality control of tests and testing procedures. Section One Score Card: Voluntary counselling and 10/10 testing Section Two Instructions Review the actions in the score card, where the sections are indicative of a minimal (1 red ribbon), good (3 red ribbons) and “blue-chip” (5 red ribbons) response. Assess your organisation’s level of competence in each. Then decide on future actions to Section Three improve your organisation’s rating. Score Card Description Rating Future Actions • Company runs VCT promotion  campaign Section Four Minimal Response • Employees access VCT in the community • VCT service integrated into clinic  services Good Response • Occupational health and EAP practitioners trained as HIV/AIDS Section Five counsellors • VCT services free to all employees • VCT campaign launched by management  taking tests publicly Blue-chip Response Appendices • Employees who test positive able to register for wellness programme, which includes ART • Structured support programme in place for counsellors Acknowledgements Costs A costing study conducted in Uganda at the AIDS Information Centre (AIC), which is an organisation established in 1990 to provide anonymous, voluntary and confidential HIV testing and counselling services, estimated the unit cost per client in 1997 at US$ 13.39. This included the Blood Bank costs – of test kits, and personnel (laboratory technicians and phlebotomists), supplies, equipment, and technical supervision, as well as counsellor time and the cost of the facilities, administration, supervision and monitoring. Such studies show that by far the most expensive component of VCT services is the counselling, not the testing. Page 143 Case Study: A VCT procedure CASE STUDY AngloGold, as part of their wellness programme, developed the following VCT procedure: Primary objective of VCT To promote change in sexual behaviour that reduces the risk of acquiring HIV infection. Secondary objective of VCT To identify those who would benefit from specialised HIV/AIDS care, including TB preventive therapy through the Wellness Clinic. Who is VCT for? All employees of AngloGold companies and dependents with medical aid. The Voluntary Counselling and Testing (VCT) service may be expanded to include other dependents in the future. Where will VCT be available? VCT centres have been identified in each region at: • Primary Health Centres & Dressing Stations/First Aid Stations located at mine shafts; • Hospitals; and • Goldmed A & B clinics. Who will conduct VCT? Workplace HIV/AIDS Programme Counsellor – only those who have attended a VCT counselling training course will participate; and Nurse tester – only those who have satisfactorily completed the rapid HIV testing course, assessment and basic quality assurance test will participate. Who will supervise VCT? The Wellness Programme Project Manager, under the guidance of the Wellness Programme Leader, Wellness Programme Doctor and Primary Care Manager. What will happen at the VCT centre? HIV testing, accompanied by pre- and post test counselling, will be available at a single session. Rapid test kits will be used which require finger-prick blood specimens. Strict confidentiality will be maintained by recording blood results only on a coded record card. If a conclusive result cannot be obtained using the rapid test kits, a laboratory test will be offered on a venous blood specimen. Counsellors will offer referral to other appropriate services. When will a VCT record card be completed? Every client attending VCT will have a VCT record card completed, even if they decline to be tested. Clients attending for repeat testing will have a new card made each time they attend for a test. A visit for follow-up counselling only does not require a new card. Page 144 Additional Information The full case study that includes the step-by-step VCT procedure is available on www.weforum.org/globalhealth/cases. The lessons learned about running VCT services (at the AIDS Information Centre Section One in Uganda) are documented in a UNAIDS case study entitled Knowledge is power: voluntary HIV counseling and testing in Uganda (1999), available on www.unaids.org. SAfAIDS published a handbook entitled Care counselling model in 1999, which can be used in training counsellors. Copies can be obtained from Section Two info@safaids.org.zw. Section Three Section Four Section Five Appendices Acknowledgements Footnotes 1 Adapted from FHI; Voluntary counseling and testing, available on www.FHI.org/en/HIVAIDS/FactSheets/ vctforhiv.htm Page 145 Section Three Prevention of Mother to Child Transmission (PMTCT) Prevention of Mother to Child Transmission (PMTCT) INFO Briefing Note What is a prevention of mother to child transmission (of HIV) programme? A PMTCT programme aims to reduce the rate (and overall numbers) of HIV transmission from infected mother to child; and to contribute to improving the health status of children and mothers, whether HIV infected or not. This can be done by preventing unwanted pregnancies, improved antenatal care and management of labour, providing antiretroviral drugs during pregnancy and/or labour, modifying feeding practices for newborns and provision of antiretroviral therapy to newborns. Workplace HIV/AIDS Programme Why is it important to have a workplace PMTCT programme? Transmission of the virus from infected mother to child is one of the three main ways that HIV is transmitted. This can happen just before or during delivery or from breast-feeding. Mother to child transmission becomes a workplace issue because pregnant workers, or the partners of workers, may be infected. The workplace therefore needs to play a role in this important prevention intervention, which constitutes an important investment in the future of any country. Contractors may employ many women, such as in the foodservice industry. In such instances they will have policies and procedures to accommodate employees who are pregnant, and provision for PMTCT services should be part of these policies. What should a PMTCT programme consist of? An obvious starting point is the information and education programme, which should not only help employees understand how this type of transmission takes place, but should also give support to women, and their partners, in making difficult choices about having a child, pregnancy termination and breast-feeding. Peer educators can inform employees about PMTCT services, and women’s workplace groups/clubs can take a lead in promoting and supporting access to PMTCT services. Page 146 PMTCT programmes that treat pregnant Maternity and paternity leave policies also provide the opportunity for action. These women in order to protect their unborn policies may need adaptation to include the special needs of pregnant employees children, offer little help to the women with HIV. themselves. PMTCT-Plus programmes are designed For women workers returning to work after their maternity leave due attention should to link PMTCT programmes to efforts to be given to the issue of infant feeding. treat infected mothers, and so increase Section One their chances of survival. Finally, companies may be able to provide antiretroviral therapy to prevent mother The essential PMTCT-Plus package to child transmission of HIV, or may act as an agent to administer state-funded includes treatment for OIs (opportunistic treatment. infections), and ART. Red Flags and Special Challenges Section Two Amongst the many challenges to an effective PMTCT programme are: • The enrolment of pregnant women into antenatal care; • HIV testing of pregnant women; Section Three • Provision of ART to pregnant women and newborns; and • Safe alternatives to breast-feeding. Tool: Checklist of basic requirements for a Section Four PMTCT programme Instructions If you have responsibility for a PMTCT programme, or for ensuring referrals to a Section Five PMTCT programme, the following constitute some of the basic requirements for such a programme: • Family planning/reproductive health and contraceptive services; • Antenatal, delivery and postpartum care services that are adequate and accessible, and a functioning referral system in case of complications; Appendices • Information campaigns and community-based efforts to increase acceptance of PMTCT programmes; • Adequate VCT services, including reliable tests and trained HIV/AIDS counsellors, for all female employees who are pregnant or thinking of becoming pregnant, and their male partners; Acknowledgements • Adequate supplies of male and female condoms; • An affordable, feasible ART regimen to prevent MTCT; • Counselling about breast-feeding, including information on alternative infant options; • Follow-up of all women, children and their families to help them deal with issues such as nutrition; and • Referral to other HIV/AIDS prevention, treatment and care programmes. Page 147 10/10 Score Card: PMTCT Instructions Review the actions in the score card, where the sections are indicative of a minimal (1 red ribbon), good (3 red ribbons) and “blue-chip” (5 red ribbons) response. Assess your organisation’s level of competence in each. Then decide on future actions to improve your organisation’s rating. Score Card Description Rating Future Actions • Pregnant employees attend private  Prevention of Mother to Child Transmission (PMTCT) Minimal Response or public antenatal services in the community – some of which offer PMTCT programmes • Information about PMTCT is included  in workplace HIV/AIDS programmes Good Response • PMTCT and PMTCT-Plus services  offered to HIV infected women at Blue-chip Response health facilities on site • Free or subsidised supplies of formula feed for 6 months Workplace HIV/AIDS Programme Costs The use of nevirapine in PMTCT programmes is cheap and easily implemented. More extensive ART provision during pregnancy is more expensive. This, however, is only one element of a PMTCT programme; other costs to be considered are the costs of testing pregnant women, which includes the costs of training counsellors, and the cost of providing formula feed. Case Study: Trade union policy on PMTCT CASE STUDY The following are extracts from the Sactwu HIV/AIDS policy. Introduction This policy framework constitutes the basis of Sactwu’s HIV/AIDS programme. As a trade union, we recognise that HIV/AIDS is a major challenge in our society. We have the challenge to launch an education programme to contribute to reducing and preventing the spread of HIV/AIDS provide counselling to members who are HIV positive, that will assist them in adapting their lives, and to live positively; and educate workers and the rest of society to ensure that those who are HIV positive are not stigmatised and that we produce a caring supportive environment for HIV positive people, at the workplace, in the union and in the wider society. We have the responsibility to campaign for treatment and aftercare to be provided to people who are HIV positive, and to interact with government, employers and the donor community to ensure this. Page 148 To achieve these goals, Sactwu commits to using its resources, and its collective and advocacy power. Crucially, Sactwu commits to entering into constructive partnerships with a range of other institutions with which we share similar goals. Nevirapine for pregnant women Sactwu will offer to provide Nevirapine to pregnant members directed at reducing Section One mother to child transmission, in any province where the state fails to do so, provided the state provides formula feed and the necessary infrastructure to make the provision of Nevirapine effective. Nevirapine will accordingly be provided in those instances where Sactwu reaches agreement with provinces, or possible partners to provide the required infrastructure, that will include appropriate post-natal care for pregnant women as well follow up care for the mother and baby. Section Two Additional Information Section Three More information on PMTCT programmes is available in the Population Council publication entitled: HIV/AIDS prevention, guidance for reproductive health professionals in developing country settings (2002). In Evian, C; Primary AIDS Care (2002) Chapter 10 deals with reducing mother to child transmission of HIV. Section Four Section Five Appendices Acknowledgements Page 149 Section Three Wellness Programme INFO Briefing Note What is a wellness programme? A wellness programme is a multi-faceted, multi-disciplinary workplace treatment, Wellness Programme care and support programme, into which HIV/AIDS has been integrated, that aims to benefit: • The organisation, by keeping HIV infected employees healthy and fit to work for as long as possible; • HIV infected employees, by delaying the onset of illness and AIDS, preventing opportunistic infections and providing a range of treatment, care and support Workplace HIV/AIDS Programme services and options; • HIV/AIDS affected employees, by providing support services and options; and • All employees, by creating an enabling, caring and supportive working environment. Why is it important to have a wellness programme? There are many reasons why an organisation should establish and implement a wellness programme. These include that: • Wellness programmes delay the need for ART. Until there is wide-spread availability of ART (antiretroviral therapy) and HAART (highly active antiretroviral therapy), employees with HIV disease will experience ever more frequent illnesses and will become progressively incapacitated. With appropriate prophylaxis these episodes can, to a large extent, be prevented and, if they do occur, they can often be managed at primary health care level (such as at an occupational health clinic). • Even where HAART is available, there is need for systems for delivery and careful monitoring. Wellness programmes also promote adherence, prevent side effects and the onset of resistance to ART • HIV/AIDS is a disease with profound psychosocial implications, which, if not managed appropriately, can be as debilitating as the physical effects of the disease. Contractors should consider ways of enhancing any existing preventive and/or curative services that are available to their employees to cater for employees who are infected or affected with HIV/AIDS. This may require creative partnerships with existing health services or an amendment to benefits (such as access to a health management programme). Page 150 What should a wellness programme consist of? A wellness programme should be situated within a continuum of care that covers: • Those uninfected but at risk; • Asymptomatic HIV infected employees; • Early HIV disease; • Late disease or AIDS; • Terminal illness; and Section One • May extend to support for dependants and family members. Obviously the needs and demands are different at each point along the continuum. The framework below lists some of the key ones. Section Two Framework for a continuum of care Target group Needs All employees • General life skills and HIV/AIDS prevention Section Three • STI prevention and care • Promotion of VCT • Access to VCT Infected and affected • Access to HIV testing Section Four employees • Counselling • Support groups and networks of PLWHAs Infected employees • Wellness management (including protecting – early HIV disease the immune system, safer sex and improved lifestyles) Section Five • Prophylaxis for opportunistic infections Infected employees • Treatment of opportunistic infections – late HIV disease • Effective pain relief Appendices • Management of symptoms • ART or HAART • Support with succession planning Affected families • Assistance with material needs and household tasks Acknowledgements • Spiritual and emotional support • Advice about wills and inheritance • Preparation for death and the funeral • Support for children orphaned by HIV/AIDS In the workplace, wellness programmes can be delivered in one or a combination of the following ways: • Third-party health insurance plans (medical aids); • Contract with stand-alone HIV/AIDS management programmes; and • In-house health management. Page 151 A wellness programme should consist of the following elements: 1. Nutritional advice and support Because nutritional difficulties are frequent with HIV disease – malnutrition, malabsorption and oral, oesophageal and gastrointestinal infections, for PLWHAs, good nutritional status is a critical requirement for continued health. Advice includes what foods to eat and not eat, how to use food to boost the immune system, on the one hand and to fight opportunistic infections, on the other, how to prepare and store food safely, and how to maintain one’s appetite. Support for good nutritional status takes the form of nutritional supplements, vitamins and trace elements. 2. Lifestyle education Often referred to as positive living, this is a way of living in which PLWHAs take control of their physical, mental and spiritual health. It involves diet and healthy nutrition, limiting unhealthy practices, such as alcohol consumption and smoking, regular exercise, relaxation and meditation, avoiding stress, safer sex practices to prevent HIV transmission and re-infection, making plans for the future, and sharing Wellness Programme problems. 3. Treatment of minor ailments Minor ailments associated with HIV disease can usually be managed at primary health care level. Traditional medicines are also very effective in treating these HIV-related symptoms and conditions. Workplace HIV/AIDS Programme 4. Treatment of STIs This should involve STI screening, treatment and education, including HIV/AIDS prevention education, as well as treatment of sexual partner/s. 5. Reproductive health services for women This includes family planning, counselling about dual protection (against pregnancy and HIV/STIs), PMTCT services, as well as information about and referrals for pregnancy termination. 6. Prevention of opportunistic infections The risk of getting sick with TB can be decreased in people living with HIV/AIDS by taking TB preventive therapy. This is possible for other opportunistic infections as well, such as pneumocystis carinii pneumonia. 7. Treatment of opportunistic infections Knowledge of the signs and symptoms of opportunistic infections, and early treatment seeking behaviour is important. Tuberculosis (TB) is the most common opportunistic infection and the most frequent cause of death in people living with HIV/AIDS in Africa. TB can be cured as effectively in those who are HIV positive as in those who are HIV negative; using the same drugs for the same amount of time. The DOTS (directly observed treatment, short-course) strategy is the ideal way to ensure that employees with TB complete their treatment. A treatment supporter can Page 152 be a health worker, employer, co-worker, shopkeeper, traditional healer, teacher, or community or family member. Because of the association of TB and HIV, every TB patient should be offered HIV counselling and testing by a trained counsellor if ongoing counselling and care can be provided. This will help to inform the patient and will help health care workers to provide improved care. It may also help to decrease the spread of HIV if patients Section One practice safer sex as a result of counselling. Example: The objectives of Debswana’s disease management programme Section Two • Ensures treatment at the right stage of the disease; • Ensures use of the correct drug combinations; • Ensures regular monitoring of patients; • Affords treating doctors direct and immediate access to consultants for clinical support and advice/support; Section Three • Ensures that treating doctors receive regular CMEs; and • Provides drug adherence assistance and support via a toll free line. 8. Highly active antiretroviral therapy (HAART) Section Four HAART involves treatment with two or more antiretroviral drugs, (ideally with 3 drugs to delay and prevent the onset of drug resistance), for people with advanced HIV disease and evidence of a compromised immune system. In addition to the other components of a wellness programme, it is important to include HAART because: Section Five • It promotes wellness; • It delays the onset of late stage AIDS disease; • It prevents disease progression and opportunistic infections; • It decreases infectiousness; • It greatly improves the quality of life and life expectancy, decreases absenteeism, Appendices hospital admissions and the cost of OI treatments; • It preserves human capital; and • It strengthens prevention through increased uptake of VCT, PMTCT, and behaviour In March 2001 Debswana Diamond change. Company in Botswana became the There is an optimal time to start HAART, often between 5-8 years after the initial Acknowledgements first employer in Southern Africa to offer employees (including workers on infection and then continuing for the rest of the employee’s life. Therapy is likely to contracts for longer than two years) extend the employee’s working life by 5-8 years on average. Some employees will antiretroviral treatment in order to extend do very well on HAART, but some may not be able to tolerate the medication as a their productive life. result of side effects or drug toxicity or may not adhere to the medication which will Notably, Debswana did not conduct result in treatment failure. a cost-benefit analysis prior to the introduction of the scheme, preferring The characteristics of a good HAART programme are: to justify it as “doing what they think • It is potent, leading to undetectable levels of HIV in patients on HAART; is best”. • It is an acceptable regimen; • There are reasonable options for future therapy; • It is affordable and sustainable; and • There is patient commitment to life-long therapy. Page 153 9. Psychosocial support Psychosocial support is arguably as important as medical care for PLWHAs. It can take the form of one-on-one counselling or support group activities. Traditional healers can play an important part in providing psychosocial support. Counselling is defined as a confidential dialogue between a client and a trained counsellor aimed at enabling the client to cope with stress and take personal decisions related to HIV/AIDS. Effective counselling requires: • Self awareness of one’s beliefs, values and assumptions; • A respectful non-judgemental attitude; • Active listening, including accurate reflection of issues and concerns; • Asking supportive questions that raise important issues; • Awareness of one’s verbal and non-verbal behaviour; • Providing practical support, advice and information; • Discussing options for care, prevention and support; • Encouraging the person counselled and his/her family to make their own decisions; • A quiet, private environment; and • Ensured confidentiality. Wellness Programme In many workplaces, counselling services are part of broader employee assistance programmes (EAP). This tends to minimise possible stigmatisation of the service. For an effective counselling service the following are necessary: • Careful selection of counsellor trainees; • Training that includes supervised placement after initial training; • On-going mentoring to maintain quality of counselling and to prevent burn-out; Workplace HIV/AIDS Programme • Integration of HIV counselling into related services; and • Referral systems that link counselling services with medical and other services. Support groups are groups of people who are facing similar challenges and who have decided to meet regularly to share experiences and to help each other. Support groups require: • Privacy, so that members feel confident to share and disclose often intensely personal matters; • A time to meet that fits with the schedules of its members; • A skilled facilitator; and • Carefully considered membership criteria and methods of operating. Post-test clubs are sometimes established by groups of people who have undergone an HIV test. They function to provide support for their members, as well as to provide HIV/AIDS-related information. 