Southern Africa HIV/AIDS Information Dissemination Service

1. Needs and Gaps in Integrating WASH and HIV in Four SADC Countries: Preliminary Findings Rouzeh Eghtessadi (MPH) Deputy Director SAfAIDS Regional Office 479 Sappers Contour, Lynnwood Pretoria, South Africa Tel: +27 76 381 2425 Website: http://www.safaids.net Email:rouzeh@gmail.com Southern AfricaHIV/AIDS Information Dissemination Service SAfAIDS - P O Box A509,Avondale, Harare, Zimbabwe, Tel: 263 4 336193/4, Fax: 263 4 336195, E-mail: info@safaids.org.zw, Website: www.safaids.org.zw

2. Building the Case • Main objective of comprehensive water, sanitation and hygiene (WASH) interventions is to improve quality of life for individuals, families and community. With advent of HIV (Wateraid positioned in epicentre of global epidemic) this becomes paramount • Wateraid (and other partners) already, as early as 2004 - shown evidence of benefits of mainstreaming HIV into WASH • Integration (multi-disciplinary/sectoral) vs Silo practice is direction the development sector/funding priorities is shifting – unavoidable! • Like all sectors, WASH sector is susceptible to HIV-reality check! • HIV can reverse gains made externally ( programmes/service delivery) • Capacity to delivery can be compromised internally ( institutional)

3. Specific HIV and WASH Linkages Perspectives categorizing linkages between HIV and WASH include: • Consumer • Health • Human Rights • Gender • Community-driven development • Poverty Alleviation Institutional: internal capacity for WASH at community and higher levels being lost, compromising delivery

4. Critical Consumer Links with HIV (1) • HIV affected households impoverished unable to pay user fees forfeit right to quality water & sanitation • Indigenous knowledge in water and other natural resource management lost leading inappropriate ways of utilisation • Households sink further into poverty exploitation of natural resources as alternative, result in water exploitation • Shift in “care-economy” from institution to home-base care (influenced by cultural pref); lack of skills on recycling and multi-water use techniques excessive water usage during home-based care; limited knowledge in hygiene practices lead to opportunistic infections (OIs)

5. Critical Health Links with HIV (2) • Quality, Quantity, Affordability, Access: • Successful adherence to antiretroviral treatment regimens , TB treatment etc • Mixing powdered formula for infant feeding as well as nutrition boosting for ill adults, need safe & ample water • Technological design & infrastructural access • Facilitate fetching water by children from HIV-affected households or people living with HIV (pump handles too low, too heavy, walls of the well too low etc) • Distance and mobility capacity need regauging

6. Critical Health Links with HIV (3) • Poor water handling, storage & sanitation practices: • Personal hygiene, domestic hygiene (ARVs, OIs), food hygiene (TB, diahorrea ) and environmental hygiene • Safe waste water disposal and drainage increase water and sanitation related diseases- OIs • Poor access to sanitation: • Stds on closing distance gaps for fetching water by care-givers or PLHIV who are weak; and disposal facilities and access – revise to suit the population need • Risk of rape while fetching water or relieving oneself in remote places, thus increasing vulnerability to HIV

7. Critical Health Links with HIV (4) • Burial issue and safety of transmission myths can be strategically addressed • Reverse erroneous beliefs that contribute to HIV related stigma and discrimination (via advocacy) eg: • “people can become infected with HIV due to groundwater pollution near burial sites” • “people (playing children) can become HIV infected through poor waste disposal practices: condoms and sanitary pads”

8. “Having no proper sanitation means that there is a vicious cycle of poverty, diseases and bad hygiene…… The cycle of epidemic is at a stage where many people are falling sick. Through home based and palliative care, people are looked and cared for. One of the important ingredients of care is water…”Nkululko Nxesi (Director, South African National Association of People living with AIDS (NAPWA)

9. Critical Community-driven Links with HIV • HIV related stigma and discrimination compromises participation of PLHIV and affected households , social cohesion is weakened and traditional participatory channels become dysfunctional . Community empowerment fails! • What in WASH sector is known as “community management” can be compared to “community HIV competence” environmental sustainability • Placing communities in the driver's seat • Requires government & civil society to be demand-responsive, to build capacities and to create an enabling environment by providing technical support, formation of partnerships and supportive policy frameworks

10. Critical Human Rights Links with HIV • Stigma & discrimination of HIVaffected/infected families becomes exclusion factor for participation in community-based WASH related decision- making • Access to safe water and sanitation is considered not only a basic need but also a human right – For ALL! (advocacy) At the Johannesburg World Summit for Sustainable Development (2002), delegates of the "The Civil Society Action Programme on Water" launched a statement saying that secure access to sufficient safe water and sanitation to meet basic human needs, including water for small-scale productive use to support livelihoods strategies, must be considered a human right

