Strategy For Addressing HIV/AIDS in Programme Activities

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StrategyFOR ADDRESSING

HIV/AIDS

UNITED NATIONS HUMAN SETTLEMENTS PROGRAMME

Supporting developing countries to achieve increase of people’saccess to safe water and healthy sanitation that provides care,support and mitigate the impact of HIV/AIDS with a special focus onthe poor and the vulnerable in urban areas.

UNITED NATIONS HUMAN SETTLEMENTS PROGRAMME

SEPTEMBER 2006

HIV/AIDSStrategyIN PROGRAMME ACTIVITIES OF THEWATER AND SANITATION TRUST FUND

FOR ADDRESSING

Building on the knowledge and know-how acquired overthe years in the field of water and sanitation, and morespecifically on its programmes in this sector, UN-HABITAT,launched a Water and Sanitation Trust Fund on WorldHabitat Day (6 October 2002), in answer to the call inthe United Nations Millennium Declaration to "Halve, by2015, the proportion of people without sustainableaccess to safe drinking water and basic sanitation". Awell-coordinated programmatic approach that allowsdonors to improve their aid-effectiveness by contributingto a consolidated fund dedicated to a clear set ofobjectives is the rationale behind the establishment of theUN-HABITAT Water and Sanitation Trust Fund. Theobjective of the Trust Fund is to contribute to theachievement of the internationally agreed water andsanitation goals and related targets by supporting thedeveloping countries to create an enabling environmentfor enhanced flow of investment in water and sanitation,specifically targeted to the urban poor.

The goal of the UN-HABITAT Water and Sanitation TrustFund is to contribute to the achievement of theinternationally agreed goals related to water andsanitation in human settlements with particular focus onthe urban poor in order to facilitate an equitable social,economic and environmental development.

The Development objective is to support developingcountries to achieve sustainable access to safe drinkingwater and basic sanitation for the poor, particularly inurban areas. The Water and Sanitation Trust Fundaddresses its objective through four inter-linked sets ofactivities:

• Two regional water and sanitation Programmes viz.Water for African Cities (WAfC) and Water for AsianCities (WAsC) Programme, which facilitate pro-poor,gender sensitive investments in partnership with thetwo regional development banks and the WorldBank;

• Replicable model-setting initiatives in Africa and Asia,notably through the Lake Victoria Region Water andSanitation Initiative (LVWATSAN) in Africa and theMekong Water and Sanitation Initiative (MEK-WATSAN) in Asia to address the water and sanitationneeds of the population, particularly the poor, in thesecondary towns in these regions.

• Normative Activities: Development of pro-poor andgender sensitive governance frameworks, includingpolicy options, norms, standards and managementtoolkits, for the urban WATSAN sector. This set ofactivities also includes the triennial report on Waterand Sanitation in the World's Cities, which wasmandated by the Governing Council 20 of UN-HABITAT.

• Monitoring and Evaluation of progress towardsachievement of WATSAN related MDG/JPOI targets;

The programme is being implemented in a phasedmanner, as follows:

• A Start-up Phase, which would focus on incorporatingknowledge sharing, awareness raising, informationexchange and partnership development;

• Consultation and Formulation Phase, for engagingnational and local level stakeholders in projectidentification and formulation and to reachagreement and consensus on the overall interventionpackage;

• An Implementation and Investment Phase, when theprogramme will be rolled out at the city level, withawareness raising, information exchange, education,and capacity building at city level implementation andfollow-up pro-poor investment; and

• A Consolidation and Dissemination Phase, for theanchoring of enhanced capacity at city and regionallevels through information dissemination and lessonsharing.

UN-HABITAT's Water and Sanitation Trust Fund

Strategy For Addressing HIV/AIDS in Programme Activities of The Water And Sanitation Trust Fund

2 STRATEGY FOR ADDRESSING HIV/AIDS IN WATER AND SANITATION

The Epidemic: Regional intensity

Sub-Saharan Africa: hardest hit

Sub-Saharan Africa remains by farthe hardest hit part of the world, with25.8 million adults and childrenincluding 13.5 million women livingwith HIV in 2005 compared to 24.9million in 2003 in Sub-SaharanAfrica. Declines in adult national HIVprevalence appear to be underway in3 Sub-Saharan African Countries:Kenya, Uganda and Zimbabwe.While HIV prevalence levels are notonly exceptionally high inMozambique and Swaziland but arealso further expanding. However, inWest and Central Africa estimatedNational HIV prevalence isconsiderably lower than in the Southand East of the Region.