10. Family support The objective of family support is to render holistic support to affected families, in particular for future and succession planning. Some of the issues that need to be provided for are: • How property or money will be managed in the event that that the employee becomes disabled, who will inherit, and should a power of attorney be prepared; • Decisions about employee benefits and personal insurance; • Planning for future medical care; • The drafting of a will; • Deciding about a living will; and • Deciding about who will have custody of the children and who will be their legal guardian. Page 154 11. Referral networks and partnerships A wellness programme requires partnerships with services and agencies – for any services and support that cannot be provided on site. It also requires the establishment of referral networks to these services and agencies. Home-based care is one of the options for caring for employees with late stage HIV disease, and many companies are entering into partnerships with NGOs providing home-based care services. Section One Characteristics of sucession planning1 Target groups • HIV positive parents • Their children Section Two • Standby guardians Programme components • Counselling for HIV positive parents on serostatus disclosure to their children; Section Three • Creation of “memory books”; • Support in appointing standby guardians; • Training for standby guardians; • Legal literacy and will writing; • Assistance with school fees and supplies; • Income-generation training and seed money; and Section Four • Community sensitisation on the needs and rights of HIV/AIDS affected children. Section Five Red Flags and Special Challenges 1. The rationale for treatment There are a number of compelling reasons for providing treatment. Appendices • The availability of treatment offers hope and this, in turn, takes away much of the fear that PLWHAs experience, and enables them to face all of the issues that they need to deal with more readily and effectively; • It is only when HIV testing is coupled with treatment that people have an incentive to be tested; Acknowledgements • Effective antiretroviral treatment lowers the viral load in infected individuals, which, in turn, has a major effect in reducing the likelihood that they will transmit HIV infection to others; • Treatment is necessary to save the very fabric of societies. Without treatment, parents will die. Without family support, children will not attend school, will live in poverty and will, themselves be vulnerable to acquiring HIV. • Treatment is necessary for continuing economic development. Without treat- ment, millions of adults in the prime of their working lives will die of AIDS and take with them the skills and knowledge base that are necessary for human and economic development. Page 155 2. Tuberculosis TB can become resistant to anti-TB drugs if health care workers prescribe incorrectly and if TB patients do not complete their TB treatment. When TB becomes resistant to drugs like isoniazid and rifampicin, it is called multi-drug resistant (MDR) TB. MDR TB is twenty times as expensive to treat as drug susceptible TB, the treatment lasts from 16 to 22 months, instead of 6 months, 30% of cases are fatal and less than half of patients are eventually cured. Tool: Minimum requirements for introducing HAART Instructions The wellness programme tool could be one of any number, but, in light of the ever-increasing emphasis on the provision of HAART, a tool on the minimum requirements that must be in place before introducing HAART has been selected. So, if your company plans to provide HAART for HIV infected employees, the following Wellness Programme are the minimum requirements that must be in place. • Availability of reliable, inexpensive tests to diagnose HIV infection; • Access to VCT; • A reliable, long-term and regular supply of quality drugs; • Support for those enrolled from their social networks, to stay with the treatment regimen; Workplace HIV/AIDS Programme • Counselling on drug information, financial considerations, adherence, etc; • Appropriate training for health care providers in treating clients with HAART; • A protocol that covers when to initiate treatment, drug regimens, medical monitoring, etc; • Laboratory facilities to monitor clients on HAART, including the early identification of adverse reactions; • Capacity to diagnose and treat OIs; • Access to functioning and affordable health care services; and • Joint decision-making between the health care provider and the client, in all decisions related to HAART. Page 156 10/10 Score Card: Wellness programme Instructions Review the actions in the score card, where the sections are indicative of a minimal (1 red ribbon), good (3 red ribbons) and “blue-chip” (5 red ribbons) response. Assess your organisation’s level of competence in each. Then decide on future actions to Section One improve your organisation’s rating. Score Card Description Rating Future Actions Section Two • Treatment of minor ailments at on-site  occupational health clinic or at public Minimal Response sector PHC clinic • DOTS for TB treatment in place and treatment completion target reached • EAP at all operations, and EAP Section Three practitioners trained in HIV/AIDS • Screening for STIs and TB  • Prophylaxis for OIs, and nutritional Good Response supplements provided and paid for by the company Section Four • Support groups meeting weekly, outside of working hours, but utilising company facilities • HAART available on a cost-sharing basis  for infected employees with CD4 counts Section Five Blue-chip Response less than 250 • Counselling, including bereavement counselling, extended to dependents • Legal assistance available for succession planning Costs Appendices Acknowledgements The cost of the HAART is coming down and more and more drug combinations are becoming available, which is likely to decrease the price further. AngloGold estimated that it would cost US$ 244 per client per month to provide employees with HAART during a trial running from November 2002 to December 2003. Harmony budgets ZAR 1 000/mth per client. Other programmes estimate the annual cost of treatment at US$ 500 per annum, and the cost of first-line drugs at ZAR 350/mth. A study in Zambia quantified the cost of providing HAART at $ 488 per person p.a. for first line HAART, or $ 408 for a more basic monitoring protocol. Drugs are responsible for 57% of the total cost and monitoring tests for 36%. VCT will cost $ 3.64 per person. The training of health workers to deliver ART was calculated at $ 1 million p.a. for 4 years. Page 157 The diagnosis and treatment of TB is free in many countries, and in such situations, should not represent a cost to companies, other than the time costs of supervising and taking treatment. Many of the other wellness programme costs will be additions to existing commitments, such as treatment for minor ailments at the occupational health clinic and counselling as part of EAP services. Case Study: The elements of wellness CASE STUDY support and management Gold Fields has a comprehensive wellness programme for HIV infected employees. The following is an extract from their VCT and wellness programme. Note that ALL chronic diseases such as HIV/AIDS, diabetes, hypertension and asthma will be managed in the Wellness Programme. See Chamber of Mines Wage Agreement 2001 clause 3.2.2.3. Wellness Programme 1. Health and life style education Education received at induction and from peer educators will be reinforced, including the value of a healthy diet, regular exercise, no smoking, no alcohol and treatment possibilities. Workplace HIV/AIDS Programme 2. Nutritional and vitamin supplements Maintaining the vitamin, mineral and other essential nutrient levels of HIV positive people, slows the rate of progression to full blown AIDS. New products suggested by parties will be considered by labour and company health professionals on a scientific basis and may be introduced to the protocols on merit. 3. Sexually transmitted infections (STIs) • The risk of HIV transmission increases drastically in the presence of STIs, hence the importance of 24 hour access to a STI management programme at every primary health care facility. • The management of STIs in communities, especially for people at high risk, is of the utmost importance to ensure the sustained reduction of STIs amongst employees. 4. Opportunistic infections (OIs) • Ensuring optimal functioning of the immune system through a healthy life style and nutritional and vitamin supplements are the most cost effective method of prevention. • Prevention of OIs such as TB, pneumonia (Pneumocystis carinii) and chronic diarrhoea will further be effectively achieved with the responsible use of isoniazide (INH) and co-trimoxazole (Bactrim). • Those infections not prevented will be timeously identified through regular visits to the Wellness clinics and primary health care facilities, and appropriately treated. Page 158 5. Surveillance and treatment of TB The Gold Fields TB surveillance and treatment programme complies with national guidelines and is regarded as one of the best in South Africa. Directly Observed Therapy (DOT) principles are applied. 6. Minor conditions These include skin, mouth, ear, nose and throat diseases and will be treated at existing Section One primary health care facilities. Monitoring The objectives are to continuously monitor the cost effectiveness of the programme and to enable health professionals to adopt the most appropriate disease management protocols timeously. Monitoring will be ongoing and accurate health records will be Section Two kept from day one. The data will be collected and analysed on an ongoing basis. The information will be made available to the GFL HIV/AIDS forum for review. Section Three Additional Information Dr Clive Evian has written a book entitled Primary AIDS Care for primary health care personnel providing clinical and supportive care to PLWHAs (latest edition published in 2002). The book deals extensively with anti retroviral therapy and Section Four is orientated to the health care realities of Africa. Metropolitan sponsored a booklet entitled Positive health, written by Neil Orr, for PLWHAs (undated). Southern Life developed a booklet on financial planning, entitled: Future Section Five positive – financial planning with HIV/AIDS. UNAIDS; Fact sheets on HIV/AIDS for nurses and midwives (2000) contains information on many components of a wellness programme. Appendices The Canadian AIDS treatment information exchange developed a handbook on living with HIV, entitled: Managing your health (1999), as well as a number of fact sheets on issues such as drug side effects, and HIV/AIDS and nutrition. All are available on www.catie.ca. The full Gold Fields case study is available at www.weforum.org/globalhealth/ Acknowledgements cases. Criteria for assessing if a site or programme can effectively initiate ART have been developed and are available on www.developmentgateway.org/download/ 194772/Readiness_Tool_final.pd. The ART protocol used by Anglo American is available on their website at www.angloamerican.co.uk/hivaids/downloads/ART%20GUIDELINES%20oct 02.doc. Page 159 A manual on nutritional care and support for people living with HIV/AIDS is available on www.fao.org/DOCREP/005/Y4168E/Y4168E00.HTM. There are a number of publications on nutritional advice and support, such as that developed by the Network of African people living with HIV/AIDS, entitled: A healthy diet for better nutrition for people living with HIV/AIDS (undated) Care and support is covered in the ILO education and training manual, Implementing the code of practice on HIV/AIDS and the world of work (2002) (Module 7), available on www.ilo.org. The Zambia ART costing study by Kombe, G and Smith, O is entitled The costs of ART in Zambia (October 2003). Wellness Programme Workplace HIV/AIDS Programme Footnotes 1 From a Horizons research summary entitled Succession planning in Uganda: early outreach for AIDS- affected children and their families. The full report is available on www.popcouncil.org/pdfs/horizons/ orphansfnl.pdf Page 160 Section Four Outreach or External Response Section Four contains the components of an organisation’s outreach or external response to the HIV/AIDS epidemic. The goal of an organisation’s outreach or external programme is to contribute to broader community, sectoral and societal HIV/AIDS responses, in areas of comparative advantage, by, for example: All sectors and spheres of society have to be involved as equal partners. We have to join hands to develop programmes • Adopting and implementing the principle of the greater involvement of people and share information and research that living with HIV/AIDS; will halt the spread of this disease and • Initiating and/or participating in HIV/AIDS partnerships and collaborative help develop support networks for those relationships; who are affected. • Playing an important role in HIV/AIDS networks; Address by President • Developing and utilising skills to enhance community-level entry for HIV/AIDS Nelson Mandela to the World Economic interventions; and Forum, Davos (1997) • Contributing, in diverse ways, to community outreach projects. Page 161 Section Four Greater Involvement of People Living with HIV/AIDS Greater Involvement of People Living with HIV/AIDS INFO Briefing Note What is the greater involvement of people living with HIV/AIDS (GIPA)? In 1994, at the Paris AIDS Summit, 42 governments declared that the principle of greater involvement of people living with or affected by HIV/AIDS (GIPA) is critical to ethical and effective responses to the epidemic. This means: • Recognising the important contribution that PLWHAs can make in any response to the epidemic; and In the context of HIV, the issue of a • Creating the opportunity for their involvement and active participation. Outreach or External Response “human face” goes beyond welfare to include the experience of those affected Why does an organisation need to adopt and embrace the GIPA – their joys, sorrows, sense of identity principle? and their need to be accepted as part There is a clear business case for GIPA, particularly in terms of ensuring the relevance of the community. and sustainability of an organisation’s response to HIV/AIDS. Giving HIV/AIDS a human face therefore includes the individuals affected showing Successful GIPA initiatives have resulted in a decrease in stigmatisation and discrimination, the rest of the world that, beyond the a personalising of the reality of HIV/AIDS and an improved environment for prevention grim statistics, they are humans – fathers, and care. mothers, sons, daughters, nieces, neph- ews, grandmothers and grandfathers who Contractors may not be in a position to employ a person living with HIV/AIDS as aspire to living a full life. part of their HIV/AIDS programme, but there are other ways to harness this powerful UNAIDS; Enhancing GIPA in force to enhance their programme, such as by involving infected employees who sub-Saharan Africa have disclosed in programme activities. This is one component that quite clearly spans both an internal, workplace response and an outreach, or external response. Workers who are HIV-positive and are willing to take part in education and training activities have a vital role to play in ensuring the development of effective programmes, and strengthening the credibility of prevention messages. Page 162 What does GIPA involve? The involvement of PLWHAs can be at multiple levels: Levels of involvement of PLWHAs1 PLWHAs as the recipients of information or services Section One PLWHAs as contributors, speakers or participants in campaigns - sometimes marginal or token participation PLWHAs as implementers - as carers, peer educators and counsellors Section Two PLWHAs as experts, on the same level as professionals PLWHAs as decision makers - as valued as other members of Section Three decision-making or policy- making bodies The message is that PLWHAs can be a valuable part of a workplace response, both Section Four within the organisation (as part of the workplace programme) and externally as part of the organisation’s community participation activities. Example of the benefits of GIPA in an ART programme2 Section Five • Active participation of clients in their own treatment encourages closer co-operation with health workers and better feedback on the effects of the treatment; • PLWHAs who are successfully on ART are powerful advocates and Appendices educators for others considering treatment; • People newly diagnosed with HIV, or starting ART value counselling from other PLWHAs who have had similar experiences; • PLWHAs have first-hand experience of what makes (or doesn’t make) a service client-friendly; Acknowledgements • Experienced PLWHAs can be involved in selecting clients for treatment, alongside physicians and other community members, ensuring equity in selection when resources are limited; • Selected PLWHAs can be trained to assist in the education of clinical and support staff, to ensure that training is grounded in real-life experiences, and equips staff to offer appropriate treatment and support; and • The visibility of PLWHAs who are using treatment successfully is a powerful tool for combating stigma and encourages people to come forward for HIV testing, counselling and treatment. Page 163 Red Flags and Special Challenges Some organisations, perhaps despite the best of intentions, have involved PLWHAs in ways that are little more than tokenism – the PLWHA ticked off a checklist as having been invited to the meeting, or as having been consulted in the policy development process. This is not only contrary to the spirit of GIPA, as these attempts can hardly be considered “meaningful involvements”, but the end results will certainly be less effective and relevant than if the process was more meaningful. Greater Involvement of People Living with HIV/AIDS Tool: Checklist to improve an organisation’s GIPA response Instructions In the UNAIDS document entitled: From principle to practice: greater involvement of people living with or affected by HIV/AIDS (1999), a number of suggestions are made of how an organisation can enhance its GIPA response. Consider if and how your organisation can adopt and implement the following: • Peer educators who are themselves HIV positive, are nominated, trained and deployed; • Support groups are established and run by appropriately skilled and supported Outreach or External Response PLWHAs; • Advertisements for staff state that HIV positive persons are welcome to apply for employment within the company; • Senior management collaborates regularly and publicly with PLWHAs in creating HIV/AIDS plans for the company; and • Training for PLWHAs on personal empowerment, communication and presentation skills, HIV/AIDS facts, the legal aspects of HIV/AIDS, and skills for organising and conducting policy dialogue is conducted to enable them to more effectively contribute to the company’s HIV/AIDS response. Page 164 10/10 Score Card: GIPA Instructions Review the actions in the score card, where the sections are indicative of a minimal (1 red ribbon), good (3 red ribbons) and “blue-chip” (5 red ribbons) response. Assess your organisation’s level of competence in each. Then decide on future actions to Section One improve your organisation’s rating. Score Card Description Rating Future Actions • Speaker from local PLWHA organisation  Section Two Minimal Response invited to address workers on World AIDS Day • Employees living with HIV/AIDS, who  have disclosed their status, serve on Good Response policy making committees to ensure Section Three that PLWHA issues are taken into account • PLWHA employed, and trained to head  the company HIV/AIDS programme Blue-chip Response Section Four Costs Section Five Many of the companies who have benefited from GIPA field worker placements, that were originally sponsored by UNAIDS, have gone on to create permanent positions for PLWHAs, particularly within their HIV/AIDS programmes. In other instances, as described below, an employee, who has disclosed his/her status, Appendices becomes involved in, if not pivotal to the company’s HIV/AIDS programme. In 1997, Alan held the position of District Manager in a hospitality company employing 9 000 people. Alan disclosed his HIV status on World AIDS Day 2000. In January 2001, Alan was appointed as Group National HIV/AIDS Manager. Acknowledgements Alan’s company took an interesting approach to his position by negotiating with the provident fund to share 50% of his employment costs, as his work would benefit the fund. Page 165 Case Study: A GIPA field worker placement CASE STUDY Mazwi Mngadi, 24, is a dynamic young man who works on the Horizons intervention study at ESKOM sites throughout KwaZulu-Natal, South Africa, serving as an HIV/AIDS workplace counsellor, educator, and activities co-ordinator – and presenting a positive image as someone living openly with HIV/AIDS. He volunteers