HIV and AIDS response program, Mongolia - Australian Red Cross

End of ProgramEvaluationSummary of findings andlessons learnedHIV and AIDS responseprogram, MongoliaAustralian Red Cross began work in partnership with Mongolian Red Cross on initiatives to address the HIV and AIDS epidemic in 2000. Photo: Australian Red Cross.BackgroundThe impact of the HIV and AIDS pandemicin Mongolia has so far been relatively low,compared to other Asian countries. As of2009, a total of 94 cases of HIV infectionhad been recorded in a population of justover 3 million. As in other countries, it isexpected that the actual number of casesis considerably higher. Within Mongoliansociety, there are several factors whichmean that the spread of the epidemiccould easily escalate.These include a low level of knowledgeacross the population as a whole about themeans and risks of HIV transmission;significant prevalence of sexuallytransmitted infections (STIs); the existenceof a significant commercial sex work sector,with most sex workers lacking knowledgeof prevention measures, or feeling unable toensure them; a high level of marginalisationand stigmatisation of the MSM (men whohave sex with men) population, amongstwww.redcross.org.auwhom most cases of HIV and AIDS inMongolia have so far occurred.Australian Red Cross began work inpartnership with Mongolian Red Cross oninitiatives to address the HIV and AIDSepidemic in 2000. The HIV and AIDSResponse Program (HARP) was launchedin June 2008, to scale up this response,within the Global Alliance Framework, andalso in alignment with Mongolia’s nationalfive-year strategic plan on HIV.The project aimed to reduce the incidenceof deaths and illness from HIV and AIDS,specifically through:• decreasing the stigma and discriminationsuffered by people living with HIV, andthose belonging to high-risk groups• increasing the incidence of safer sexpractices among high-risk groups andthe population as a whole.This was to be done through strengtheningthe capacity of Mongolian Red Cross bothat central level and through its mid-levelbranches to implement effective HIV andAIDS activities.Project designThe HARP initiative built on some standardmethods which have proven to be effectivein other situations, particularly the use ofpeer educators among high-risk groups. Italso made some important innovations inthe Mongolian context, especially:• Targeting journalists for education andconsciousness-raising, as a keystrategy to improve knowledge anddecrease stigma across the communityas a whole.• Identification of single mothers as adistinct at-risk group, and developmentof strategies to target them specifically.• Working through community-basedorganisations (CBOs) which hadexisting strong networks among thehigh-risk groups, as well as through thestructure of Mongolian Red Cross itself.CRISIS CARE COMMITMENT

Education around HIV and AIDS was complemented with livelihoods skills training. Photos: Australian Red Cross/ Tanya Cugura.Evaluation methodologyThe final evaluation of the project wasconducted over three months concluding inAugust 2011, with in-country work overtwo weeks from 20 June. The focus of theevaluation was on partner performance andproject outcomes.MethodologyStages of the evaluation included:• Document review, encompassing allregular project reports; the report of theMay 2010 mid-term review; and thebaseline survey conducted in 2008.• Distribution of questionnaires tobeneficiaries, measuring knowledgeand behaviour change against theresults of the original baseline survey.• Through this, all pertinent quantitativeinformation was readily available.• Direct interviews and focus groupdiscussions, including Mongolian RedCross at national and branch level;other donor programmes in-country;beneficiaries; and local ‘opinionleaders’, including government figuresand technical bureaus, and local police.Interviews were conducted in the capital,Ulaanbaatar, at both central and communitylevel; and in the two provinces (aimags) ofDornod and Arkhangai, respectively in thefar-east and the centre of the country.Only a small number of direct beneficiariescould be interviewed in the end, but as therewas extensive individual and FGDdiscussion with peer educators, all of whomwere drawn from the risk groups, and staffof the CBOs which have long and closeworking relationships with them, the reviewteam felt the qualitative information obtainedwas sufficiently reliable. Due to timeconstraints, it was only possible to have thesurvey questionnaires completed bybeneficiaries in Ulaanbaatar, so results havea possible bias towards urban respondents.Key findings of theevaluationResults of both document survey andinterviews show real success inachievement of the project objectives; interms of changed behaviours and attitudesamong the primary target groups. In purelynumeric terms, of the 39 indicatorsincluded in the design, 32 were measurablein the evaluation, and of these, 22 wererated as fully achieved, and a further fivepartially achieved 1 . Quantifying the impacton the ultimate incidence of HIV and AIDSin the target groups and the broaderpopulation was beyond the scope of thisexercise; however, what is probably mostimportant and encouraging to note is thatthere appeared to be real qualitativechange in both behaviour and attitudeamong most of those who had beentargeted by the project, of a kind which islikely to substantially reduce risk of HIVtransmission, and ensure better treatmentfor people living with HIV (PLHIV).Also important to note is that thesechanges were achieved in an unusuallydifficult operating environment, wherestrong stigma has been attached both toHIV and AIDS, and to most of the high-riskgroups, particularly female sex workers(FSW) and MSM. Discussions with peereducators indicated notable shifts inawareness, but also in self-esteem, and theability of MSM, FSW and single mothers toprovide each other with support. This hasthe potential to serve as the foundation forlonger-term change and decreasedvulnerability to infection, as the capacitywithin target groups to share knowledgeand reinforce safer sex practice increases.Results by groupMen who have sex with menMSM are currently the single most at-riskgroup in Mongolia. Of HIV infectionsrecorded in 2008, 68 percent had occurredthrough male-to-male sexual transmission.Both the group themselves, andgovernment and other stakeholders statedthat the MSM population was highlyinvisible, and consistently subject todiscrimination and stigma; and that this iseven more so outside of the capital city.1. Noting that the indicators were a mixture of outcome and output and included qualitative measures around knowledge and behavior change.