The percentage of people living withHIV/AIDS in countries covered underWater for African Cities Programme

With an estimated 40.3 million people already living with the HIV virusand the death of 25 million people since it was first recognised in 1981,AIDS has earned itself being one of the most destructive epidemics inrecorded history of mankind (UNAIDS, WHO. AIDS epidemic update,December 2005). The epidemic has rapidly become the world’s mostserious public health threat, imperiling several regions and erasingdecades of gains in international development.

The number of people living with HIV has increased in all but one regionin the past two years. While in Caribbean –the second most affectedregion in the world- HIV prevalence overall showed no change in 2005compared with 2003, in the rest of the world there was an increase. Buteven with the non-increment in prevalence, AIDS is now the leading causeof death in the Caribbean region among adult aged 15-44.

Currently Africa is within the high prevalence zones, while Asian cities arewithin the low prevalence zones.

Phase II and countries covered underLake Victoria Water and SanitationInitiative in the adult age group(15-49) ranged between 0.8 per cent(Senegal) and 28.9 per cent(Lesotho). The share of infectedwomen to infected adults was muchhigher, ranging between 55.0 percent (Ethiopia) and 65.45 per cent(Kenya).

Sub-Saharan Africa accounts for 64per cent of all world’s people livingwith HIV and for 76 per cent of HIV-infected women. National epidemicsin sub-Saharan Africa appear to bestabilizing generally, although athigh levels in many countries andseven epidemics in Southern Africaare not likely to decline in the nearfuture.

Asia: moderately hit

The epidemic is growing in CentralAsia as well as in East Asia andEastern Europe. In East Asia, thenumber of people living with HIV in2005 increased by one fifthcompared with two years earlier.National HIV infection levels in Asiaare low compared with some othercontinents notably Africa. However,the populations of many Asiannations including India and Chinaare so large that even low nationalHIV prevalence means large numbersof people are living with HIV.

The percentage of population withHIV/AIDS in the countries coveredunder Mekong Water and SanitationInitiative ranged between 0.1 per cent(Lao PDR) and 2.6 per cent(Cambodia) with adult age group(15-49); the share of infected womento infected adults in the Asian regionbeing the lowest at 12.9 per cent(Pakistan) and highest at 38.0 percent (India).

The HIV/AIDS epidemic - present scenario


3 UNITED NATIONS HUMAN SETTLEMENTS PROGRAMME

Linkages between HIV/AIDS andthe Water and Sanitation Sector

• The perspective of consumers and users of water andsanitation facilities, especially poor people

• The perspective of service providers:– Formal water and sanitation water service

providers, such as public or private utilities– Non-formal water and sanitation service providers,

such as small scale independent providers, vendorsor community based systems

The Consumer Perspective

• Vulnerability to water and sanitation related diseases• Water for home-based care and productive uses

Sanitation and water-related infections are among themost common causes of illness and death in developingcountries and affect mainly the poor. Poverty is oftenconnected to high HIV/AIDS infection rates and a pooraccess to water and sanitation services.

Depending on the type of HIV and other aspects likeaccess to health and reproductive health services, hygieneand access to water and sanitation services, the period oflatency lasts about seven to ten years. The prevention ofthe mentioned opportunistic diseases through safe waterand sanitation and better hygiene helps infected people tostay healthy longer, what means that they can continue towork and sustain their families.

Water is a basic need for AIDS patients at their homes(home based care) to wash and bathe their patients, togive them medicine and to clean and disinfect the homeenvironment. Access to water and sanitation services andhygiene is not just a basic need but a human right, key tohuman development and human dignity.

Many poor households grow vegetables and fruits in littlegardens to supplement their diet. The availability of waterplays an important role for these productive uses anddecreases the risk of infection to secondary diseases.