much of his free time to the Treatment Action Campaign and other South African HIV/AIDS activist organisations. MM: I lead educational sessions on HIV/AIDS with groups of workers and provide training for peer educators and for new trainers. I give out a lot of condoms and make sure that “condom cans” are kept full. I also offer counselling to individual Greater Involvement of People Living with HIV/AIDS workers and their families and partners, often in their homes. I’ve distributed a booklet about my own story at the dozens of ESKOM plants and substations in KwaZulu- Natal, so I’m well known within the workforce. A lot of workers, even those who haven’t been tested, are afraid to speak to me in public for fear of being identified as HIV positive, but I circulate my phone number, so instead they phone me to talk about their concerns and get advice. These calls are strong evidence to me that my presence at ESKOM makes a big difference. Just a few months ago we created a confidential support group for workers with HIV/AIDS that meets outside of ESKOM, after work hours. So far, there are about six workers who participate, and we share our personal stories and our problems, and I usually invite a speaker to talk about such topics as nutrition and treatment of opportunistic infections. We also discuss what’s happening around the country. Outreach or External Response One of the most common problems is being afraid to tell partners that they’re HIV infected. Additional Information The full interview with Mazwi Mngadi is contained in the Horizons Report (June 2003), available on www.popcouncil.org/horizons/newsletter/horizons(6). The following are available on the UNAIDS website at www.unaids.org • From principle to practice – greater involvement of people living with or affected by HIV/AIDS (1999); and • Enhancing the greater involvement of people living with HIV/AIDS in sub-Saharan Africa (2000). Footnotes 1 From UNAIDS: From principle to practice – greater involvement of people living with or affected by HIV/AIDS (1999) 2 Adapted from a draft toolkit for programme managers developed by the International AIDS Alliance and WHO, entitled A public health approach for scaling up ARV treatment (2003) Page 166 Section Four HIV/AIDS Partnerships and Collaborative Section One Relationships Section Two INFO Briefing Note What is a partnership? Section Three Partnerships are voluntary collaborations that build on the respective strengths of each partner, optimise the allocation of resources and achieve mutually beneficial results over a sustained period. They imply innovative interaction and linkages that increase resources, scale and impact. They also imply a preparedness to share benefits and losses. Section Four Partnership examples South Deep will work with municipal authorities to ensure that ill-health retirees have reasonable access to required services including: water; sanitation; and clinics and hospitals. Anglo Platinum is working closely with the local authorities to set up services Section Five and to build houses to replace informal settlements. They are about communication, consultation, co-ordination and collaboration and usually involve written agreements that specify the purpose and duration of the Appendices partnership, the formal governance structure, roles and responsibilities of the various participants as well as exit arrangements. There are different kinds of partnerships, such as: • Public/private/NGO partnership combinations or tripartite partnerships Acknowledgements (government, business and labour); • Operational partnerships, around a specific programme; • Policy and strategy partnerships, which typically deal with new challenges that cut across sectors; and • Advocacy partnerships to promote action on key issues. Some partnerships evolve to encompass a combination of the above. Why does an organisation need to build HIV/AIDS partnerships? Building HIV/AIDS partnerships is about working with others to achieve what we cannot achieve on our own, or because we do not have the necessary expertise. A partnership is a relationship in which people and organisations combine their resources to carry out a specific set of activities that address one or many aspects of the HIV/AIDS epidemic. Page 167 The benefits of an HIV/AIDS partnership include: • The resource commitments that are made by each party: - Funds or finance - Staff time; - Expertise; - Local knowledge; - Technical equipment; and - Mediation skills. • A wider response – with different types of organisations and sectors involved; • Influence with and access to key individuals and places, willingness to adopt a leadership role and capacity to leverage resources from others; • A more co-ordinated response – including better referral between HIV/AIDS Partnerships and Collaborative Relationships organisations; • A larger response – financial, political, technical, practical and in-kind support; • Better support and policies for PLWHAs and their families; • Stronger services and increased access for vulnerable communities; • Fewer constraints; • More creative and effective HIV/AIDS programmes; • Opportunities to develop knowledge and skills; and • Shared lessons and experiences. Coalitions of businesses are one form of HIV/AIDS partnership, to work together to pool data and talent to accelerate and streamline HIV/AIDS responses. Similarly, public-private HIV/AIDS partnerships can be more efficient than if they work independently. Outreach or External Response Contractors, even small companies or those operating in a less formal manner, such as small scale mining companies1, identify the importance of forming HIV/AIDS partnerships, to benefit both their response and the response of their partners. There will usually be good precedents for this kind of partnership, which can be used as a model for an HIV/AIDS partnership. Who are the potential HIV/AIDS partners and how should HIV/AIDS partnerships operate? Debswana example … suppliers that provide goods and services to Debswana must have their own workplace policy and programme, as well as be supportive of Debswana’s community HIV/AIDS initiatives. Suppliers are audited on a periodic basis. 1. Suppliers, customers and contractors Large companies have a number of relationships with suppliers, customers and contractors, many of which are smaller, informal enterprises. Those large companies should identify all small enterprises with which they have production relations. The aim then would be to convince the firms which supply them with goods and services to participate in their workplace HIV/AIDS programmes, or to develop their own programmes, possibly assisted by the large company. Staff who visit suppliers, contractors and customers could distribute literature on the basics of HIV/AIDS. They could receive special training so that they can discuss and explain issues. Staff in purchasing and sales departments are perhaps not normally Page 168 involved in the company’s HIV/AIDS response, but they could have a huge impact. They meet customers and suppliers regularly, get to know many of them, and understand their problems. They are more likely to be trusted than strangers. Suppliers and customers could also be invited to in-house training and information sessions on HIV/AIDS. This would involve little additional cost, and strengthening the relationship between the company and the customer/supplier could be good Section One for business. 2. Local small businesses Around every large organisation there will be a cluster of small businesses, not necessarily with any kind of formal relationship, but dependent on the existence of the company in some way. For example, there may be stalls nearby selling food and Section Two drink to workers. There are cleaners and security guards. Workers travel to and from work on mini-buses and other forms of informal transport. Here again, the influence of the larger organisation can be used to get the HIV/AIDS message across. 3. Trade unions Section Three The same principle applies to workers’ organisations, that could extend an invitation outside their own membership, to organisations sharing a common goal. 4. Membership organisations Then there are numerous membership-based institutions such as community associations, credit unions, co-operative societies, and mutual insurance schemes. Section Four Large employers or employers’ organisations can work with these in a number of ways. They can sponsor or ‘adopt’ an HIV/AIDS programme for such associations, or partnerships can be set up to help companies implement activities for the local community. Section Five 5. National and international organisations and research institutions Aurum Health Research, sponsored At national, and indeed at international level, the mining sector can and has contributed by AngloGold, exemplifies effective to advancing the frontiers of knowledge and research on HIV/AIDS. interaction between the mining and the scientific community as well as 6. Government Appendices resource mobilisation from local and Mining companies can use their existing relationships with government as an opportunity international donors. to develop HIV/AIDS partnerships that benefit both parties. 7. People living with HIV/AIDS Debswana example In April 2003, Debswana entered into a partnership with the Ministry of Acknowledgements Health, offering the use of the Debswana medical facilities and staff for the rollout of the government ART programme. The benefit to government was that ART access was extended to more citizens, without the cost of additional staff or infrastructure. The benefit to Debswana was (i) that infected dependents (children), who are not covered by the company’s programme, are now catered for; (ii) ART drugs can be purchased at government tender prices; and (iii) government laboratories can be used for blood tests (reducing the costs associated with using private laboratories). Page 169 And finally, there are associations of people living with HIV/AIDS, who are a valuable resource in helping to develop programmes of prevention and care for both informal and formal workplaces. The golden rules for initiating partnerships include: • Defining specific goals for the partnership. These might be related to a challenge that the organisation is facing, eg a lack of counselling skills. • Identifying the people and organisations to work with to achieve the goal. An organisation can also make an assessment of its current partners, in terms of any joint activities that may achieve progress towards the goal, or the potential to work with current partners in achieving the goal. • Deciding how to approach each partner in a way that is appropriate to the posi- HIV/AIDS Partnerships and Collaborative Relationships tion and interests of the partner. In order to build strong, effective partnerships an organisation needs to know and understand its partner – what it does, its views and positions and areas of influence. • Identifying champions, to get the partnership off the ground. • Agreeing, with identified partner organisations, to shared governance. • Defining the details of the collaborative relationship, and formalising these in a memorandum of understanding. Mapping (or recording) a partnership’s ‘ups’ and ‘downs’ can help identify the strengths and weaknesses in a relationship, and can be used in monitoring a partnership. A partnership review is an opportunity to build on successes and learn from mistakes. Outreach or External Response Red Flags and Special Challenges The challenges reflected below should not detract from the fundamental truth, which is that partnerships can and do benefit those involved to achieve their own or shared goals. Having stated that, organisations should be alert to possible pitfalls, which may include: • That there is no guarantee that civil society organisations or government agen- cies that the company wishes to engage in partnership with, will be “willing” partners; • That there is also no certainty that, if “willing”, these partners will bring resources, knowledge, skills or leadership that would add value to what the company could achieve alone; • That partnerships with NGOs may, in some instances, be tainted by prevailing negative images of NGOs as not able to get results; • That NGOs, as community activists, may create problems by calling attention to difficult issues; • That broaching or pursuing the issue of HIV/AIDS with suppliers, customers and contractors could be difficult and will need strong and sustained leadership; • That HIV/AIDS can pose special challenges to the building of partnerships, such as personal attitudes and beliefs, and institutional practices, policies or beliefs; and • That partners may not feel comfortable or competent in the HIV/AIDS field. Page 170 Tool: Guidelines for conducting a partner analysis Instructions When embarking on HIV/AIDS partnerships, it is useful to have a clear idea of who is out there, doing what. Follow this step-by-step process to conduct such a partner Section One analysis. Task 1: Identify (i) your organisation’s current partners and (ii) any potential future partners from: • Within Government – different Ministries; Section Two • Within Government – different spheres/levels; • Parastatals; • Agencies (including other donors); • Networks; • Boards; • Associations (professional and voluntary); Section Three • Private sector (commerce and industry); • Training institutions; • Research institutions; • NGOs and civil society structures; and • The informal sector. Section Four Task 2: Identify their (i) current and (ii) potential future areas of involvement – both those that are HIV/AIDS-related and those that are not. For example, who is, or can be involved in: • Policy making; • Advocacy; Section Five • Planning; • Co-ordination; • Implementation; • Technical input; and • Other areas. Appendices Task 3: Describe who they work with, where and at what level (coverage). Task 4: Then describe how they work together and how effectively. Task 5: Describe how those with the potential to become involved, but who are Acknowledgements not as yet involved, should be recruited. Task 6: Finally, from the list, identify those organisations whose involvement is key to the success of your organisation’s HIV/AIDS programme. These then become the prioritised organisations with whom to pursue collaborative relationships. Page 171 Questions to be asked about company HIV/AIDS partnerships The following constitute reality checks for successful partnerships: • Goals – what do we hope to accomplish and can a partnership help achieve our goal/s? • Rewards – what are the tangible and intangible benefits we can expect from the partnership/s? • Risks – are there any apparent or potential risks involved in the partnership/s? • Success – how will we know if we are making progress? • Capacity – does capacity exist to afford the partnership and give it a chance of success? • Timing – is partnering the best option now, and if so why? HIV/AIDS Partnerships and Collaborative Relationships • Weightings – have we considered issues of control, direction and need for speed? Score Card: HIV/AIDS partnership 10/10 Instructions Review the actions in the score card, where the sections are indicative of a minimal (1 red ribbon), good (3 red ribbons) and “blue-chip” (5 red ribbons) response. Assess your organisation’s level of competence in each. Then decide on future actions to improve your organisation’s rating. Outreach or External Response Score Card Description Rating Future Actions • Discussions to extend memorandum  of understanding (MOU) with agency Minimal Response providing non-HIV/AIDS-related services (eg basic adult education courses for less literate employees) to include HIV/AIDS • Interested parties able to access information about company HIV/AIDS programme • Audit of current partners conducted, to  identify opportunities for collaborative Good Response relationships on HIV/AIDS issues • MOU with public sector health services  to extend wellness programme to Blue-chip Response infected dependents of employees Costs The costs associated with establishing and sustaining HIV/AIDS partnerships should always be assessed in terms of the cost benefits of the partnerships, and the possible cost of “going it alone”. Page 172 Case Study: HIV/AIDS partnerships CASE STUDY Sishen Iron Ore Mine is situated in the Northern Cape Province of South Africa. Sishen’s approach to addressing HIV/AIDS has taken seriously the need to engage not only employees, but also stakeholders – in the workplace and the surrounding community – who can have an impact on employees’ lives. Collaboration with these partners and stakeholders takes many forms, from responsiveness to requests Section One for information and speakers, to support for district level strategic planning around HIV/AIDS and training of community peer educators. Some key partnership roles and approaches that are part of Sishen’s HIV/AIDS response are described below. Section Two 1. Unions Engagement in the promotion of a KAP survey and the Know Your Status (KYS) campaign. They are also part of the committee reviewing and approving the Kumba Resources-wide HIV/AIDS policy. 2. Departments of Health and local government Section Three Involvement with them in the district HIV/AIDS committee; support for district-level strategic planning; training of service providers in peer education techniques; and engagement of local home-based care providers in the KYS and other awareness campaigns. Section Four 3. Medical aid plans and resources Contract with medical aid provider for half-time nurse and social worker to provide HIV/AIDS services (including voluntary counselling and testing, condom distribution and STI treatment). Engagement of medical aid provider in implementation and follow-up of the KYS campaign. Section Five 4. Community groups and schools The Sishen drama group and peer educators receive regular invitations to give lectures at community events. They have visited a number of local schools and churches, and participated in community day activities through HIV/AIDS exhibitions, videos and drama. They have performed a drama for farm workers on a large commercial Appendices farm. Sishen has also engaged proactively in partnerships with local police and other community groups to raise awareness of and promote action on violence against women; has held an HIV/AIDS programme launch that raised awareness throughout the community; and, perhaps most importantly, they have trained a number of Acknowledgements community members and home-based care providers as peer educators. These individuals are now part of the Sishen peer education team, and receive the same ongoing training and support as the Sishen team members. 5. Complementary health care providers Sishen has contractual relationships with several local practitioners to provide various forms of complementary therapy. Other partnerships are being explored, including the establishment of a herbal garden from which plants could be distributed to PLWHAs and their families through the home-based care network. Home-based care providers would be trained by qualified practitioners in the use of herbs for the treatment and control of a variety of infections. Page 173 Much of this collaboration is responsive and ad-hoc and there is no on-going HIV/AIDS partnership plan with these groups. As valuable as many of these partnerships undoubtedly are, these relationships could perhaps benefit from more formal agreements between the various partners (like MOUs). Additional Information UNAIDS and the Prince of Wales Business Leaders Forum published a document entitled: The business response to HIV/AIDS: innovation and partnership (1990). The document includes the seven principles of partnerships HIV/AIDS Partnerships and Collaborative Relationships (p27), which are a useful additional tool for organisations developing their competency in the field of HIV/AIDS partnerships. Generic information on partnerships is available on the Business Partners for Development website at www.bpd-naturalresources.org. For the mining sector, examples of tri-sector partnerships are given at each of the different project phases. The agreement, signed by the NUM and the Chamber of Mines on behalf of their member mines in August 1993, defines the commitments of all parties to work together to find effective, sustainable and affordable solutions to the HIV/AIDS epidemic, in accordance with the documented strategy. The agreement is contained in the ILO education and training manual, entitled Implementing the ILO code of practice on HIV/AIDS and the world of work Outreach or External Response (2002), which is available on www.ilo.org. Other useful references include: • Gates Foundation; Making health alliances successful; and • Harvard University Business School and Kennedy School; HIV/AIDS and business: building sustainable partnerships. Footnotes 1 At the CASM AGM and Learning Event held in Ghana in September 2003, participants attending the HIV/AIDS session identified a wide range of creative partnerships to enable them to mount comprehensive responses to the HIV/AIDS epidemic Page 174 Section Four HIV/AIDS Networks Section One Section Two INFO Briefing Note Section Three What is an HIV/AIDS network1? An HIV/AIDS network consists of individuals and/or organisations willing to assist one another or collaborate to achieve common goals. Networks are created out of a powerful sense of shared mission, shared vision, shared In the process of creating these networks, commitment and shared action. Networks are created by people who want to be Section Four we are learning that they are fragile connected, to communicate, plan and act in concert. A network is a process of rapidly entities, difficult to get established and to disseminating information – lessons, innovations, techniques, ideas, news, requests, sustain. They require much commitment questions. A network gives its participants a strong sense of solidarity. and patience from their members, particularly their founding members. But we are also learning that they form an Why is it important for an organisation to participate in an HIV/AIDS Section Five essential part of the community response network? to the epidemic. Without them, people Organisations must recognise that, however good their workplace HIV/AIDS responses are often merely told what others think may be, they will be limited if there is no participation