11. Overview of Rapid Assessment (1) • Where: Four countries in SADC region: Lesotho, Mozambique, Swaziland and Zambia • What: • Assess the extent to which HIV and WASH related policies allow for provision of integration/already reflect integration • Identify WASH needs of people living with HIV (PLHIV) • Determine the extent to which HIV and WASH are integrated at service delivery level • Identify bottlenecks in-country that influence sustainable and effective HIV and WASH integration • Recommend pragmatic and feasible actions to inform HIV and WASH integrated practice

12. Overview of Rapid Assessment (2) • Methodology: • Cross-sectional design, qualitative data, triangulation, purposive and snowball sampling • Data collection at 4 levels: policy makers, donors/ development partners, implementers, community in rural and urban settings • Data collection methods 5: FGDs (12), KIIs (85), direct observation (photos taken) & household case studies (4 types), desk review (over 50 docs) • Tools pre-tested • Methodology matrix developed & sought in-country authorization • Data analysis: thematic approach

13. Overview of Rapid Assessment (3) • Met >90% of stakeholders targeted, including government, CSOs, community cadres and members, donors and other key stakeholders • Conducted field work and visited project sites in all countries (collected data from all 4 levels) • Ethical considerations in line with UN Evaluation Group Ethical Guidelines, and in-country cultural sensitivity considered, including voluntary and anonymous participation as necessitated • At advanced draft assessment report • Clear picture emerging

14. Findings

15. Policies and Frameworks (1) • Regional level: • SADC Regional Water Policy silent on integration, yet speaks to HIV with regard integrated water resource management (IWRM) • SADC HIV & AIDS Strategic Framework (2010-2015) silent on integration of WASH and HIV, yet speaks to water development/ agriculture & nutrition security for HIV in Clause 7.2.3 • Lesotho: • Both HIV and WASH policies/ frameworks make provisions for HIV and WASH integration eg special WASH support for OVC and vulnerable households, and equitable access to services etc • However consistency of the policy provisions and operationalization remains challenging

16. Policies and Frameworks (2) • Mozambique • National Strategic HIV and AIDS Response Plan (2010-2014) has no clear provisions for addressing WASH issues • National Water Policy (1995) has no provision for HIV • Interventions that rely on adequate WASH facilities, such as Home based care (HBC), are well articulated in the policy, but they do not specifically include the need to address WASH • National Rural Water Supply and Sanitation Programme (NRWSSP, 2010 – 2014) emanates from the Rural Water and Sanitation Strategic Plan 2007 and recognizes contribution of WASH to mitigating impact of HIV, designed to meet 62% of population

17. Policies and Frameworks (3) • Swaziland • National Water Policy (2009), makes no specific mention of WASH, does not clearly make provisions for WASH and HIV integration. Although makes mention that access to water contributes to the response to HIV; does not explicitly address water needs of vulnerable groups including PLHIV • National Multi Sectoral Strategic Framework for HIV and AIDS (2009-2014/extension 2014-2018) recognizes WASH as key in improving access and adherence to HIV treatment and care services, however not integration of the two sectors • Health Sector Response to HIV/AIDS Plan (2009-2014) Section 5.2.5 focuses on community based care and support and reflects efforts for integration of WASH components e.g. waste disposal management

18. Policies and Frameworks (4) • Zambia • National Rural Water Supply and Sanitation policies and programmes (2006-2010) clearly establish the link between WASH and HIV and spells out clear strategies on how this will be done • National HIV/AIDS Policy (2005) does not make provisions for WASH integration or linkages • National AIDS Strategic framework (2011-2015) does not show any efforts to strengthen linkages between HIV and WASH though it is mentioned that NASF supports strategies that address issues of WASH for vulnerable groups

19. Linkages between WASH and HIV (1) • Consensus at all levels in all countries that HIV & WASH are interlinked and hence the need for integration • Specific PLHIV needs included need for: • Clean water to maintain good hygiene (bathing and cleaning of clothing and other materials); adhere to ART (medication), breastfeeding, avoid related illness such as cholera etc • Sanitation for diarrhea associated with HIV • Safe disposal of materials used in the care of PLHIV such gloves, napkins, contaminated water and other items require proper sanitation facilities • Safe potable water for good nutrition – establishment of nutrition gardens, hygienic food preparation and storage practices etc

20. Linkages between WASH and HIV (2) • Lesotho – Divided opinions on the need to integrate. Policy makers are pro , but implementers are not keen due to issues of stigma and discrimination, and lack of understanding on the long-term benefits of integration. No deliberate integration but organizations with both WASH and HIV have some degree of integration. • Swaziland – Stakeholders indicated that linkages in the community are weak due to limited advocacy and vertical programming. Lack of policy commitment and coordination on the WASH side blamed for lack of integration. Some perceive integration already exists but needs strengthening

21. Linkages between WASH and HIV (3) • Mozambique – Only a few organizations integrating despite most appreciating the need to do so. While recognizing the need for integration, do not see need for formalization within existing systems • Zambia – Linkages are weak and in some cases non-existent. Only a few organizations such as DAPP are integrating HIV and WASH in their programmes, yet not systematically reporting on change as a result • In all countries - No dedicated budget, monitoring and evaluation, documentation and reporting systems on WASH and HIV integration, not institutionalized

22. Influence of Funding on Integration • WASH and HIV mostly externally funded • Stakeholders indicated that to some extent these mechanisms affect strengthening of integration of HIV and WASH particularly if funds are earmarked for certain programmes with limited flexibility, and within silo implementation • Under HIV programming the UNAIDS investment framework spells out areas of high impact of which WASH is not one • Commonly posed questions hindering integration: (a) Capacity- who will lead this integration? Within organisations? External? and (b) Mainstreaming versus integration- semantics?