In many of the countries with high infection rates, it is thetask of girls and women to fetch water. The risk oftransmitting the virus from HIV-positive mothers throughbreast-feeding is 1:3. An alternative is to feed the childwith a bottle of powdered milk mixed with water. If thewater used is unsafe and water-handling practices are nothygienic, the risk that the child will die of diarrhea risesenormously. In order to prevent this, safe water, soundsanitation practices and hygiene education are essential.

The Perspective of Water and SanitationService Providers

HIV/AIDS has a great impact on the provision andsustainability of water and sanitation services at severallevels:

• Loss of skilled staff/labour• Decline of productivity• Decrease in quality of services

In areas with medium to high infection rates, HIV/AIDScauses a severe decrease in human resources. Manywater companies’ lose skilled or semi-skilled staff forexample, engineers, technicians or administrators. Acompany in Nakuru, Kenya, lost 20% of their employeesto the disease and some organizations in Botswana haveeven started to hire employees from oversea countrieswhere HIV/AIDS rates are lower.

In Kusa, Kenya, there is a project to train young menand women to construct water tanks, spring boxes andwells in the villages. One day, 24 technicians were calledto implement the project. Just half of them showed upand later investigation revealed that three of them died ofHIV/AIDS, five were sick of HIV/AIDS and four technicianstook care of their infected relatives.

Examples show that the impact of HIV/AIDS is huge andthis means that far fewer skilled people and funds will beavailable within the water and sanitation sector in thefuture. Obviously, loss of staff means a decline ofproductivity within the water sector. In the absence ofdata on people infected with HIV/AIDS, water andsanitation demand will be hard to estimate for the waterresource managers.

According to household surveys in Africa and Asia,families living with HIV/AIDS have a reduction of theirincome by 40 to 60 %. This makes them unable to payfor services such as electricity, water supply andsanitation.

Also, there is still a sense of shame related to the issue ofHIV/AIDS and many families don’t want to admit thatone of their members is HIV-positive. Sometimes peoplebury their relatives secretly in “unofficial” graveyards,which may lead to the contamination of ground waterthat is used as a community water supply. Increasednutrient levels and bacteria are likely to enter the groundwater from the graves. This posses potential health risk tocommunities, which rely on boreholes or wells to getwater from shallow aquifers.



Feminization of HIV - The Gender context


HIV/AIDS

Gender Water andSanitation

Strong knowledge base & experience

Weak knowledgebase & experience

HIV Prevalence - Orphans andVulnerable Children

The orphans and vulnerable childrenpose a great crisis now and in thefuture. Currently an estimated 14million children are reported to havelost one or both parents. Furthermore90% of AIDS cases occur between 20-40 years of age, which sadly deprivesmany children of their parents. By2010, the AIDS effect is estimated/projected to leave 25 million orphansand 50 million vulnerable children. Ifthe Orphans and Vulnerable Children(OVC) crisis is left unattended,development projects could faceeconomic collapse in threegenerations (World vision, 2005)

Around the world an increasingnumber of women are being infectedwith HIV. It is often women with littleor no income who are most at risk.Widespread inequalities includingpolitical, social, cultural and humansecurity factors exacerbate thesituation for women and girls(UNAIDS/WHO, 2005).

In several southern African countries,more than three quarters of all youngpeople living with HIV are women,

while in sub-Sahara Africa overall,young women between 15 and 24years old are at least three timesmore likely to be HIV-positive thanyoung men. The biological factors,gender inequalities (socio-culturalfactors, feminization of poverty,unequal or unfavorable laws),violence against women (partnerviolence, sex work trafficking andmigration), HIV testing anddisclosure, rape (wars and conflict) alladd up to the escalation.

HIV Prevalence (UNAIDS 2005)

HIV prevalence among 15-24 year-old men and women selected countries insub-Saharan Africa, 2001-2005

Sources: Demographic and Health Surveys. ORC Macro (Ghana, Burkina Faso, Mali, United Republic of Tanzania, Cameroon, Lesotho, Kenya, Zambia);Department of Health, Uganda HIV/AIDS sero-behavioural survey 2004 - 2005 (Uganda); Ministry of Health and Child Welfare, Zimbabwe National FamilyPlanning Council, National AIDS Council, and CDC, The Zimbabwe Young Adult Survey 2001 - 2002 (Zimbabwe); Pettifor AW, et al. HIV and sexualbehaviour among South Africans: a national survey of 15-24 year olds (South Africa).”