in broader community-wide they should do. With them, we can and sector-wide HIV/AIDS activities. Participation in HIV/AIDS networks is a pre- strengthen the process of questioning, requisite to this wider involvement. Appendices reflection and learning. They are the places in which an Contractors may find participation in a local HIV/AIDS network challenging, particularly individual in search of help can go, if their area of operation frequently changes. There are, however, obvious benefits spaces in which communities can seek – such as sharing information, resources and experiences – that membership of an to understand how, wisely and humanely, HIV/AIDS network brings, and contractors should recognise these and participate they can respond. whenever possible. Acknowledgements Elizabeth Reid What are the characteristics of an HIV/AIDS network? Most networks have some or all of the following characteristics: • Member-ownership; • Commitment to shared objectives and means of action; • A jointly developed structure; • Shared responsibility; • Shared action; • Reduced duplication and resource wastage; • Communication, exchange and mutual learning; and • Synergy (the effect of things done together is greater than the sum of individual activities). Page 175 The additional characteristics of an HIV/AIDS network include that it: • Involves people living with HIV/AIDS; • Maintains the trust of involved communities; • Strengthens advocacy; • Influences others (inside and outside the network); • Broadens understanding of HIV/AIDS (by bringing together different constituencies); and • Provides a sense of solidarity, and moral and psychological support. Structure Networks can sometimes be established within existing structures: at other times, new structures are required. Networks can be formal or informal in nature. Typically, most networks fall somewhere along a continuum between a loose, single-purpose network for information exchange and a highly formalised network conducting and/or co-ordinating activities. It is also important to note that network structures are not static, and tend to change over time. Factors that will influence the structure of a network are: • What the network is trying to achieve; • What resources (time, money and people) are available; and • How the members want the network to be organised. HIV/AIDS Networks Membership Most networks have both individual and organisational members. Individuals should ideally have a constituency that they represent. In the case of HIV/AIDS networks, in order for the network to be truly representative of and responsive to the needs of Outreach or External Response people living with HIV/AIDS, it is imperative to ensure the involvement of PLWHAs in a meaningful way. Membership should therefore consist of individuals and organisational representatives, PLWHA, local NGOs providing HIV/AIDS-related services, decision-makers from key sectors or people who can influence decision- makers, and technical experts. Red Flags and Special Challenges The nature of networks means that they are loose entities and this can limit their value, particularly if members are constantly changing, or dropping in or out of the network. Tool: Checklist of HIV/AIDS network activities Instructions Although there are many different reasons why HIV/AIDS networks are formed and many different ways in which they operate, there are some basic activities that are common to most HIV/AIDS networks, such as building solidarity, enhancing collective capacity and uniting in common cause. Use the following checklist when deciding on the activities that your HIV/AIDS network will undertake. Page 176 • Alliance building Networks can provide for relationships among partners. • Generating and sharing information Networks can provide a structure for members to establish and maintain essential communications with each other. • Advocacy Section One Networks can co-ordinate advocacy action on HIV/AIDS-related matters identified by members. • Skills and capacity building Networks can provide both formal and informal opportunities for enhancing the HIV/AIDS skills of members. Section Two • Building solidarity Networks can assure members that their HIV/AIDS work is important, particularly when the political and social environment is not hospitable. • Creating opportunities for co-operation Networks can generate and/or support HIV/AIDS programmes which are Section Three complementary, collaborative and which reinforce one another. • Monitoring network indicators Networks can assess progress being made and identify problems needing to be addressed. Section Four One of the activities that HIV/AIDS networks often undertake is to set up a database of organisations offering HIV/AIDS-related services. The need for such a database is consistently identified when groups gather around a common concern and recognise that they do not know each other, or what their respective organisations do. Section Five The following are simple steps that can be followed in creating a database. 1. Set up a task team with responsibility for overseeing the creation of the database. Appoint a suitably qualified person (or persons) to take responsibility for leading the process of developing the database. 2. Define the areas of information to be collected and the questions. There Appendices are many model questionnaires available that can be used or adapted for this purpose. 3. Decide in what form the database will be – hard copy or electronic. 4. Identify mechanisms to distribute the database questionnaire and distribute. Acknowledgements 5. Advertise the database process, with details of how to get the questionnaire. 6. Collect and collate all the information. It is preferable to use a suitable computer package for this purpose. 7. Check the information provided. This is usually done telephonically. 8. Layout and print the final product (if hard copy) or develop the web page (if electronic). Include the means to submit additional entries or amendments. 9. Disseminate copies to all the organisations listed in the database, and to any other stakeholders who could use it. 10. Advertise the database, including details of how to access it. 11. Agree on a process to maintain and update the database and establish this process. Page 177 Score Card: HIV/AIDS Network Score Card 10/10 Instructions Review the actions in the score card, where the sections are indicative of a minimal (1 red ribbon), good (3 red ribbons) and “blue-chip” (5 red ribbons) response. Assess your organisation’s level of competence in each. Then decide on future actions to improve your organisation’s rating. Score Card Description Rating Future Actions • HIV/AIDS Co-ordinator attends meetings  of the local HIV/AIDS network Minimal Response • Database of AIDS Service Organisations (ASOs) created • Company is a driving force in the local  HIV/AIDS network – represented by the Good Response members of the HIV/AIDS Committee • Secretariat for the network provided by the company HIV/AIDS Networks • Company successful in securing  representation on the network of all Blue-chip Response major sectors in the area • Strategic planning for the network facilitated by the company Outreach or External Response Costs The costs of participation in a local HIV/AIDS network are not likely to be significant, outside of the time of those involved, and unless the organisation chooses to provide certain services to the network (such as copying and posting minutes), that have cost implications. Case Study: An HIV/AIDS network CASE STUDY Namakwa Sands is a division of the Anglo American plc Group, with an operation in the Western Cape Province in South Africa. The company participates in the West Coast Employee Organisation HIV/AIDS Forum. The terms of reference of the forum are as follows: 1. To perform a needs analysis within the identified communities in order to iden- tify projects, programmes and activities which will assist with addressing and managing the HIV/AIDS threat facing the communities, with an emphasis on the following: • The promotion of awareness, training and education regarding HIV/AIDS within the ranks of organised labour, as well as in the community; • The identification of projects to enhance existing employer/employee initiatives to address HIV/AIDS in the workplace and community; Page 178 • The implementation of organised labour policies regarding HIV/AIDS in the region; and • The mustering of support and commitment of members and their families, and recruitment of volunteers to be trained as counsellors and helpers to assist with the initiatives. 2. To provide assistance and advice to the other HIV/AIDS forums. Section One 3. To prioritise the identified projects, programmes and activities and do cost estimates. 4. To develop a five-year strategic and business plan, in accordance with the priorities, for submission to the West Coast HIV/AIDS Initiative Board, for Section Two consideration and inclusion in the main strategic and business plans. 5. To receive funds allocated by the Board, to implement the strategic plan and initiatives. Section Three 6. To effectively manage all the approved/agreed initiatives and provide feedback on progress to the Board. Additional Information Section Four There are many references that provide information and guidelines on networks, generally within the NGO/CBO sector. Useful information can be extracted from these and applied to HIV/AIDS networks as well. The International Council of AIDS Service Organisations; HIV/AIDS networking Section Five guide (1997) provides guidance on setting up HIV/AIDS specific networks. Appendices Acknowledgements Footnotes 1 With acknowledgements to the International Council of AIDS Service Organisations; HIV/AIDS networking guide (1997) Page 179 Section Four Community Entry Strategies for HIV/AIDS Interventions Community Entry Strategies for HIV/AIDS Interventions INFO Briefing Note What HIV/AIDS-related tools and skills are required for entry into communities? Many of the tools and skills that are used in development work can be usefully adapted for use in HIV/AIDS community projects. Two such tools have been selected – a risk mapping tool and a community consultation tool. Why do we need the tools? Whilst, on the face of it, the tools may seem over-simplified, they (and others like Outreach or External Response them) constitute necessary entry processes for successful community-level HIV/AIDS interventions. 1. The purpose of the risk mapping tool is to depict HIV/AIDS related facts (such as groups at risk, hot spots for HIV transmission and AIDS-related services) in a way that can guide planning, action and monitoring. We need the risk mapping tool to assist in targeting HIV/AIDS activities appropriately. Although everyone is vulnerable to HIV infection, some groups are more vulnerable, due to a host of factors such as age, gender, socio-economic status and so on. And, whilst interventions for an entire community or for the general public are important, there is much evidence to support targeting interventions (which are tailored for specific groups). This is both more effective as well as more cost effective. Identifying where these groups are, and understanding the situations that place them at risk, can be helpful in defining appropriate interventions. 2. The purpose of the community consultation tool is to structure the consultation process. We need the community consultation tool to facilitate engagement with communities around HIV/AIDS and to ensure that it takes cognisance of important community dynamics. Many people have trouble talking about sensitive issues like HIV/AIDS. Discussion about HIV/AIDS is even more difficult when talking in a public forum, with people from different backgrounds (social and educational). Nevertheless, involving communities in HIV/AIDS prevention, and care and support activities is essential to an effective response to the epidemic. In addition, public discussion on HIV/AIDS fosters private discussion among partners, parents and children, and extended families. Page 180 These sorts of exercises can inform: • Policy and strategy development; • Advocacy efforts; • Stakeholder and community mobilisation; and • Intervention targeting and design. Contractors, particularly when moving into a new location, should utilise such tools Section One and skills in their engagement with local communities. Red Flags and Special Challenges Section Two The best-intentioned initiatives to establish HIV/AIDS projects in communities run very real risks of failing if certain principles are not observed. These include that: • Many communities are experiencing HIV/AIDS, donor and/or project fatigue and disappointment regarding unfulfilled expectations. It is important to recognise this, and to take care not to aggravate the situation further. • There are community “gatekeepers” whose permission and support must be sought Section Three and secured for any project – whether internally or externally initiated; • All communities are unique, and a “one size fits all” approach is unlikely to succeed; • Any project must be grounded in the concerns and priorities that community members identify, which may mean that dedicated/vertical HIV/AIDS projects have Section Four to take on some of these issues in order to survive; • Community time frames must be respected, which means going at the pace set by the community; • The lead person should be carefully selected – language, race, gender and age are important, as is experience working at community level. Section Five Tool: Risk mapping Instructions Appendices Follow these steps when conducting a risk mapping exercise. 1. Establish a small multidisciplinary mapping team. Identify representatives from different areas (who can provide local knowledge and information). 2. Obtain the largest scale map of the area, depicting significant physical features, roads, suburbs/populated areas and services. Acknowledgements 3. Call a consultative meeting of the team and the local area representatives. 4. Agree on the purpose and process of mapping. 5. Conduct an exercise to arrive at a common understanding of vulnerability and risk within the local context. Capture these characteristics – both those that represent high risk as well as those that represent low risk – in a template, such as the one below. 6. Using different colours or symbols, depict on the map the location of identifiable risk groups (eg students, migrant workers) and risk situations (eg truck stops). 7. Now discuss interventions to reduce risk, facilitate access to services and record the discussions in the template under the heading of “possible mitigation actions”. 8. Agree on the process to take this information into the planning process and the means to check that the mapping information has been used. Page 181 Template for mapping risk areas and activities Risk Possible Characteristic mitigation High Low Present Absent actions Location X On major trading/transport route X Near a port Community Entry Strategies for HIV/AIDS Interventions X Geographically isolated X Located in very poor area X Near a border Demography X Refugees X Extended family structures Type of work and employment X Mobile workers Outreach or External Response X Seasonal workers ? ? Source of migrant workers Operations X Result in family dislocation ? ? Challenge traditional authorities Social conditions X Poor housing/informal settlements X Poor access to water X Family housing X Single sex hostels X Poor access to health services Facilities X Sports grounds X Recreation facilities X Youth-friendly health services Page 182 Tool: Community consultation guide Instructions Use the list below to facilitate your community consultations about HIV/AIDS1. Preparing for the consultation Section One • Talk to community stakeholders (chiefs, church leaders etc) in advance to let them know that you want to discuss HIV/AIDS at the next formal consultation. Get their support and encourage them to bring up HIV/AIDS themselves during the consultation. • Identify community “champions.” These are people who will help you include Section Two HIV/AIDS in community consultations and support interventions. • Identify specific language or words that people in the community use to talk about HIV/AIDS to avoid confusion and misunderstandings. Use words you are comfortable with. • Talk with a local NGO or CBO who works in the community for suggestions on the best way to start discussion and to identify major problems and concerns Section Three about HIV/AIDS in the community. • Practice talking about HIV/AIDS with your colleagues or fellow employees and others to increase your comfort in discussing HIV/AIDS. Get advice from HIV/AIDS counsellors who specialise in helping people talk about HIV/AIDS. • Do your homework. Gather information about the community and be sure about Section Four what you will be talking about, including anticipating what kinds of questions may be asked. • Take someone with you who is knowledgeable about HIV/AIDS. During the consultation • Ask for permission to talk about HIV/AIDS if no one has brought it up. “It is very Section Five important that we talk about AIDS. This is a crisis for our area. Does everyone agree?” • Some people will not want to face dealing with HIV/AIDS and may exhibit various forms of denial (eg nothing can stop the epidemic). Acknowledge that talking openly about HIV/AIDS can be difficult and embarrassing. Even confess your Appendices own discomfort (if it exists) but remind community participants that there is no other way to fight the epidemic. • Ask about HIV/AIDS activities already underway and what seems to be working. This will help people identify unmet needs and problems. • Ask anyone currently working in HIV/AIDS prevention or care to volunteer Acknowledgements information and suggestions. • Tell people about HIV/AIDS projects that are operating in other parts of the country to give them ideas about other approaches and opportunities. • Reassure participants that supporting HIV/AIDS interventions will not take money from other activities. • People often say, “We cannot talk openly about sexual issues. It is not part of our culture.” The reality is that there are very few cultures that embrace open discussion about sexuality either between partners or especially among parents and children. However losing young adults to a disease like HIV/AIDS, in the prime of their lives, is also not part of any culture. HIV is a crisis. In times of crisis, cultures must adapt. • Remember that HIV/AIDS is not a moral issue. It is a public health and devel- opment crisis. Making judgements will not help prevention, care and support. Page 183 After the consultation • Review the discussion. Think about problems that blocked discussion and how you can be better prepared for the next consultation. • Get some feedback. Ask a community participant for his or her opinion on the consultation. What could you do better the next time? • Give some feedback. • Document the issues raised and the opportunities identified carefully. • Be sure to follow-up on any tasks that are allocated to you. Score Card: Community-level skills and 10/10 Community Entry Strategies for HIV/AIDS Interventions tools Instructions Review the actions in the score card, where the sections are indicative of a minimal (1 red ribbon), good (3 red ribbons) and “blue-chip” (5 red ribbons) response. Assess your organisation’s level of competence in each. Then decide on future actions to improve your organisation’s rating. Score Card Description Rating Future Actions • Official with community credibility  appointed as lead person for the Minimal Response company’s external HIV/AIDS response Outreach or External Response  • Wide range of community-level Good Response techniques employed in engaging with local communities • External HIV/AIDS response focuses on risk areas identified during risk mapping exercise • Community “gatekeepers” endorse the  company’s external HIV/AIDS response Blue-chip Response • Community consultation takes place at planning, implementation and monitoring stages of the company’s external HIV/AIDS response Page 184 Costs Time may be the most significant investment when gaining access to communities. Otherwise, there may be some small expenses associated with the processes themselves. Section One Section Two Section Three Section Four Section Five Case Study: Advocacy checklist and report Appendices CASE STUDY The Bambisanani Project operates in the Eastern Cape Province, in South Africa, in the area previously known as the Transkei. The project provides a range of services to community members, including home-based care. Many of the clients are ex-miners who have been repatriated back to their rural homes with terminal illnesses, Acknowledgements primarily HIV/AIDS. The following checklist was developed for use in the community mobilisation phase of the project. Page 185 Instructions: Complete this checklist in preparation for the meeting. Part A: What is the purpose of the meeting? For example: To give information about the project in order to lobby for support for the project Audience analysis Who is the target audience (Church leaders, local government, health staff etc)? Community Entry Strategies for HIV/AIDS Interventions Who are the influential people? Who are your allies? Who are your opponents? Advocacy design What is the key message? Outreach or External Response What information/data/research do you need to get across your key message? How will you deliver the message? Have you practiced your presentation? Yes Đ No Đ What action do you want the audience to take? Have you briefed your allies? Yes Đ No Đ Getting ready What resources are needed for the meeting? • Handouts • Presentation aids What arrangements need to be checked? • Invitations and responses • Venue (electricity, lighting, seating) • Catering (where, what, when) • Speakers (who, what, when) Page 186 Instructions: Complete this report following the meeting. Part B: Submitted by:……………………...........….. Date……………………...........….. Meeting details Date Section One Time Place What were the key responses? 1. 2. 3. Section Two What was the main outcome of the meeting? Section Three Who made contact at the meeting? Name: Contact details: 1. 2. 