The program focused on decreasing the stigma and discrimination suffered by people living with HIV, and those belonging to high-risk groups. Photo: Australian Red Cross.Outreach to the MSM community wasconducted mainly by Youth for Health, aCBO which also targeted female sexworkers. Peer educators were trained, and adrop-in centre established. 600 MSM madeuse of the centre over the project’s lifetime.Interestingly, reported rates of condom useamong MSM surveyed by questionnairehad not risen from the 2008 baseline of80 percent; though it should be noted thatthis is a higher rate than among MSMpopulations elsewhere in Asia. Respondentsalso expressed strong appreciation for thedrop-in centre as a safe space, whichfacilitated passing on of safer sex messages.Female sex workersThis group was also targeted through peereducation programs, with all educatorshaving themselves worked as sex workersin the past, and through drop-in centresrun directly by Mongolian Red Cross andCBOs. The education model usedfocussed not only on safer sex practices,but also on how women could protectthemselves in violent or threateningsituations, and tactics to negotiate condomuse with clients.As well as reporting increased levels ofsafer sex practice, the peer educators saidthere was a change in women’s confidenceand assertion, particularly in accessinghealth testing services, and in relations withtheir families. Reducing alcoholconsumption was one strategy taught forreducing vulnerability; and positive changesin the behaviour of women attending thedrop-in centre were observed in this areaover the project’s lifetime.Single mothersInclusion of this population was because oftheir perceived higher vulnerability, as beingmore likely to have a number of differentsex partners, and particularly, undertakeeither occasional paid sex work, or othertransactional sex as a necessity for survival.They were more likely than average to beunemployed, and to have little or noknowledge about HIV transmission. Singlemothers were also targeted through a peereducator program, and peer supportgroups established. Education around HIVand AIDS was complemented withlivelihoods skills training, and a key functionof the groups was to ensure better peersocial support than the women hadpreviously had access to.Women interviewed reported strongsatisfaction with the knowledge and skillsthey had acquired, and particularly that theyhad gained the confidence to talk openly totheir sex partners and to other women aboutsafer sex practices. Rates of increasedknowledge about HIV transmission and safersex practice varied according to location, butbetween 70 and 95 per cent of thosetargeted showing increased knowledge bythe end of the program.For example, one peer educator’s storyrecorded clearly demonstrates the effect ofthe program in breaking down isolation andraising confidence.Young peopleResults among young people were moredifficult to track, given the size and diversityof the target population, ranging from 17 to30 years of age. There were difficulties ofattribution, as it seemed young peoplewere exposed to a larger variety ofinformation sources on HIV and AIDS,including electronic media; information

Peer educator and peer support groups were central to the program. Photo: Australian Red Cross.through schools; educational institutions;and elsewhere. Peer educators alsoreported a greater degree of difficulty ingetting participation in HIV informationactivities.Peer educators’ experience with this groupalso showed up some of the deficiencies inmessage targeting. Counselling forabstinence was not considered useful;also, when talking about exercising greatercaution outside of ‘long term faithfulrelationships’, they found that youngpeople might well consider a six-monthrelationship as ‘long-term’. Centralmessages need to be fine-tuned todecrease risk.As with the three other target groups,young people who were recruited as peereducators reported high satisfaction withtheir work and its effectiveness, and theknowledge and skills they had gained.Reducing stigma throughworking with journalistsA total of 246 journalists working in printmedia, television and internet weresuccessfully targeted by the program,specifically to improve media coverage byreducing sensationalist stories likely toincrease discrimination and maintainconfusion about the causes of AIDS andtransmission of HIV. Final results in mediastories run during the project lifetime weremixed, partly due to one high-profile casein Mongolia of a blood donor being foundto be HIV-positive. However, focus groupdiscussions among journalists who hadparticipated showed significant change inknowledge and attitude for the better, anda greater preparedness to present storiesbased on fact, and to include the voices ofpeople living with HIV, and of those in highriskgroups.ConclusionHARP’s most important achievement hasbeen in laying a basic foundation for theon-going response to HIV in Mongolia. Theprogram has broken important newground in not only demonstrably increasingthe capacity of Mongolian Red Cross andits branches, but in establishing a peereducation model which can effectivelyreach high-risk groups and effect realknowledge and behaviour change there.Mongolian Red Cross’ own knowledgeand capacity to implement promotionaland educational activities around HIV hasincreased, as has its ability to workthrough CBO partners and to use nontraditionalmodels of communityeducation. The community developmentwhich has taken place within high-riskgroups is a very distinctive and importantachievement, and it is hoped that this canbe built on further.- 2011