20

15

10

5

0

% H

IV p

reva

len

ce

Ghana2003

Burkina Faso2003

Mali2001

Tanzania2003

Cameroon2004

Uganda2004/05

Kenya2003

Zambia2002

South Africa2002

Lestho2004

Zimbabwe2001/02

Phase two: This phase cantake 7 to 9 years where aperson looks healthy andthe immune system is stillbattling with the HIV virus.Even though the person ishealthy looking and goesabout his duties asnormal, it must be notedthat he is infectious andcan transmit the virus toanother person. At thisphase, the focus ofintervention is directedtowards positive living.

The four phases of HIV/AIDSPhase 1: This is when aperson gets infected by thevirus that causes AIDS(HIV). During this phase itis not easy to recognisethat one has been infectedby HIV as there are nodistinct signs norsymptoms. Normally aperson may experience ashort bout of fever, orcough, flu, sore throat etcwhich quickly disappearwithout any treatment.Confirmation of aninfection can only beknown 6 weeks to3 months from the time ofinfection through alaboratory test. This stagemay also be calledasymptomatic as there areno symptoms. During thisphase the focus andintervention is directedtowards awareness raisingand prevention.

Phase three: This is theAIDS phase where aperson’s immune systemhas been destroyed by HIVvirus and now suffers to agreat extent from variousopportunistic infections.Various signs andsymptoms appear andshe/he becomes weak andmore often needs care andsupport in order tocontinue to survive. Inplaces where there isaccess to ART, she/he mayaccess the same to helpboost the immune and toprolong life. At this stagethe focus of intervention isdirected towards treatment,care and support.


Phase four: This is the laststage in a person’s lifewhen the body immunesystem can no longermanage to contain theinfections. It might also bereferred to as the deathstage. At this stage eventhe treatment can nolonger sustain life.Depending on one’s abilityto fight off the infections itmay take up to 2 yearsfrom the time individualreached phase three of theinfection- from AIDS stageto death may take up to 2years. At this stage, thefocus is normally on impactmitigation.

HIV/AIDS Vulnerability and Mitigation Matrix for Countries Participating in Water for African and Asian CitiesProgrammes (WfC)

AIDS HIV/AIDS Adult PrevalenceImpactLevel LOW HIGH

LOW Phase 1: Low adult prevalence, Phase 2: High adult prevalence, low impactlow impact

Indicators: low HIV prevalence, low number of orphans, Indicators: high HIV prevalence, slightly increasing number of orphans, slightlylow number of affected households, low employee increasing number of affected households, slightly increasingabsenteeism employee absenteeism

Focus on: Awareness raising, advocacy Focus on: Preparedness, Impact mitigation preparation, workplace policiesand human values education

Example WfC Countries: India, PR of China, Nepal Example WfC Countries: Cambodia, West Africa, Ethiopia

HIGH Phase 4: Levelling or even reducing Phase 3: High adult prevalence, high impactadult prevalence, high impact

Indicators: stable or even decreasing HIV prevalence, Indicators: increasing high HIV prevalence, high number of orphans,high number of orphans, high number of high number of affected households, high increasing employee absenteeism andaffected households, high increasing employee increasing mortalityabsenteeism and increased mortality

Focus on: Impact alleviation and rehabilitation Focus on: Impact alleviation

Example WfC Countries: Uganda, Tanzania Example WfC Countries: Mozambique, Zambia

Women

Men

Phases of HIV/AIDS (IRC 2003)

Firstinfection

Healthcurve

Blind period First opportunistic diseases AIDS Death

First disease

Period oflatency 7-9years or more

1st stage 2nd stage 3rd stage 4th stage

1. Purpose of the checklist

Mainstreaming HIV/AIDS intopolicies and strategies

Water Agencies need aHIV/AIDS policy to lowerthe impacts on thecompany itself and tointegrate HIV/AIDS into theprovision of service.