3. Section Four What follow-up action is required? *1. By whom? *2. *3. Section Five How successful was the meeting? What can be done to improve the next meeting? Very Đ Moderately Đ Unsuccessful Đ Appendices Action *1: Taken Đ Pending Đ Not taken Đ Comments: Acknowledgements Action *2: Taken Đ Pending Đ Not taken Đ Comments: Action *3: Taken Đ Pending Đ Not taken Đ Comments: Page 187 Additional Information The International HIV/AIDS Alliance has multiple publications that have been developed to assist with HIV/AIDS work at community level. These are listed on their website, at www.aidsalliance.org. Community Entry Strategies for HIV/AIDS Interventions Outreach or External Response Footnotes 1 With acknowledgements to the Ministry of Local Government (Botswana) Page 188 Section Four Community Outreach Projects Section One Section Two INFO Briefing Note Section Three What is the mining sector’s role in terms of broader, community- based responses to HIV/AIDS? The mining sector, as a significant sector in most Southern African countries, can assume many important roles within the broader community-based response to HIV/AIDS. These include: • Leadership; Section Four • Governance; • Policy and strategy development; • Support – financial, material, human or in-kind; • Responding to requests for specific needs (eg by NGOs); and • Building relationships and partnering with others to make a difference. Section Five Promoting technical education Why is it important for organisations in the mining sector to be involved in outreach or external responses to HIV/AIDS? Companies in the mining sector can act as catalysts for local economic development, which is often associated with addressing the factors that fuel the HIV/AIDS epidemic. Appendices There are HIV/AIDS-related opportunities associated with each stage of a mining project’s life cycle. These opportunities range from employment, human resources, small businesses and infrastructure development to service delivery, the generation of revenue and post-closure local economic development. Acknowledgements Involvement in external outreach activities can be justified in many ways: • It is a way to safeguard direct commercial interests, by protecting employees and their families; • It can contribute to the protection of other stakeholders, by educating customers, contractors and suppliers; • It is an opportunity to influence community-based programmes to deal with the HIV/AIDS epidemic in an holistic manner; • It can represent a platform for proactively securing future skills pools and markets; Page 189 • It is an opportunity to strengthen and scale up small initiatives, to benefit more individuals, families and communities, some of whom may be employees and their families; • It is an opportunity to reduce duplication, improve efficiency and leverage resources; • It is an investment in the future and can create a positive image of the company; and • Companies have a responsibility to society. Contractors, like bigger companies, can benefit community projects by sharing their expertise and resources with these projects. At the same time, involvement in these projects can support and strengthen the contractor’s HIV/AIDS response. For example, supporting a home-based care project can ensure that employees (and their families) have access to quality community-based care when or if this is required. Harnessing business expertise1 Community Outreach Projects The Global Business Coalition on HIV/AIDS identified the following corporate expertise that can benefit broader external HIV/AIDS interventions. Corporate expertise Benefit to HIV/AIDS response Communications and marketing Behaviour change programmes, particularly those targeting specific groups, like young people Outreach or External Response Logistics expertise and Ensuring materials, condoms and distribution capacity treatments are distributed promptly, and securely, on a sustainable basis, particularly to hard-to-reach areas, such as rural communities Strategic and long-term Identifying medium to long-term planning priorities in setting macro HIV/AIDS strategic plans Business administration More effective, less bureaucratic management of HIV/AIDS services Rapid monitoring and Ensuring programmes can respond evaluation quickly to changing environments and situations, and failing approaches can be adapted swiftly Employee training and Maintaining performance of both paid development staff and volunteers Application and use of Improved networking and access to information technology important HIV/AIDS-related information Page 190 What are the elements of successful outreach projects? Successful outreach projects require the consideration of a multitude of issues, amongst which are the following: 1. Understand the context – the geography, the population profile, the leadership dynamics and the prevailing socio-economic conditions. Local people will have lots of information, but not always all the information required. Section One 2. Look at and learn from existing models, but be prepared to change to model to fit the circumstances. 3. The project may be introducing a new idea – such as home-based care. Take time to explain this and to lobby support from Chiefs and other community leaders, health and social services, local government, and other significant role players and potential partners. Section Two 4. Always budget for some base-line research, to fill any gaps in the information that is available. But, never assume the right to research a community and be sure to feed back the results. 5. Decide in consultation on the goal or aim of the project, the guiding principles Section Three and focus, the beneficiaries, the expected outcomes, and the indicators. Review all the above from time to time. 6. Identify the means to collect data to monitor progress and measure impact, and institutionalise these processes. Be sure to build in ways to “hear the voices” of service providers and clients, and to respond. Section Four 7. And finally, be prepared to move at the pace set by the community, to do otherwise could spell early failure. Communities are concerned about HIV/AIDS, but they have multiple other priorities and needs as well, and they have their own, well-developed processes for doing things. 8. Recognise that sustainability will always be an issue that will require time and effort. Section Five Appendices Acknowledgements Red Flags and Special Challenges The following questions should be asked to check the relevance of outreach activities: • Does the project build on community consultation, ideas and existing action? • Does the project strengthen the coping capacity of individual’s families and communities? • Does the project include an economic intervention to help affected families? • Is there an active approach to destigmatising HIV/AIDS? • Does the project contribute to information exchange and build partnerships with others in the sector, with NGOs and with government? Page 191 Example of the parameters of a home-based care project For patients/clients: • Reduced suffering and improved quality of life • Appropriate treatment, care and support • Enhanced end-of-life care For families: • Improved capacity to cope and to care • Practical support • Bereavement support For care givers: • The capacity, resources and support to deliver quality care • Access to colleagues and community networks of support Community Outreach Projects For communities: • Improved capacity to cope • An enhanced environment for care and reduced stigma • Skills development and job creation For women: • Skills development • Networking and support Outreach or External Response For children/youth: • Early identification of children in need • Enhanced HIV prevention • Access to holistic care and support • Access to IGAs For PLWHAs: • Skills development • Access to networks of support For health services: • Reduced pressure on services • Effective referrals between different levels and different service providers • Cost savings For welfare services: • Improved utilisation of social services • Better access to grants • Enhanced ability to place orphaned children in alternative care For the country: • Lessons learned • Replicable models Page 192 Tool: Model for moving to meaningful involvement in outreach activities Instructions Identify where your organisation fits in the following model and the areas where its Section One involvement can be strengthened towards an optimal outreach response. Model for moving towards an optimal outreach response Section Two Government agenda Mining sector agenda Civil society agenda relating to HIV/AIDS relating to HIV/AIDS relating to HIV/AIDS Mainstreaming Management support, Active involvement in Section Three Financial support HIV/AIDS across CSI staff time and community HIV/AIDS Gifts in kind programmes secondments projects Section Four Philanthrophy Phil th h Corporate Citizenship Optimal O i lO h Outreach Response Score Card: Community outreach 10/10 Section Five Instructions Review the actions in the score card, where the sections are indicative of a minimal (1 red ribbon), good (3 red ribbons) and “blue-chip” (5 red ribbons) response. Assess your organisation’s level of competence in each. Then decide on future actions to Appendices improve your organisation’s rating. Score Card Description Rating Future Actions • Peer educators attend community  Acknowledgements Minimal Response HIV/AIDS events • HIV/AIDS stand at company open day, to which employees’ families are invited  • Company pays a local NGO a nominal Good Response amount per incapacitated employee who receives home-based care services • Company initiates, co-funds and actively  participates in a comprehensive Blue-chip Response HIV/AIDS prevention project in the community Page 193 Costs Costs could be financial, material, human resource or in-kind, or a combination of these; and, whilst the benefits to the company may be difficult to quantify, efforts to do so should be made. Case Study: The Powerbelt initiative CASE STUDY In the Mpumalanga Province of South Africa, Anglo Coal, Ingwe Coal and Duiker Coal, as the major coal mining companies, joined together with Harmony Gold Mine and Ferro Metals, Sasol, local government and the unions represented by COSATU, to address the HIV/AIDS epidemic in the area. The Council for Scientific and Industrial Research (CSIR) manages the project, with each mining company committed to R 150 000 (approximately $ 20 270) per annum seed capital. The Powerbel model has the following components: Community Outreach Projects • The introduction of a comprehensive primary health care programme for treating STIs, ensuring that everyone in the area has equal access to treatment, and reducing the time between infection and treatment; • Home-based care programmes for PLWHAs who are ill, and for those who are dying; • Condom distribution programmes through formal channels, as well as through peer educators and commercial sex workers; • Behaviour change education targeted at high risk groups in the community; Outreach or External Response and • Socio-economic upliftment projects aimed at improving the basic living standards of local communities. Case Study: Home-based care for CASE STUDY ex-mineworkers In April 2002, a groundbreaking initiative to provide home based care for mineworkers who are repatriated with chronic or terminal medical conditions was launched. Using the services of long-term partner, TEBA, and working with local structures and NGOs, this has become an important part of the mining industry’s response to the HIV/AIDS epidemic. The Home-based Care Programme, as it has been is named, was conceived to address a number of stark realities facing the industry. The first reality is that many mineworkers have already died as a result of AIDS and many more have advanced HIV disease. Whether the prevalence is 20% or 40% – and both figures have been released by different mining companies at different times – is less important than the challenge that this presents to an industry that relies on the fitness and strength of its workforce. Page 194 The second reality is that the majority of mineworkers have their homes in rural areas – Lesotho, Swaziland, Mozambique, northern KwaZulu-Natal and the Eastern Cape. These are the areas to which they return when they are no longer able to work (due to ill health) and these areas are amongst the poorest and least resourced in the sub-continent. And the third reality is that home-based care is an acceptable and, indeed a preferred Section One option for people with terminal conditions. Until the launch of this initiative, wellness programmes for infected mineworkers included the prevention and treatment of opportunistic infections but lacked the next step, namely rehabilitation at medical incapacity and separation. With more Section Two and more employees retired due to ill health, and returning to their rural homes, usually in areas with no NGO home-based care services, and often with not even the most basic resources from local hospitals and clinics. The burden on families was immense – and when the ex-mineworker died, the finalisation of benefits often presented yet a further obstacle for the bereaved family. Section Three There were only two options for the mines, either to keep terminal mineworkers in mine hospitals – to eventually die there without their families, or to create a system that would encourage them to retire before the onset of terminal illness, to return home when they could still enjoy some quality of life and, when they do become terminal, to receive good quality care in their homes. Section Four The choice was clear – from every perspective - moral, financial and pragmatic. Discussions begun in earnest; and a model was agreed that was based on a community- based project in the Eastern Cape called Bambisanani. The Home-based Care Programme is implemented by TEBA DEVELOPMENT, the Section Five mining industry’s development organisation. TEBA has offices in all the rural areas of Southern Africa. In phase one of the programme, TEBA appointed fieldworkers at each of its rural offices. These 40 fieldworkers are the frontline workers of a family support programme that includes home-based care, counselling and welfare support. Appendices The fieldworkers establish exactly where all existing families of ill ex-mineworkers are, in the process creating a valuable database. Then, as new mineworkers are repatriated, the fieldworker visits the family, conducts an assessment and links the family with the Home-based Care Programme. Building on TEBA’s experience in rural areas, firm links have been established with Acknowledgements communities, government and other service organisations to ensure appropriate referrals, when necessary, and access to services. In time it is hoped to spread the service beyond mineworker families, forming partnerships with other service providers to provide care to all in need in the community. Mining companies receive regular reports on the progress of ill ex-mineworkers through quarterly reports. Ex-mineworkers and their families are assisted to access grants and other support that is available through public channels. Page 195 The cost of the programme is borne by the mining industry, through a per capita charge levied on employed miners from the areas where the programme operates. The programme will be a learning experience for TEBA and for the mining industry. It is expected that many valuable lessons will emerge from the programme, not least how to form partnerships between business, communities and the government. Additional Information Many examples of mining sector community outreach projects can be found in the MMSD report, available on www.iied.org/mmsd/rrep/s_afr.html. Community Outreach Projects Outreach or External Response Footnotes 1 From Plumley B, Bery P and Dadd C; Beyond the workplace: business participation in the multisectoral response to HIV/AIDS Page 196 Section Five Measuring and Monitoring an HIV/AIDS Response Section Five contains the final component of an organisational HIV/AIDS response, namely monitoring and evaluating, and recording and reporting on the response. Our opportunity is historic. For when the history of AIDS and the global response is written, our most precious contribution may well be that at a time of plague we did not flee, we did not hide, we did not separate ourselves. Jonathan Mann Page 197 Section Five Monitoring, Evaluating, and Recording Monitoring, Evaluating, and Recording and Reporting an Organisation’s and Reporting an Organisation’s HIV/AIDS Response HIV/AIDS Response INFO Briefing Note What is implied by monitoring, evaluating, and recording and reporting on an organisation’s HIV/AIDS response? Measuring and Monitoring an HIV/AIDS Response Monitoring is the routine, daily assessment of on-going activities and progress. Evaluation is the episodic assessment of overall achievements (which may be conducted internally or externally). Monitoring looks at what is being done, whereas evaluation examines what has been achieved or what impact has been made. An effective monitoring and evaluation strategy is nothing more or less than an open and critically reflective communication process that will serve to improve practice and strengthen partnerships. Recording and reporting is the formal documentation of processes and events, and the release of information, which may be a statutory requirement, a requirement in order to meet certain set specifications, or an internal requirement (for shareholders or management). Monitoring, evaluation, and recording and reporting are functions that all organisations are familiar with, and, as far as is practical, HIV/AIDS-related M&E, and recording and reporting should be integrated into these functions. This applies equally to large organisations and contractors, though the ways in which this will be done may vary. Page 198 Why should an organisation monitor, evaluate, and record and report on its HIV/AIDS response? It is important to monitor and evaluate a project or programme in order to: • See what has been achieved; • Collect evidence of activities and results; • Measure progress and programme effectiveness in reaching predefined objectives and targets; Section One • Improve monitoring and management; • Identify strengths and weaknesses; • Judge whether the cost was reasonable for what was achieved; • Collect information to help run activities better; and • Avoid repeating mistakes by sharing experiences. Section Two It is important to record and report on a project or programme in order to: • Document successes and failures; • Develop a body of knowledge and of good practices; and • Meet internal and external reporting requirements. Section Three What are the components of an M&E strategy? The following are important components of any M&E strategy: 1. Defining responsibilities The responsibilities for M&E include: Section Four • Planning and developing systems for M&E; • Collecting and generating data from different sources; • Verifying data; • Analysing and interpreting data; and • Reporting and dissemination. Section Five 2. Identifying indicators Indicators are the cornerstone of M&E. An indicator is a measure of the progress made towards an objective. It can be quantitative or qualitative. It can be a process, outcome or impact indicator. It can also be a project target. Appendices Indicators should be: • Simple, clear and understandable as a measure of project effectiveness; • Reliable – conclusions based on any indicator should be the same, regardless of who, when and under what circumstances the assessment is conducted; • Replicable, allowing for comparative analysis and potential replication of the project; and Acknowledgements • Available – using data that is available. In workplace HIV/AIDS policies and programmes, consistent indicators are desirable to enable comparisons to be made and in order that trends can be identified. So-called “core” indicators are those that are globally defined, such as: • The percentage of respondents who report at least one non-regular sex partner in the last 12 months; and • The percentage who say that they used a condom the last time they had sex with a non-regular partner. Page 199 If used across countries and across sectors, these allow for comparisons to be made. However, if core indicators are combined with local indicators, it is more possible to get a complete picture. The following table describes different types of indicators, and the different stages in a project’s life that they can be used. Types of indicators Monitoring, Evaluating, and Recording and Reporting an Organisation’s Project stage Indicator type Sexual and reproductive health examples Pre-intervention • Existing attitudes and self-reported Participatory exploratory research Base-line behaviours Existing data review • Existing service utilisation data • STI/HIV prevalence Training, participation Process • # of people trained Information distribution • #of materials distributed Service provision • # of condoms distributed HIV/AIDS Response Short-term, post activity Intermediate • Changes in knowledge and attitudes • Changes in social/peer norms Medium-term, post activity Outcome • Self-reported adoption of positive behaviours • Increased service utilisation Measuring and Monitoring an HIV/AIDS Response Long-term, sustained Long-term • Maintenance of positive self-reported outcomes and behaviours impacts • Reduced HIV/STI incidence • Changes to social/peer norms The NOSA HIV/AIDS management system1 lists multiple indicators related to: • Commitment and HIV/AIDS management policy; • Planning of HIV/AIDS management system; • Implementation, operational controls and management of HIV/AIDS management system; • HIV/AIDS management system evaluation, corrective and preventive action; and • HIV/AIDS management review. 