23. Household and Community Level (1) • Household level: • While there is no apparent discrimination in provision of water and sanitation; access by those who need it the most is influenced by various factors including: distance, ill-health, self-stigma etc • Creative/innovative mediums to mobilise/motivate access often not explored • Community level: • WASH – water point committees. Open to all community members and hence can include PLHIV • HIV – Community cadres (egCBVs) educate community on health and hygiene, monitor hygiene & sanitation issues among other duties

24. Household and Community Level (2) Access to quality water is still a challenge for some in all the countries. Access better in the urban areas vsrural areas • Lesotho – ground water distributed as piped water to rural water points, boreholes, protected wells. Use solar for water pumps and hence during low temperatures can go for weeks without water. Demand exceeds supply and hence a challenge for some households. Households resort to use unprotected water sources • Swaziland – Urban water system, Water harvesting, Swaziland Water Services Corporation, boreholes and dams. First three sources have a cost implication and hence some cant afford. Some communities far away from boreholes, households travel an hour to fetch water. In dry season boreholes dry up. Reported that some households use dam water. Treat with water-guard and jik if available.

25. Household and Community Level (3) • Knowledge on WASH and HIV • Community members are generally knowledgeable on WASH and HIV hygiene needs but point to the issue of poverty affecting adherence to standards. However some argue that some are reluctant to build toilets • Access to sanitation services • Not all homesteads have toilets because some cant afford but others particularly in Lesotho and Swaziland do not see the importance. In Zambia most household share pit latrines and some resorted to use of shake-shake (traditional brew) containers or plastics at night and dispose off in the morning.

26. Household and Community Level (4) • Primary caregivers use gloves, detergents and soap when handling and cleaning a person living with HIV patient if available. But there is a challenge in availability of these materials in the community and hence use plastics as gloves or just bath with water without detergent • Sanitary pads (MHM) not always available hence use rags, diapers or napkins. Issues of handling, frequency of change and evening cleaning for reuse becomes a challenge if one does not have the resources

27. Conclusions • Key stakeholders do not question if there are linkages between HIV and WASH. • In all countries there are not set Guidelines for integration. • There is inadequate research done on the links between HIV & WASH. • These are real challenges that any new intervention should seriously consider. Among these are • Lack of coordination • Lack of inclusiveness among key populations • Discontinuity in flow of interventions • Cultural influences • Ownership and poor targeting, and • Inadequate allocation of resources to sustainability options

28. Recommendations (1) • Learn from other Integration BPs - Take note of other effective integration initiatives already taking place, including those on between HIV and TB, SRH, and nutrition. • Guidelines on ‘how-to’ - Develop for local context integration • Respond to barriers - WASH/HIV integration should adequately assess existing implementation barriers in the respective sectors and provide adequate mitigation efforts to address them • Coordination- Ensure that a critical mass of stakeholders from both sectors have adequate buy-in to the WASH/HIV integration initiative. An entry point to creating this critical mass is to ensure that key Govt Ministries (Health, Water, etc.) UN agencies and ICPs that already have considerable stakes in both sectors

29. Recommendations (2) • Inclusion- Ensure that the voice of households and individuals affected by poor HIV and WASH service delivery are heard (platforms beyond tokenistic). Creative linkages with the media and other advocacy networks can help amplify this voice and ensure that due attention is rendered. Care must be taken, though, so that the voices remain constructive in directing service delivery. • Funding- Both WASH and HIV are not adequately funded. Strategic framework documents for both WASH and HIV lament inadequate funding as one cause of failure to reach set targets. When allocating resources for WASH/HIV linkages and integration, it is important and ideal to ensure that such funding is new, and does not take away from planned WASH or HIV initiatives

30. Recommendations (3) • Culture- Ensure that culture is addressed in integration initiatives. This can be done through a strong advocacy programme at community level • Sustainability- Build sustainability by planning for local ownership of interventions, and including aspects that address economic challenges faced by beneficiary households. For example, a water development initiative could integrate HIV aspects by ensuring that the most vulnerable households (PLHIV, disabled etc) are supported by an income generating activity associated with the water development project.

31. Way forward • Finalize study • Package and disseminate strategically via HIV and WASH related CSO, development partner and other advocacy paths to inform: policy, program/service delivery & resource mobilization towards systematized integration • Disseminate to motivate lessons learnt and best practice documentation of “what works” and what does not work, for replication, scale-up and uptake • Develop guidelines on bi-directional HIV and WASH integration, based on findings and evidence gathered – and advocate and motivate national and regional harmonization

32. Thank you …..