In many Southern Africancountries, there is a lack ofregion-wide programmesof action and manygovernments deny havingan AIDS epidemic in theircountry. Some governmentwater departments, forinstance, the ZimbabweNational Action Committeefor Rural Water Supply andSanitation understands theimportance ofmainstreaming HIV/AIDSinto every single dimensionof the sector. TheZimbabwe Water andSanitation Sector HIV/AIDSReport was published inJune 2003 points out thechallenges of the WaterSector concerning HIV/AIDS-prevention, care,mitigation, advocacy andresearch activities.

Strengthening the role of localcommunities

Community-basedapproaches are known asthe best way to ensurereliable and sustainablewater services. Localresidents and localorganisations should takepart in planning andsupporting effectiveoperation andmaintenance of waterservices, and combine thatwith rising awareness ofHIV/AIDS-issues.

Importance of HIV/AIDS inWater Supply and Sanitation(WSS) projects

“The fight against HIV/AIDS calls for a multi-sectoral approach in whichthe water and sanitation sector funds its place and plays its role effectively.The sector, therefore, responds positively to the challenge through itsprojects to utilize its knowledge and expertise to face the pandemic.”

The WSS projects should provide guidelines/strategic for the integration ofHIV/AIDS awareness into the water and sanitation activities. They have toprovide approaches in prevention, care and impact mitigation measuresagainst the spread of HIV/AIDS as well as to relevant WSS-HIV/AIDS researchlinks.

It is now recognised that a better provision of safe water and adequate/acceptable sanitation improves the health and status of people living withHIV/AIDS.

Challenges for the Water and Sanitation Sector


Priorities for areas with highinfection rate

Programmes and Policymakers should give higherpriority to water supply,sanitation and hygienepromotion in areas withhigh infection rates.

In Limpodo Province, SouthAfrica, the followingmeasures have beenrecommended to be takenwithin the country

• Municipal WaterServices DevelopmentPlans must take theimpact of HIV/AIDS onwater demand intoaccount

• Water and sanitationtariffs and subsidymechanisms should bepro-poor and considerhouseholds affected withHIV/AIDS

• The best use of existingcapacity in water servicesprovision should bemade, particularly in thelight of potential lossesin human resourcecapacity through HIV/AIDS

Integrating health and hygieneeducation

There is need to integratehealth and hygieneeducation for the mitigationof HIV/AIDS, theimportance of promotinghealth and hygieneeducation by the watersector must be stronglytaken into account.Programmes for health andhygiene education can helppeople living with HIV/AIDSto minimise the negativeimpacts of the disease.These programmes shouldinvolve local initiatives whichcan be much more effective.


Mainstreaming HIV/AIDS is a process that enablesdevelopment actors to address the causes and effects ofAIDS in an effective and sustained manner, both throughtheir work and within their workplace. It thereforeaddresses both direct and indirect aspects of HIV/AIDSwithin the context of the normal functions of anorganization or community. Critically, mainstreamingtakes into account an organisation’s mission, mandateand comparative advantages and relates these to thedirect and indirect aspects of the epidemic.

The purpose of mainstreaming is to help people at alllevels get beyond “business as usual” and to address theissues in meaningful ways in all sectors, both inside theirown organizations and in the communities they serve.

The effectiveness of mainstreaming HIV/AIDS needs along term, systematic approach with a high levelcommitment from the senior managers and staff, and inthe case of private sector, the commitment of theshareholders. Mainstreaming can be viewed from threemain aspects:

HIV/AIDS in the workplace

To enhance the ability of an organisation and its staff toanticipate, minimize, and cope with illness, death andpossible financial resources associated with the HIV/AIDSpandemic by providing major thrust on the following.

• Staff awareness• Staff health policies• Performance management system• Budgets and financial planning• Human resource workforce planning

Mainstreaming HIV/AIDS into strategy and programming

Given the nature of HIV/AIDS, regardless of the work theorganization undertakes, some clients are affected byillness and death associated with HIV. Many more are atrisk, and some will eventually contract HIV themselves, orbecome directly affected by the illness and death ofothers. The overall effect which calls for immediatestrategic programming includes:

• Risk of the organisation’s ability to run efficiently andeffectively

• Incomplete activities due to illness and funeralsattendance

• Community members succumbing to illness orreduced to the role of careres

• Changes in household composition• Vulnerability of children, women and elderly as they

assume greater roles and burdens• Asset ownership of the affected families.