3. Developing an M&E framework A commonly used M&E framework consists of a pathway of results, beginning with inputs, and progressing to outputs, outcomes and impacts. Page 200 M&E framework Outputs Outcomes Impacts Inputs (quality, access, (short and intermediate (long-term, major, coverage, costs) effects) measurable effects) Section One • Resources • Condom availability • Behaviour change • HIV trends • Staff • Trained staff • Attitude change • AIDS-related mortality • Funds • Quality of services • Change in STI trends • Social norms • Facilities • Knowledge of HIV • Increase in social • Coping capacity in • Equipment transmission support communities • Supplies • Economic impact Section Two • Training Many companies use tailor-made roadmaps as a means to monitor and report on their HIV/AIDS responses. Section Three 4. Using and disseminating data Once data has been collected, analysed and interpreted, it should be properly disseminated and used. The results of M&E activities should be communicated to all relevant stakeholders. Results should also be shared with those who collect the data, so that they may provide feedback on the results. Section Four Dissemination can be done in many ways, such as through annual reports, at annual planning and evaluation meetings and in scientific publications. What are the important features of recording and reporting? In South Africa, the 2002 King Report on corporate governance for South Africa Section Five sought to ensure that the standards of governance in South Africa were current and competitive with international norms and best practice. In relation to HIV/AIDS, King 2, as it is known, the recommendation on HIV/AIDS is that the board of directors of an organisation should: • Ensure that it understands the social and economic impact of HIV/AIDS on Appendices business activities; • Adopt an appropriate strategy, plans and policies to address and manage the potential impact of the pandemic on business activities; • Regularly monitor and measure performance using established indicators; and • Report on all of these aspects to stakeholders on a regular basis. Acknowledgements The Johannesburg Securities Exchange (JSE) of South Africa is also promoting a more formalised approach towards reporting on HIV/AIDS. The JSE announced in 2002 that it was investigating the introduction of a listing requirement for all companies on the exchange to report on HIV/AIDS. The Global Reporting Initiative (GRI) is a multi-stakeholder process and independent institution whose mission is to develop and disseminate globally applicable sustainability reporting guidelines. The guidelines are for voluntary use by organisations for reporting on the economic, environmental, and social dimensions of their activities, products, and services. Page 201 The GRI has recently developed guidelines for voluntary disclosure of HIV prevalence within, and impact on, companies2. The GRI proposes using a comprehensive set of indicators for reporting on an organisational HIV/AIDS response, in the following categories: • Good governance: policy formulation, strategic planning, effective risk management, stakeholder involvement; • Measurement, monitoring and evaluation: prevalence and incidence of HIV/AIDS, actual and estimated costs and losses; Monitoring, Evaluating, and Recording and Reporting an Organisation’s • Workplace conditions and HIV/AIDS management; and • Depth/quality/sustainability of HIV/AIDS programmes. There are indicators that can be used by companies with well-established HIV/AIDS programmes and for those companies (small or low-capacity organisations) reporting for the first time. Basic-level GRI indicators for small or low capacity organisations Indicator Response 1. Does the organisation have an HIV/AIDS policy? Yes/No HIV/AIDS Response (please attach copy) 2. Is there a strategic plan to manage the current and future Yes/No impact of HIV/AIDS on the organisation? 3. Has the organisation involved stakeholders in the planning and Yes/No implementation of the response to HIV/AIDS? Measuring and Monitoring an HIV/AIDS Response 4. Has the organisation arrived at an HIV/AIDS prevalence Yes/No rate for the workforce? 5. What is the organisation’s estimated HIV/AIDS costs/losses for the current year in terms of: 5.1 The cost of programmes in questions 6-9 below? R……….. 5.2 Other costs/losses arising from HIV/AIDS? R……….. 6. Does the organisation have HIV/AIDS awareness/education/ Yes/No training programmes for its workforce? 7. Does the organisation have a VCT programme for its Yes/No workforce? 8. Does the organisation have HIV/AIDS prevention interventions such as behaviour change interventions, STI treatment assistance, and a distribution programme for: 8.1 Behaviour change programme Yes/No 8.2 STI treatment assistance Yes/No 8.3 Condoms Yes/No 8.4 Femidoms Yes/No 9. Does the organisation have programmes to assist workforce Yes/No members who are AIDS sick? 10. Does the organisation provide antiretrovirals to HIV positive Yes/No employees, or those who are AIDS sick? Page 202 GRI’s reporting principles (contained in Part B of their Guidelines) are an essential platform for all GRI reporting, including that on HIV/AIDS. The principles, in brief, are as follows: • Completeness. All information that is relevant to users for assessing the organisation’s performance should be as complete as possible. • Inclusivity. The reporting organisation should systematically engage its stakeholders to help focus and continually enhance the quality of reports. Section One • Consistency. The organisation should maintain consistency in the boundary, scope and content of reporting. • Accuracy. A high degree of exactness and a low margin of error in reported information will enable users to make decisions with a high degree of confidence. Section Two • Clarity. The reporting organisation should make information available in a way that is responsive to the maximum number of users while still maintaining a suitable level of detail. • Neutrality. Reports should avoid bias in the selection and presentation of information, and should strive to provide a balanced account of the organisation’s performance. Section Three • Timeliness. Reports should provide information on a regular basis which meets user needs. • Auditability. The reported data should be provided in a way that will enable internal auditors or external assurance providers to attest to its reliability. • Transparency. Full disclosure of the processes, procedures and assumptions in Section Four the report preparation are essential for its credibility. • Sustainability context. The reporting organisation should strive to place its performance in a broader context, where such context will add significant meaning to the reported information. Section Five Red Flags and Special Challenges Most programmes/projects collect far more data than they can use. M&E systems Appendices must be as simple as possible. The more complex an M&E system, the more likely it is to fail. M&E must be built into the design of a programme. The process of establishing and implementing M&E systems can itself improve programme Acknowledgements performance and enhance sustainability. Combining financial and programme monitoring provides a basis for sound finance/programme cross-verification. No matter how sound an M&E system may be, it will fail without widespread stakeholder “buy-in”. Effective training and support for those collecting M&E data is vital for the success of M&E systems. Page 203 Tool: Template for an M&E plan Instructions Use the following template as a basis for your M&E plan3. Template for an M&E plan Monitoring, Evaluating, and Recording and Reporting an Organisation’s Indicator Agreed target Progress towards Rating of target progress Impact level • • Outcome level • • Output level • • HIV/AIDS Response Input level • • Measuring and Monitoring an HIV/AIDS Response Tool: Template for recording and reporting Instructions The NOSA HIV/AIDS Management System (AMS) provides a template for reporting on an organisational HIV/AIDS response. This can be adapted and used to reflect your organisation’s HIV/AIDS priorities. Template for reporting on HIV/AIDS Effectiveness criteria Community Employee Post-exposure Screening Number Behavioural outreach and family prophylaxis and testing of ribbons change programme assistance treatment programme programme 5 Ribbons 100% in place 100% in place 100% in place 100% in place 100% in place (Excellent) 4 Ribbons 75% in place 75% in place 75% in place 75% in place 75% in place 3 Ribbons 50% in place 50% in place 50% in place 50% in place 50% in place 2 Ribbons 25% in place 25% in place 25% in place 25% in place 25% in place 1 Ribbon Informal Informal Informal Informal Informal Page 204 NOSA certification is based on a scoring system in which points are allocated for: • Risk assessment (10%); • Systems (20%); • Compliance (30%); and • Effectiveness (40%). Score card for M&E, and recording and Section One 10/10 reporting Instructions Review the actions in the score card, where the sections are indicative of a minimal Section Two (1 red ribbon), good (3 red ribbons) and “blue-chip” (5 red ribbons) response. Assess your organisation’s level of competence in each. Then decide on future actions to improve your organisation’s rating. Section Three Score Card Description Rating Future Actions  • Company monitors the workplace Minimal Response HIV/AIDS programme • Company reports on its HIV/AIDS in the health section of its annual Section Four report • Company monitors all aspects of its  HIV/AIDS response Good Response • Company integrates HIV/AIDS reporting into all internal and Section Five external reporting requirements • External evaluation of company’s  HIV/AIDS response commissioned Blue-chip Response • Results shared at a broad stakeholder Appendices consultation • Company policy supports full disclosure of all HIV/AIDS-related data and impact Acknowledgements Costs The cost of M&E relate to designing and then operating the M&E system. Different sources quote allocations for M&E from 2-3% to 5-6% of a total programme or project budget. Economic evaluations of HIV/AIDS interventions can provide important information. Horizons provides the following framework for understanding different forms of economic evaluation. Page 205 Different forms of economic evaluation Type of analysis Considers … Useful for … Budgeting or planning for Cost analysis Inputs only continuation or scaling up of a programme or services Assessing costs of providing Monitoring, Evaluating, and Recording and Reporting an Organisation’s Cost estimation – per service, Inputs and outputs outputs such as services, or or person served for comparing revenues to costs Inputs, outputs Setting budget or resource Cost effectiveness and outcomes allocation priorities, when options are available The AIDS Impact Model for Business, developed by the Futures Group4, can be used to conduct cost-benefit analyses. HIV/AIDS Response Recording and reporting costs will include: • The costs of documenting the HIV/AIDS response; • Layout, printing and dissemination costs; and • The costs of feedback processes (whatever form these may take). Measuring and Monitoring an HIV/AIDS Response Page 206 The Construction Industry Development Board has developed a specification for reporting on HIV/AIDS-related activities5. • The contractor shall prepare and attach to his claims for payment a brief report which outlines how the actions taken by the contractor in the period for which payment is claimed satisfy the requirements and a schedule which lists the names, identity numbers, trade/occupation and name of employer of all construction workers exposed to the Section One programme (see annex C). • The employer’s representative shall certify the report and schedule described in 5.3.1 whenever a claim for payment is issued to the employer. Note: In the event that the contractor fails to satisfy the requirements of this specification, the employer may apply any of the sanctions provided for in the contract. Sanctions may include Section Two the rejection of claims for payment as being incomplete or the withholding of completion certificates (interim or final). Annex: C Compliance report Section Three Contract number: .......................................................................................... Payment claim number: ................................................................................. Period covered by payment claim: ................................................................. • Distribution of condoms (briefly describe where and how condoms are distributed) Section Four • Posters / pamphlets (briefly describe where posters were placed/how pamphlets were distributed) • Voluntary HIV/STI testing (briefly describe the actions taken/information provided to promote testing) Section Five • Counselling, support and care (summarise information provided) • HIV awareness programme (briefly describe action) • Schedule of construction workers exposed to the HIV awareness programme Appendices Name: ............................................................................................................ Identity number: ............................................................................................ Trade/occupation: .......................................................................................... Name of employer: ....................................................................................... Acknowledgements I hereby declare the above to be a true reflection of actions taken to ensure compliance with the specification For the contractor: Employer’s representative: Name: ............................................. Name: ............................................. Signature: ........................................ Signature: ........................................ Date: ............................................... Date: ............................................... Page 207 Case Study: Recording and reporting on an CASE STUDY organisational HIV/AIDS response Assmang Ltd. has a number of mining operations (iron ore and manganese) in the Northern Cape Province in South Africa. They have 450 employees and more than 450 contractors at their Beeshoek mine and 1 200 employees and around 400 contractors at their Black Rock mine. Monitoring, Evaluating, and Recording and Reporting an Organisation’s Since 1999, they have kept records of all HIV/AIDS-related activities. The following is an extract from the AIDS Sequence Report for Beeshoek, which is presented regularly to management. May 2003 E pap to all night shift workers, and installation of sleeping facility to night shift workers, as part of the wellness programme 12 June 2003 Installation of anonymous AIDS help line HIV/AIDS Response – 053 311 6446 at Assmang, for Assmang and communities July 2003 Beeshoek domestic workers and gardeners workshops Measuring and Monitoring an HIV/AIDS Response From Weekly AIDS awareness workshops for: mid-July 2003 • Cerecast company • Booysen Bore • Leave returnees, as part of induction 9 July 2003 Postmasburg feeding project to community AIDS patients Meeting with the Steering Committee 23 & 24 EAP/Wellness course by Careways (Johannesburg) July 2003 8 August 2003 AIDS audit feedback from Head Office, at Black Rock Mine Northern Section of Assmang places second in AVMIN Group Consultation with auditors and HO presidents 9 August 2003 AIDS audit feedback from Head Office, at Beeshoek Mine Beeshoek placed first in a group of 12 mines on AIDS interventions at the mine and in the community Company and community stakeholders attended the feedback Meeting also held with AIDS Committee, peer educators and unions Presentation done to stakeholders and directors, from the AVMIN Mine Group Page 208 12 August 2003 Rape and AIDS counselling meeting held at trauma centre (SAPD, Postmasburg) SAPD commitment emphasised 12 August 2003 AIDS feedback session held at AVMIN HO (Johannesburg) Gap analysis done on all HIV/AIDS interventions Section One Morning session Brainstorming done with different mines Afternoon Presentation to delegates on healthy living session Workshop on compiling new score card for AIDS audit for AVMIN Mines 14 August 2003 Planning strategy to address gaps in the 2003 AIDS Section Two audit 25 August 2003 Finalised the HIV/AIDS campaign programme in Kuruman, for 1-5 September 2003 26 August 2003 Visit to person who has revealed his HIV status at Section Three home, but not publicly 10 September Training needs analysis questionnaire to all 2003 HIV/AIDS peer educators (mine and contractors) Section Four Section Five Appendices Acknowledgements Page 209 Additional Information HIV/AIDS-related M&E information and guidelines are available from a number of sources: • UNAIDS, at www.unaids.org; • WHO, at www.who.int; • MEASURE, at www.cpc.unc.edu/measure; Monitoring, Evaluating, and Recording and Reporting an Organisation’s • FHI, at www.fhi.org; • CDC, at www.cdc.gov; and • USAID, at www.usaid.gov. Family Health International (FHI); Evaluating programs for HIV/AIDS prevention and care in developing countries: a handbook for program managers and decision makers (2002), available on www.fhi.org/en/aids/ impact/impactpdfs/evaluationhandbook.pdf UNAIDS/MEASURE; National AIDS Programmes: a guide to monitoring and evaluation (2000), available on www.cpc.unc.edu/measure/guide/ guide.html HIV/AIDS Response The GRI HIV/AIDS Resource Document offers a practical reporting framework for: • Organisations that want to report on their performance – including policies and practices – with respect to HIV/AIDS; and • Stakeholders that require a reputable reporting benchmark to measure Measuring and Monitoring an HIV/AIDS Response or compare organisations’ HIV/AIDS performance. The HIV/AIDS Resource Document can be found on www.globalreporting.org/ guidelines/HIV/hivaids.asp. Although this document was developed in South Africa, GRI believes its content will be useful in any country affected by HIV/AIDS. Phase II of the project will see pilot testing of this resource in India, China and Brazil. Footnotes 1 Available on www.nosa.co.za 2 As an expansion of the Core Social Performance Indicator (Labour practices and decent work), number LA8 (Description of policies or programmes for the workplace and beyond on HIV/AIDS) 3 Adapted from UNAIDS and World Bank; Monitoring and evaluation operations manual for National AIDS Councils (2002), available on www.unaids.org 4 See www.futuresgroup.com/aim 5 See www.cidb.org.za Page 210 Appendices Appendices Appendix One: Comparative country data Appendix Two: Fact sheet on the mining sector in Southern Africa Appendix Three: IFC corporate roadmap on HIV/AIDS Appendix Four: Resources, references and contacts Appendix Five: Glossary Page 211 Appendices Appendix One: Comparative Country Data1 Basic demographic data Area Population Country (Km²) Population growth Political system Comparative Country Data Angola 1 246 700 10 366 031 2.15% Unitary Republic Botswana 582 000 1 700 000 0.47% Parliamentary Republic DRC 2 345 410 53 000 000 ? Transitional government Appendix One Lesotho 30 355 2 177 062 1.49% Constitutional Monarchy with an elected Parliament Malawi 118 484 10 180 000 2% Constitutional Republic with Unicameral Parliament Mozambique 801 590 17 200 000 1.3% Unitary State Namibia 825 418 1 800 000 1.38% Multiparty democracy South Africa 1 225 815 44 600 000 0.26% Parliamentary democracy with President as Head of State Swaziland 17 363 980 000 1.83% Monarchy; the bi-cameral Libandla (Parliament) is an advisory body Tanzania 945 087 36 232 074 2.61% Republic with elected President and National Assembly Zambia 752 614 10 290 000 2% Constitutional Republic with Unicameral Parliament Zimbabwe 390 580 11 365 366 0.15% Parliamentary democracy Page 212 Key economic data Country GDP Inflation Foreign debt Unemployment rate Angola $ 10.1 billion 325% $ 10.8 billion +50% Section One Botswana $ 2.37 billion 8.6% $ 698 million 40% DRC $ 5.8 billion 358% ? ? Lesotho $ 899 million 6.1% $ 700 million ? Section Two Malawi $ 1.8 billion 29.5% $ 2.6 billion ? Mozambique $ 3.8 billion 11.4% $ 1.4 billion ? Section Three Namibia $ 5.5 billion 9.1% $ 180 million 30% to 40% South Africa $ 125.9 billion 5.7% $ 24.8 billion 40%2 Swaziland $ 1.28 billion 7.3% $ 258.4 million ? Section Four Tanzania $ 7.7 billion 5.9% $ 7.5 billion ? Zambia $ 3.5 billion 18.7% $ 6.5 billion 10.3% Zimbabwe $ 28.2 billion 60% $ 4.1 billion ? Section Five Appendices Acknowledgements Page 213 Development data Infant Life expectancy Literacy Human development mortality (years) index Country (per 1 000 (out of 162 countries) live births) Male Female Angola 193.72 37.36 39.87 42% 146 Botswana 63.2 37.13 70% 114 DRC ? 47.2 51.1 M: 86.6% 155 (of 173 countries) F: 67.7% Lesotho 82.77 47.97 49.74 M: 72% 120 F: 93% Malawi 121.12 36.61 37.55 58% 151 Comparative Country Data Mozambique 139.2 37.25 35.62 42.3% 157 Namibia 71.66 42.48 38.71 38% 111 Appendix One South Africa 60.33 47.64 48.56 81.8% 94 Swaziland 109.19 37.86 39.4 M: 78% 113 F: 75.6% Tanzania 79.41 51.04 52.95 M: 79.4% 140 F: 56.8% Zambia 90.89 36 37 M: 78% 143 F: 69% Zimbabwe 62.61 38.51 35.7 M: 90% 117 F: 80% Footnotes 1 Data from Canadian Department of Foreign Affairs and International Trade – see: http://www.dfait- maeci.gc.ca/africa 2 Source: media reports from the Growth and Development Summit (June 2003) Page 214 Appendices Appendix Two: Fact Sheet on the Section One Mining Sector in Southern Africa Section Two Section Three Mining is defined as the extraction, dressing and treatment of naturally occurring minerals which are solids such as coal and ores, liquids such as crude petroleum and natural gases. The mining sector covers underground and surface mines, quarries and oil and Section Four gas wells as well as all supplemental activities such as crushing, screening, washing, cleaning, grading, milling, flotation, melting, pelleting, topping and any other activities required to render the minerals marketable. Included in the concept of a mining community are all stakeholders and organisations Section Five that interface with a mining operation. This would include those providing goods or services to mining companies, such as engineering supplies, safety equipment, medical supplies, geological studies, construction, transport, environmental management and impact mitigation services, research and development, recruitment, security, canteen and laundry etc. In addition, stakeholders and partners, like government ministries, Appendices local government, NGOs, and training and research institutions are also members of a mining community. Mining is a vital component of the national economies of numerous countries, particularly as a major foreign exchange earner. In classic development economies, it is the surplus generated from mining and agriculture and the related processes Acknowledgements which stimulates economic growth and leads to the emergence of a modernised economy. Although led by the large companies, it is estimated that, in a number of Southern African countries, small scale mining contributes as much as 5% to the GDP , and in Zimbabwe and Tanzania, for example, small scale miners contribute up to 25% of the total gold production. Page 215 Estimates of the mining and minerals sector’s contribution to economies of continental SADC states in 1999 1,2 SADC Mining and minerals sector’s Member economic contribution Angola Official diamond exports of 2 132 937 carats valued at US$ 296.24 million Botswana US$ 2.0 billion diamond earnings out of a total of US$ 2.7 billion exports DRC 28% of GDP and 70% of exports Lesotho Artisanal diamond production to end-March 2000 – 1 053 carats valued at US$ 85 000; US$ 15 million is being invested in rehabilitating former De Beers operations Fact Sheet on the Mining Sector in Southern Africa Malawi <1% GDP comprising US$ 1 million 95% of which was gemstones (informal gemstone exports are thought to exceed US$ 2 million) Mozambique 1.4% of exports and <0.25% of GDP; US$ 1.34 billion Billiton Mozal aluminium smelter commissioning in 2001 with anticipated operating revenues of US$ 400 million annually Namibia Mineral exports total 49% of total exports by value, to which diamonds contributed 68% South Africa 33% of export revenue, and 6% of working population Swaziland 2% of GDP with ex-mine revenues contributing US$ 20 million to total export Appendix Two earnings of US$ 825 million Tanzania 2.1% of GDP and 14.5% of export earnings and a sectoral growth rate of 9.1%, with sectoral FDI of US$ 720 million in the three years to end-2000 Zambia Copper mining provided 85% of foreign exchange and 20% of GDP Zimbabwe 6% of GDP, 7% of the labour force and 40% of foreign exchange earnings3 Contribution of mining to GDP, selected countries (source: SADC 2001 in RTS MacFarlane) 35% 30% 25% 20% 15% 10% 5% 0 la tho * * a i ue ica ia d ia law e* an lan bia go zan mb biq Afr so tsw bw Ma An azi mi Za Tan Le zam uth ba Sw Bo Na Zim So Mo * Some authorities consider mining’s direct contribution to Namibia’s GDP to be 15% (Schneider, pers. comm., 2001) **Figures for Zimbabwe from Murangani (pers. comm., 2001). The contributions to GDP listed above exclude the significant indirect contribution arising from the activities of the sector. No data was available for the Democratic Republic of Congo. Page 216 The exploitation of mineral resources has accelerated during the past century with the discovery of new ore bodies and the development of new mining and metallurgical technologies. These mineral resources hold the promise of exceptional long-term social and economic benefits for the region. Such potential benefits are recognised as a key component of the recently launched and widely supported New Partnership for Africa’s Development (NEPAD). Section One In Southern Africa, over 60 minerals and metals are mined, including platinum, gold, diamonds, coal, asbestos, semi-precious stones, base metals, ferrous metals and industrial metals. Mining and migrancy are inextricably linked in Southern Africa, with large numbers of men migrating from their homes to work on the mines. Section Two Employment of foreign migrants in the South African mining industry4 Country of origin 1984 1989 1994 1998 Section Three Lesotho 75 787 98 085 84 700 60 450 Botswana 18 599 15 229 10 837 7 752 Swaziland 12 152 16 555 14 829 10 336 Section Four Mozambique 42 294 44 015 44 044 51 913 Mines are located where the minerals are, meaning that mining communities often Section Five exist in areas which are remote and inhospitable. The work is dangerous and occupational injuries and diseases, as well as deaths, are more common in mining than in other occupations. For example, the average gold miner has a one in forty chance of being killed and a one in three chance of suffering a reportable injury in a twenty-year mining career. Appendices Mines frequently operate as self-sufficient communities with housing, education, health care and sporting facilities provided. The health care or medical services range from first aid stations to fully equipped hospitals serving either the workers only or also the community surrounding the mine. In recent years, companies have elected to outsource many non-core functions, eg, in 2003, 50% of the workers on Acknowledgements site at Debswana mines are contractors. Most countries have legislation which seeks to limit the risk of illness and injury by regulating the responsibilities of employers. Trade unions have traditionally played a prominent role in the mining sector, particularly in the areas of occupational safety and health. Footnotes 1 Quoted in Pharoah, R and Schönteich; AIDS, security and governance in Southern Africa – exploring the impact, ISS Paper 65 (January 2003) 2 Source; MIGA: African Mining 2000 Symposium, London, Mining Journal Ltd. (2000) 3 http://www.sadcreview.com/country%20profiles%202001/zimbabwe zimMining.htm 4 Quoted in Whiteside, A and Sunter, C; AIDS, the challenge for South Africa (2000) Page 217 Appendices Appendix Three: IFC Corporate Roadmap on HIV/AIDS INTE R NATIONAL FINANCE COR POR ATION World B ank Group Awareness, Educationand Prevention IFC Corporate Roadmap on HIV/AIDS Program Item Description Status Rating HIV/AIDS Policy The “public” policy statement endorsing the company's commitment In draft 1 with respect to HIV/AIDS for internal briefing and also provision to Formally adopted 2 third parties. Communicated actively and reviewed 3 Tools for Awareness Posters, signs, ribbons, news clips on notice boards, talks, video, live 1-5 of these elements in place 1 theatre, radio, television, competitions (e.g. posters), sponsored events, 6-8 of these elements in place 2 messages in pay packets, in-house magazine articles, “Health Question Maintained and updated 3 Box”. Training Modules HIV/AIDS education is a component of the company's training, Employees module 1 (e.g., recruitmentprocess, new employees' induction programs, Plus management training module 2 health education, safety briefings, module for managers). Ongoing training exists 3 Appendix Three Targeting and High risk (long-distance drivers, migrant workers) and vulnerable Analysis to identifygroups 1 addressing high risk groups (women and youth), should be targeted for education and Programs for these groups in place 2 and vulnerable groups prevention programs. >50% trained or analysis confirmed no 3 high risk/vulnerable groups in company Workplace discussion A key step in the educational process is to engage in a dialogue Discussion leaders identified 1 forum and the opportunityfor this should be established (with union Discussion clearly scheduled 2 involvement)in all workplaces. Discussion sessions once a month 3 Peer educators Informed dialogue is essential for properly developing an Process for group formation 1 understanding of how HIV is spread and the impact it can have on Peer educators in training 2 people. Target ratio should be 1 educator : 50 employees. Ongoing peer education programs 3 People Living With The involvementof People Living with Aids is a powerful way of PLWA involved in education as visitors 1 HIV/AIDS (PLWA) strengthening the educational process, especially if they are PLWA in discussion sessions 2 involved representatives from the immediate community . PLWA as peer group educators 3 Condoms distributed Condom distribution (male and female) is an essential component Available through clinics 1 of an education and prevention program. They should be free of Through dispensers at a cost 2 charge (or a nominal cost) and readily available. Through dispensers free of charge 3 Trained HIV/AIDS Trained counselors are a pre-requisite to ensure appropriate At least one trained counselor available 1 counselors support available to those affected by HIV/AIDS and to implement All clinical staff trained 2 Voluntary HIV Counseling and Testing (VCT). Counselors should be Ongoing training for counselors 3 available in the company but visiting counselors can also supplement the company's staff. Voluntary HIV Access to safe, confidential and convenient voluntary HIV testing VCT available 1 Counseling and and counseling integrated in the company's activities (e.g. VCT available and actively advocated 2 Testing (VCT) communication efforts, medical examinations, disease prevention). VCT taken up by >50% employees and 3 The test is performed within the company's clinics or externally . extendedto the community Prevention of vertical Many children acquire HIV from their mothers before, during or Available to employees 1 transmission (mother- after birth. The company can undertake or support such a program Available to employees and their partners 2 to-child transmission) with VCT and anti-retroviral drugs for mother/child to invest in “the 80% pregnancies covered 3 next generation”. Page 218 Treatment and Care Program Item Description Status Rating HIV and Occupational The company has adopted and enforced a procedure for In draft 1 Health and Safety occupational blood or body fluids post-exposure to prevent Formally adopted 2 Section One (OH&S) accidental HIV transmission in the workplace. Implemented 3 Clinical staff training Continuing professional training on HIV/AIDS and infectious Some staff members trained 1 diseases is ensured to the clinical and laboratory staff of the All clinic’s staff attended one training 2 company. Continuing training attended yearly 3 Nutritional program Appropriate dietary supplements to support good general health Advice available on diet to support health 1 and resistance to opportunistic infections will significantly delay the Target program > affected employees 2 onset of AIDS. Free supplements available 3 Section Two Opportunistic The impact of a decline in the immune system with the onset of Treatment protocol in draft 1 infections, TB, STDs AIDS can be prevented or mitigated by prophylactic and/or Treatment available for some infections 2 medication for other infections and quick response when they occur. Treatment and prophylactics available 3 Anti-retroviral (ARV) The company considers implementing therapy with medical staff or Feasibility study 1 treatment by partnering with others possessing experiencein this treatment so Available to some employees as a pilot 2 Section Three highly-active anti-retroviral therapy (HAART) becomes part of the Available to all employees 3 medical coverage of HIV+ employees and possibly dependants. Home-based care Terminally ill patients with AIDS require specific care. This could Home-based care under development 1 include hospice or home-based care developed with thesupport of Access for >20% of terminally ill patients 2 appropriate third parties. Access for >50% of terminally ill patients 3 Monitoring and Leveraging the Program Section Four Monitoring Indicators/items are used for monitoring, incentives, accountability Evaluation method identified 1 effectiveness and and evaluation. Qualitative information includes general awareness Qualitative data used to measure 2 results of HIV/AIDS evaluated through questionnaires or Knowledge, effectiveness of the program Attitudes, Practices and Behavior (KAPB) Studies. Quantitative Quantitative data and qualitative 3 information includes productivitymeasures, absenteeism averted, information used to measure effectiveness condom use, requests for VCT or counseling. and make adjustments Section Five Advocacy with Business partners should be encouraged to have their own Program information provided 1 customers, suppliers programs and to ensure they have assessed and dealt with relevant Formal advocacy/educational meetings 2 and other business risk. For key suppliers, the latter could involve a system for supplier Accreditation scheme for key suppliers 3 partners compliance certification. Commemorate World World AIDS Day is a unique opportunity , every year, to go beyond Day commemorated 1 AIDS Day the workplace and to highlight the profile and reach of the Activities open to employees' families & 2 Appendices December 1st company's program. community Activities open to suppliers/service providers 3 The Road Map contains a list of possible interventions that can be put into place in the private sector . The “status” and “rating” columns provide companies with a means to set targets and evaluate their progress. Acknowledgements Source: Unilever, the PIA Working Group on HIV/AIDS, and IFC Against AIDS. Page 219 Appendices Appendix Four: Resources, References and Contacts The following are suggested readings and resources for further information to assist organisations in mining communities in Southern Africa to develop comprehensive Resources, References and Contacts HIV/AIDS responses. Codes • International Labour Organisation; Code of practice on HIV/AIDS and the world of work (2001), available on www.ilo.org; • SADC Code of good practice on HIV/AIDS and employment (1997), available on www.hri.ca/partners/alp; Appendix Four • Department of Labour; Code of good practice on key aspects of HIV/AIDS and employment (2000), available on www.labour.gov.za; and • South African Department of Labour; HIV/AIDS Technical Assistance Guidelines (2003), available on www.labour.gov.za. Toolkits • Harvard University, in co-operation with the World Economic Forum (WEF), UNAIDS and the ILO, is developing a set of tools to build capacity for combating HIV/AIDS in developing countries. The tools include inventories of good manage- ment principles and practices, and model curricula for executive training. • The ICFTU (International Confederation of Free Trade Unions), in collaboration with the ILO’s Bureau for Workers Activities, ILO/AIDS and other partners are developing a “tool box” on HIV/AIDS for young workers. • UNAIDS has developed a toolkit entitled Methods and approaches for local responses to HIV/AIDS: Techniques (undated). • KIT is a project of the Royal Tropical Institute in the Netherlands, see www.kit.nl. Kit manages a “local responses to HIV/AIDS” information exchange forum funded by UNAIDS. This project provides a database of practices, techniques and train- ing manuals in the form of tools (available in English, French and Portuguese). • UNDP has designed tools to facilitate the mainstreaming HIV/AIDS into governance institutions. • WHO and the International HIV/AIDS Alliance have developed a toolkit for programme managers entitled: A public health approach for scaling up ARV treatment. Page 220 • The Synergy APDIME Toolkit is a user-oriented, electronic one-stop-shop of HIV/ AIDS programming resources. The toolkit contains 5 modules of the program- ming cycle; Assessment, Planning, Design, Implementation, and Monitoring and Evaluation – go to www.synergyaids.com. • The LSHTM HIVTools Research Group has a website from which tools on costing and mathematical models for estimating the impact of different HIV prevention interventions can be downloaded, see www.hivtools.lshtm.ac.uk/. Section One • The Barnabas Trust in Port Elizabeth, South Africa, developed a community level toolkit; The New Toolbox – a handbook for community-based organisations (2002), which is available from barntrust@mweb.co.za. References Section Two Governance • UNDP , UN-Habitat; HIV/AIDS and local governance in sub-Saharan Africa – occasional paper 1 (June 2002). • CADRE; The economic impact of HIV/AIDS on South Africa and its implications Section Three for governance (2000). Modelling • Actuarial Society of South Africa (ASSA): Their AIDS model is available at www.assa.org.za/aidsmodel.asp. Section Four • AIDS Impact Model for Business; AIM-B, available on www.futuresgroup.com/aim is an economic and demographic model designed to help managers analyse how HIV/AIDS is affecting their businesses and project how it will affect them in the future. • GOALS for Business, also available from the Future Group, enables organisa- tions to effectively allocate resources to HIV/AIDS programmes implemented in Section Five the workplace. The model assesses whether an organisation’s current HIV/AIDS strategies are realising their full potential and if they can be adapted to improve results. Workplace and HIV/AIDS Appendices • Department of Public Service and Administration; Managing HIV/AIDS in the workplace (2002), available on www.dpsa.gov.za. • FHI; Workplace HIV/AIDS programme; an action guide for managers, available on www.fhi.org/en/aids. • Family Health International; search for information on HIV/AIDS education on Acknowledgements www.fhi.org. • Loewenson R, ed. Best practices: company actions on HIV/AIDS in Southern Africa: Organisation of African Trade Union Unity (OATUU) Health Safety and Environment Programme (1999). Economics • The Joint Center for Political and Economic Studies; a literature review on the economic impact of HIV/AIDS on South Africa, available on www.jointcenter.org/ international/hiv-aids/1_lit-review.htm. • A paper on the economic impact of HIV/AIDS in Southern Africa is available on the Brookings website at www.brookings.edu (#9; September 2001). Page 221 • Haacker M; The economic consequences of HIV/AIDS in Southern Africa (2002). This IMF working paper provides some tools for analysing the economic consequences of HIV/AIDS, in particular, the fiscal implications and the effect on economic growth. Epidemiology • UNAIDS; Epidemiological Fact Sheets (which provide country-specific HIV/AIDS statistics), available on www.unaids.org/hivaidsinfo/statistics/fact_sheets/ index_en.htm. Employee benefits • M. Stevens (Centre for Health Policy); AIDS and the workplace with a specific focus on employee benefits: Issues and responses, (2001). Legal issues • The AIDS Law Project (based in South Africa) has developed a number of workplace Resources, References and Contacts resources with a focus on legal and ethical issues; go to www.law.wits.ac.za/cals/ alp. Mainstreaming HIV/AIDS • Health Economics & HIV/AIDS Research Division (HEARD), numerous publications and AIDS Briefs for sectors and professions, available on www.und.ac.za/und/ heard; Gender Appendix Four • UNIFEM, in collaboration with UNAIDS, has a comprehensive gender and HIV/AIDS website, www.GenderandAIDS.org, for researchers, policy-makers and practitioners. PLWHA • GNP+; Positive development: setting up self-help groups and advocating for change. A manual for people living with HIV (1998). Care and support • Catholic AIDS Action in Namibia published a manual entitled Caring for ourselves in order to care for others. Contact info@caa.org.na. Contacts • The Global Health Council publishes a Global Health Directory every year. The 2003-2004 version contains information on the contacts, mission statements, regions/countries served, target groups and service focuses of over 440 organisa- tions. To order, contact membership@globalhealth.org. • UNAIDS Country Co-ordinators/ Country Programme Advisers Angola: Alberto Alejandro Stella Rua Major Kanhangulo, 197 PO Box 910, Luanda, Angola Tel: +244 2 331181/331188 Ext. 237/302 V-Sat: 004724136812; E-mail: unaids.angola@undp.org Page 222 Botswana: Dr Kwame Ampomah UNAIDS, UN Place, Plot 22 PO Box 54, Khama Crescent, Gaborone, Botswana Fax: +267 393 1243; Tel: +267 395 2121 Ext. 401 Mobile: +267 721 2124; E-mail: kwame.ampomah@undp.org DRC: In course of assignment Section One UNAIDS Office Assistant, Mr Marcel Kabeya Mobile: 243 88 00 840 and 243 99 05 676 E-mail: marcel.kabeya@undp.org Lesotho: Tim Rwabuhemba Ground Floor, UN Building PO Box 301, Maseru, 100 Lesotho Section Two Tel: +266 22 313 790; Fax: +266 22 313 571 E-mail: rwabuhembat@unaids.org Malawi: Mr Erasmus Morah UNAIDS, Evelyn Court, Area 13, PO Box 30135, Lilongwe 3, Malawi Section Three Tel: +265 1 773 329/927; Mobile: +265 9 960 130 Fax: +265 1 773 992; E-mail: emorah@unaids.unvh.mw Mozambique: Ms Aida Girma UNAIDS, Rua Lucas E. Kumato Nº 301 PO Box 4595, Maputo, Mozambique Section Four Tel: +258 1 49 17 75; Fax: +258 1 49 23 45 Mobile: +258 82 31 45 59; E-mail: aida.girma@unaidsmz.com Namibia: Ms Mulunesh Tennagashaw UNAIDS, Sanlam Building, 13th Floor Section Five 154 Independence Avenue, Windhoek, Namibia Tel: +264 61 204 6219; Fax: +264 61 204 6203 Mobile: +264 811 246 543 E-mail: mulunesh.tennagashaw@undp.org South Africa: Mbulawa Mugabe Appendices 7th Floor Metropark Building, 351 Schoeman Street P.O. Box 6541, Pretoria 0001, South Africa Tel: +27 12 338 5182; Fax: +27 12 338 5193 E-mail: mmugabe@un.org.za Swaziland: a.i. Ms Brigitte Imperial 5th Floor Lilunga House, Gilfillan Street Acknowledgements PO Box 261, Mbabane, Swaziland Tel: +268 404 8559/ 404 2301/3; Fax: +268 404 9931 E-mail: b.imperial@undp.org Tanzania: Bernadette Olowo-Freers UNAIDS; c/o UNDP , Matasalamat Mansion Samora Avenue/Zanaki Street PO Box 9182, Dar es Salaam, Tanzania Fax: 255 22 213 9654 Tel: 255 22 213 0350 or 211 8081-8, Ext. 3232 Mobile: 255 744 30 87 97; E-mail: olowofreersb@unaids.org Page 223 Zambia: a.i. Namposya Nampanya-Serpell, PhD. UN Annex, Plot 4609 Andrew Mwenya/Beit Road Rhodes Park, P.O Box 31966, Lusaka 10101, Zambia Tel: +260 1 252 645; Fax: +260 1 261 214 E-mail: nnserpell@who.org.zm Zimbabwe: a.i. Ms. Hege Waagan Tel: +263 4 792 681-6 ; Fax: + 263 4 250 691 E-mail: hege.waagan@undp.org Websites • www.ifc.org/ifcagainstaids; This IFC project aims to assist companies with information, tools and guidance to develop their responses to the HIV/AIDS epidemic. • www.weforum.org; The World Economic Forum’s Global Health Initiative is designed to foster greater private sector involvement in the global response to HIV/AIDS (TB Resources, References and Contacts and malaria). The website has resources and best practices to help companies in developing their responses. • www.unglobalcompact.org/Portal/; The Global Compact brings companies together with UN agencies, labour and civil society in support of human rights, labour standards and the environment. The Global Compact, the ILO and UNAIDS have joined forces to mobilise businesses, encourage increased action on HIV/AIDS in the workplace and combat stigmatisation. Appendix Four • www.icftu.org; The ICFTU believes that trade unions are uniquely placed to address the HIV/AIDS epidemic , as the workplace is a major entry point for information, prevention and rights campaigns. • www.businesssfightsaids.org/; The Global Business Coalition on HIV/AIDS brings together a growing number of international businesses dedicated to combating the HIV/AIDS epidemic. The website contains resources and information for employers on ways to address HIV/AIDS in the workplace. • www.iaen.org; The International AIDS Economic Network (IAEN) provides data, tools and analysis on the economics of HIV/AIDS prevention and treatment in developing countries, to help developing countries devise cost-effective responses to the global epidemic. • www.who.int/hiv/pub/en/; The World Health Organisation has numerous publications on HIV/AIDS, in particular health-related publications. • www.redribbon.co.za; is a website supported by Metropolitan Life. It is the primary link to the official website of SABCOHA (the South African Business Coalition on HIV/AIDS). Page 224 Resources BCC materials • All National AIDS Programmes develop and distribute small media materials, like posters and pamphlets. Some of these may be suitable for use within a workplace context. Section One Condoms • In some countries Ministries of Health procure and distribute free male condoms, and may agree to provide supplies to companies for workplace distribution; • Condoms are available commercially from a range of suppliers. Names and contact details of local suppliers can usually be obtained from the Ministry of Health; Section Two • Population Services International (PSI), known as the Society for Family Health (SFH) in some countries, provide socially marketed condoms (which are subsidised and therefore cheaper than commercial brands). Angola: Susan Shulmann Section Three E-mail: psiangola2@ebonet.net Botswana: Judi Heichelheim E-mail: judi.heichelheim@psi.co.bw DRC: John Loftin E-mail: johnnybloftin@cs.com Section Four Lesotho: Aaron Maselwane E-mail: progmanager@psi.co.ls Malawi: Desmond Chavez E-mail: dchavasse@psimalawi.org Section Five Mozambique: Brian Smith E-mail: bsmith@psi.org.mz Namibia: Susan Holland E-mail: sholland@africaonline.com.na Appendices South Africa: Katie Schwarm E-mail: katie@sfh.co.za Swaziland: Babazile Dlamini E-mail: psi@africaonline.co.sz Acknowledgements Tanzania: Brad Lucas E-mail: bwl@sfh.raha.com Zambia: Nils Gade E-mail: nilsg@sfh.org.zm Zimbabwe: Andrew Boner E-mail: aboner@psi-zim.co.zw Page 225 Appendices Appendix Five: Glossary Absenteeism The process of collecting and analysing information relating to absenteeism management and taking appropriate action on the basis of such information. The aim is to identify serious illness in employees as early as possible, so that the correct medical intervention can be implemented. The most successful absenteeism management programmes rest on two pillars: daily analysis of sick leave information and interpretation and recommendations by medical practitioners. Acquired immune The last and most severe stage of the clinical spectrum of HIV-related disease. deficiency syndrome (AIDS) Glossary Affected persons Persons whose lives are changed in any way by HIV/AIDS due to infection and/or the broader impact of the epidemic. Appendix Five Antibodies Substances produced by cells in the body’s immune system in response to foreign substances that have entered the body. Antiretroviral drugs Substances used to kill or inhibit the multiplication of retroviruses such as HIV. Asymptomatic Infected by a disease agent but exhibiting no medical symptoms. Audit A systematic examination to determine whether activities and related results conform to planned arrangements, and whether these arrangements are implemented effectively and are suitable for achieving the organisation’s policy and objectives. Base-line data Data about characteristics, figures of people/places, collected before a programme/project starts, and which can be collected again in the same manner during, or at the end of, a programme/project to see what changes have occurred. Casual contact Day-to-day social contact. Collective bargaining Collective bargaining is a process in terms of which employers and employee collectives seek to reconcile their conflicting goals through a process of mutual accommodation. Confidentiality The right of every person, employee or job applicant to have their medical information, including HIV status, kept private. Page 226 Contact tracing Refers to the method of finding and counselling the sexual partner(s) of a person who has been diagnosed as having a sexually transmitted infection. Cost-effectiveness Cost-effectiveness is a measure of the comparative efficiency of discrete strategies and methods for achieving the same objective Discrimination Discrimination is an action based on a pre-existing stigma. In the case of Section One PLWHA, it may result from the worker’s actual HIV status, his/her perceived HIV status, or even his/her sexual orientation. Enzyme-linked A laboratory test to determine the presence or absence of antibodies to HIV immunosorbent assay in the blood. A positive ELISA result is generally confirmed by a second test, (ELISA) eg a Western blot test. Section Two Employee benefits Any benefit granted to an employee or his/her family by an employer in respect of the period of employment of the employee, over and above salary. The term is usually used in the sense of retirement and life insurance benefits. Section Three Employer A person or organisation employing workers under a written or verbal contract of employment which establishes the rights and duties of both parties, in accordance with national law and practice. Governments, public authorities, private enterprises and individuals may be employers. Epidemic A disease, usually infectious, that spreads quickly through a population. Section Four Epidemiology The study of the distribution and determinants of disease in human populations. Evaluation An assessment, and analysis of, the design, implementation and results of an on-going, or completed, project. Section Five False negative HIV A negative test result that suggests a person is not HIV infected when, in fact, antibody test he or she is infected. False positive HIV A positive test result that suggests a person is HIV infected when, in fact, he or Appendices antibody test she is not infected. Gender Differences in social roles and relations between men and women. Going to scale Replication of a pilot project throughout, for example, a geographical area, or a project made larger in extent. Acknowledgements Hazardous biological Any micro-organism which may cause infection or otherwise create a hazard agents to human health. High-risk behaviour Activities that put an individual at greater risk of developing or transmitting a particular disease. High-risk activities associated with HIV/AIDS include unprotected sexual intercourse and sharing of needles and syringes. HIV-1 The retrovirus that is the principal worldwide cause of AIDS. HIV-2 A retrovirus closely related to HIV-1 that also causes AIDS in humans, found principally in West Africa. Page 227 HIV/AIDS management The part of the overall management system that facilitates the management system of the HIV/AIDS risks associated with the business of the organisation. This includes the organisational structure, planning activities, responsibilities, practices, procedures, processes and resources for developing, implementing, achieving, reviewing and maintaining the organisation’s HIV/AIDS policy. HIV-negative Denotes the absence of HIV or HIV antibodies upon HIV testing HIV-positive Refers to the presence of HIV infection as documented by the presence of HIV or HIV antibodies in the sample being tested. HIV testing Refers to any laboratory procedure – such as blood or saliva testing – done on an individual to determine the presence or absence of HIV infection. HIV transmission The transfer of HIV from one infected person to an uninfected individual, most commonly thought sexual intercourse, blood transfusion, sharing of intravenous needles and during pregnancy, childbirth or breast- feeding. Human A virus that weakens the body’s immune system, ultimately causing AIDS. immunodeficiency virus (HIV) Glossary Ill-health retirement A member retiring prior to normal retirement age due to reasons of ill health. Immune system A complex system of cells and cell substances that protects the body from Appendix Five infection and disease. Incidence of HIV The number of new cases of HIV in a given time period, often expressed as a percentage of the susceptible population. Incubation period The period of time between entry of the infecting pathogen into the body and the first symptoms of the disease. Informal sector Very small scale units producing and distributing goods and services, and consisting largely of independent, self-employed producers, which operate with very little capital, technology and skills, and which generally provide low and irregular income and highly unstable employment. Informed consent Refers to the voluntary agreement of a person to undergo or be subjected to a procedure based on full information, whether such permission is written, or expressed indirectly. Inherent requirements The inherent requirements of a job are an essential characteristic, quality or capacity that is required in order to fulfil the duties of a job. Key performance Statements that describe the dimensions of performance which are indicators (KPIs) considered key when assessments and reviews are undertaken. Page 228 Medical confidentiality Refers to the relationship of trust and confidence created or existing between a patient or a person with HIV and his attending physician, consulting medical specialist, nurse, medical technologist and all other health workers or personnel involved in any counselling, testing or professional care of the former; it also applies to any person who, in any official capacity, has acquired or may have acquired such confidential information. Section One Medical scheme A legal entity established with the purpose of undertaking liability in return for a premium or contribution in order to assist with the defraying the medical expenses of its members. Medical testing The process of gathering information, usually from duly qualified medical practitioners or from the applicant for membership or employment, Section Two concerning the health status of the individual. Monitoring The regular collection and analysis of information then used to guide a project – either to continue on its course, or to change direction. Section Three Occupational disease A disease contracted as a result of or during the course of an employee’s employment. Occupational exposure An incident or accident in the working environment involving blood or body fluids, and which may expose a person to the risk of HIV infection. Section Four Occupational health The conditions and factors that affect the well-being of employees, temporary and safety workers, contractor personnel, visitors and any other persons in the workplace. Occupational health A term used in accordance with the description given in the Occupational services (OHS) Health Services Convention, 1985 (No. 161), namely health services which Section Five have an essentially preventative function and which are responsible for advising the employer, as well as workers and their representatives, on the requirements for establishing and maintaining a safe and healthy working environment and work methods to facilitate optimal physical and mental health in relation to work. The OHS also provide advice on the adaptation Appendices of work to the capabilities of workers in the light of their physical and mental health. Occupational injury An injury caused as a result of an accident arising out of and in the course of an employee’s employment. Acknowledgements Openness A climate in which HIV and AIDS is freely discussed and acknowledged, and people living with HIV/AIDS feel enabled to disclose their HIV status. Opportunistic infection An infection with a micro-organism that does not ordinarily cause disease, but that becomes pathogenic in a person whose immune system is impaired, as by HIV infection. OIs common in persons diagnosed with HIV/AIDS include pneumocystis carinii pneumonia (PCP), Kaposi’s sarcoma, cryptosporidiosis, histoplasmosis, other parasitic, viral, and fungal infections, and some types of cancers. Page 229 Organisation The organisation, company, operation, firm, enterprise, institution, association or any part thereof, whether incorporated or not, public or private, that has its own functions and administration. For organisations with more than one operating unit, a single operating unit may be defined as an organisation. Palliative care Care that promotes the quality of life for people living with HIV/AIDS, by the provision of holistic care, good pain and symptom management, spiritual, physical and psychosocial care for clients and care for the families into the bereavement period. Pandemic An epidemic occurring simultaneously in many countries. Post-exposure Anti-retroviral therapy taken immediately after an exposure to HIV (such as a prophylaxis needle-stick injury) to reduce the risk of HIV transmission. Post-test counselling Refers to the process of providing risk-reduction information and emotional support to a person who submitted to HIV testing at the time that the test result is released. Pre-test counselling Refers to the process of providing an individual with information on the biomedical aspects of HIV/AIDS and emotional support for any psychological implications of undergoing HIV testing and the test result itself before he/she is subject to the test. Glossary Prevalence of HIV The number of people with HIV at a point in time, often expressed as a percentage of the total population. Appendix Five Prophylaxis for OIs Treatments that will prevent the development of conditions associated with HIV disease such as TB and PCP . Reasonable Any modification or adjustment to a job or to the workplace that is reasonably accommodation practicable and will enable a person living with HIV or AIDS to have access to or participate or advance in employment. Retirement fund A legal entity established with the purpose of providing retirement benefits to its members. Contributions are collected from members and invested to secure retirement benefits at a member’s normal retirement age. Other benefits such as death in service, disability and spouses’ pensions are often also provided through a retirement fund. Screening Measures whether direct (HIV testing), indirect (assessment of risk-taking behaviour) or asking questions about tests already taken or about medication, designed to establish HIV status. Sentinel surveillance Surveillance conducted through “watchpost” sites that provide access to populations that are of particular interest or representative of a larger population. Seroconversion The point at which the immune system produces antibodies and at which time the HIV antibody test can register an HIV infection. Serological testing Testing of a sample of blood serum. Seronegative Showing negative results in a serological test. Page 230 Seropositive Showing positive results in a serological test. A person who is seropositive for HIV antibodies is considered HIV infected. Seroprevalence The proportion of a given population with a particular marker in the blood, such as antibody to HIV, at a specific time. Serosurvey Systematic testing of sera from a group of persons to determine the frequency Section One of a particular marker, such as antibody to HIV, in that population. Sexually transmitted refers to any disease – such as syphilis, chancroid, chlamydia, gonorrhoea infection (STI) – that may be acquired or passed on through sexual contact. Section Two Source person Person whose blood may have been exposed to another person, in an occupational accident. Stigma The holding of derogatory social attitudes or cognitive beliefs, the expression of negative effect, or display of hostile or discriminatory behaviour towards Section Three members of a group, on account of their membership of that group. Surveillance A method of determining HIV prevalence rates in a population. Symptomatic With symptoms. Section Four Tripartite The term used to describe equal participation and representation of governments, employers and workers. Unfair discrimination Unfair discrimination is when a policy or practice differentiates between people on an arbitrary ground, in a way which adversely impacts on the person’s dignity, and in a way which is not reasonable or justifiable in terms of Section Five the laws of the land. Universal precautions A simple standard of infection control practice to be used to minimise the risk of blood-borne pathogens. Appendices Virus Infectious agent (microbe) responsible for numerous diseases in all living beings. They are extremely small particles, and in contrast with bacteria, can only survive and multiply within a living cell at the expense of that cell. Voluntary HIV testing HIV testing done on an individual who, after having undergone pre-test counselling, willingly submits himself/herself to such a test. Acknowledgements Vulnerable groups Vulnerable groups refer to groups of person who, by reason of socio- economic disempowerment and the existing cultural context, are vulnerable. In the working environment, working situations that make workers more susceptible to the risk of infection may cause vulnerability. Vulnerable groups Persons in employment or service who become exposed to or come into (occupational) contact with infected body fluids through, for example, cuts or accidental “needlestick” injuries such as health care and community workers, eg doctors, dentists, nurses, first-aiders, emergency services personnel. Usually education in universal precautions is provided. Page 231 Window period The period of time, usually lasting from two weeks to six months during which an infected individual will test negative upon testing for HIV antibodies, but can transmit the infection. Workers’ In accordance with the Workers’ Representatives Convention, 1971 (No. representative 135), these persons are recognised as workers’ representative by national law or practice whether they are: (a) trade union representatives, namely, representatives designated or elected by trade unions or by members of such unions; or (b) elected representatives, namely, representatives who are freely elected by the workers of the undertaking in accordance with provisions of national laws or regulations or of collective agreements and whose functions do not include activities which are recognised as the exclusive prerogative of trade unions in the country concerned. An alternate glossary, which includes a number of medical terms, is available on the IFC Against AIDS website, at: www.ifc.org/ifcext/aids.nsf/Content/Glossary. Glossary Appendix Five Page 232 Acknowledgements Section One Section Two Thanks are extended to all who contributed to the development of the Guide. Technical input was provided by: • Richard Smith, Golder Associates Ltd.; Section Three • Gail Steckley, CARE Canada; • Michelle Munro, CARE Canada; • Clive Evian, AIDS Management and Support; • Roy Mwilu, International HIV/AIDS Alliance (Zambia); • Chris Archibald, Director of Health, Canada’s Division of HIV/AIDS Epidemiology and Surveillance; Section Four • Sabine Durier, IFC Against AIDS, • John Middleton and Diana Baird, IFC; • Jeffrey Davidson, World Bank; and • Jaco Brits, FB Vending. Section Five The following persons provided inputs during the phase I field testing: 1. At the workshop hosted by Debswana (Botswana): • Tsetsele Fantan, Bekezela Mbakile, Dudley Wang, Ewetse Mathaba, Keitiretse Tshukudu and Marianyana Selelo from Debswana; Appendices • MP Ndwapi and Itumeleng Kwape from BDVC; and • Moses Kololo and Topo Antlwetse from BMWU. 2. At the workshop hosted by Gold Fields (South Africa): • Andre Bester and Stella Ntimbane from Gold Fields. Acknowledgements The following persons provided inputs during the phase II field testing: 1. At the 2003 Community and small scale mining (CASM) workshop (Ghana): • Rachel Golden, Victor Chipofya, Felix Kwaku, John Agyei Duodo, Pare LaZare and Jeffrey Davidson 2. At the workshop hosted by TEBA Ltd. (South Africa): • Raymond de Broize, Malitaba; • Osafo Gyimah, Construction Industry Development Board; • Tumi Malepe, TEBA Ltd; • Sebastian Biehl, Solidarity; and • Bongi Xaba, Mineral MEPC. Page 233 3. At the workshop hosted by Sishen/Kumba Mine (South Africa): • SL Adelanté and JH Kasper, Assmang Mine; • N Baffets, Dept. of Social Services; • ST Muller, C Muller, MC Geldenhuys, L Strauss, D Sehularo, S Jack, B Bodenstein-Smit, N Mawashe and P Cloete, Sishen/Kumba ; • MS Myedi, Kuruman Hospital; • G Eksteen, Home-based care project, Dingleton; • LN Merementsi, Dept. of Education; • H Seekoei, SAPD Kuruman; • L Hannam, Protector; • M Matsipane, NUM, Sishen; • G Lekgetho, De Beers Finsch Mine; • OE Bosaletse, Provincial Traffic, Kuruman; • N Ditshetelo, KJ Boeryang, LP Montshioagae and AHJ Scheepers, Kgalagadi District Municipality; • E Maitse, Samancor; and • B Orapeleng. 4. At the workshop hosted by Konkola Copper Mines (KCM) (Zambia): • Henry Loongo, CARE International; Acknowledgements • H Sensenta, M Banda, FH Kolala, GC Mwelwa, EC Chomba, MK Trivedi, G Mulenga, MW Banda, J Chabu, M Mubangwe, A Chamululu and J Sikambe, KCM plc; • J Nsofwa, World Vision; • C Kabaghe, MCM plc; • J Nankamba, BMML; Acknowledgements • H Mvula, Trentyres; • VM Njovu, JCB; • B Maanya, DA’s Office; • F Mubanga, Standard Chartered Bank; • J Choobe and J Nondo, Barclays Bank; • I Chishimba, GTL; • L Musonda, ZANACO; • WL Silungwe, Dept of Education; • JK Sindazi, Secondary Union; • S Mwape, NUMAW; • DN Kombe, Mines Safety; • KCA Chense, AHC MMS; • JC Bwalya, Nchanga North Hospital; • D Daka, Occupational Health Management Board; • R Mwale, ZHABS; • M Sishekanu, Indotech; • K Moomba, Chingola Municipal Council; • JNW Kalulu, CEC plc (Kitwe); and • EC Nkowani, Chibuluma Mine Hospital. Page 234 In November/December 2003, during a mission by IFC and Golder, consultations on the Guide were held with: • Sishen/Kumba, De Beers, Assmang, PPC in the Northern Cape Province • KCM and others in Zambia • Mrs Fantan and Brad Ryder from ACHAP , Kabelo Ebineng of the Botswana Business Coalition Against HIV/AIDS and Dr Banu Khan, head of NACA in Bo- Section One tswana • Zen Fourie and Dr Deon van Zyl, SABS • The HIV/AIDS Committee, MINTEK • David Cooper and Tumi Malepe, TEBA • Brian Brink, Anglo American and Tracy Peterson, De Beers Group • Fazel Randera, Chamber of Mines Section Two • Osafa Gyimah, CIDB • Tracey King, SABCOHA • Martin Zhuwakinyu, Mining Weekly • Theuns Kotzé, NOSA • Clive Evian, AIDS Management and Support cc Section Three • Tanja Nowers and Estelle Goran, Compass Group • Joseph Ajakaye and Margherita Licata, ILO Section Four Section Five Appendices Acknowledgements Page 235