Sound economic and social development helps affectedpeople mitigate the impact of illness and death, andincreases their options. Imperatively, organisations in allsectors need to take steps to ensure their core business isrelevant to the changes in societies and families broughtabout by HIV/AIDS.

Links with focused interventions on HIV/AIDS

This type of mainstreaming involves direct support tofocused HIV/AIDS interventions such as those dealingwith prevention, care, and treatment or supporting thoseliving with HIV or affected by the illness and health ofothers. The relationship between HIV/AIDS focusedinterventions and work in other sectors is fundamental tomainstreaming and has two key benefits:

• Supports and builds on the strengths of all• Ensures that complementary services are offered and

help minimize the opportunity costs that mayundermine efforts of a single organization.

Mainstreaming HIV/AIDS



HIV/AIDS is having, and will continueto have, significant social andeconomic consequences in thecountries affected. In the developingcountries, for example, in Africa, thespread of AIDS has coincided with aperiod of protracted economicstagnation that has seriouslycompromised the standard of livingof the population. Inadequate andovercrowded housing conditions anda general lack of cautionarymeasures to prevent infection, providea conducive environment for thespread of the disease. In the case ofshelter, the significant increase ofhomeless people in countries affectedby HIV/AIDS and more often thannot, AIDS orphans have beensignificantly increasing the number ofstreet children. This increase ofhomeless and street children hasimpaired the safety and security incities. Related factors have increasedincidences of poverty, shelter povertyin particular, and have led to a

marked deterioration of humansettlements conditions in the affectedcountries.

Across countries studies show that thegreatest need for people with HIV/AIDS, apart from medical treatment,is Housing. Aligning humansettlements to HIV/AIDS preventionand management involves:

• Identifying current or plannedpublic works and developmentprojects where HIV/AIDS impactmay be significant, and useimpact assessments to modifyplanning

• Identifying which features ofhealth care facilities, educationalfacilities and orphanages are bestable to respond to changedneeds and demands as a result ofHIV/AIDS

• Reviewing specifications for thedesign of buildings for publicinstitutions to encourage thefeatures identified above

• Ensuring that the location, sizeand design of facilities take intoaccount welfare policies andplans for housing and care oforphans, expected migration anddemographic impacts of HIV/AIDS

• Reviewing and streamlining policythat may unnecessarily hinder therecycling of unused buildings forshelter and care or orphans

• Incorporating projections of AIDSdeath in planning mortuaries,burial space and crematoriafacilities or encourage this actionacross relevant local authorities

• Finding ways to encourage localprojects to identify useful featuresof houses or tenure arrangementsin the context of high HIVprevalence and altered householdcomposition

• Revising tenure legislation ifnecessary to ensure it balancesthe need to provide adequateprotection for AIDS sufferers withsustainability of company housing

In June 2001, 29 UN system entitiescontributed to the creation of the UNSystem Strategic Plan for HIV/AIDS(UNSSP). In accordance with theGlobal Strategy Framework on HIV/AIDS, the UNSSP sought to clarifyroles and responsibilities on HIV/AIDS in the UN system, so as topromote system-wide coherence andstrategic effectiveness, and to improvecoordination and communicationamong diverse UN systemorganisations. The UNSSP articulatedsystem-wide objectives and identifiedthe responsibilities of individual UNentities in achieving these objectives.

Objective

The UNSSP has an overarching goalof ensuring that UN systemorganisations, individually andcollectively, contribute to theMillennium Development Goal ofhalting and beginning to reverse thespread of HIV/AIDS by 2015 andmeeting the targets of UNGASSDeclaration of Commitment.

Strategic objectives

The UN will pursue 8 strategicobjectives:

A. Build capacity and leadershipB. Protect and promote human rights

C. Strengthen and accelerate HIVprevention and vulnerabilityreduction

D. Facilitate the provision of care,support and treatment

E. Alleviate socio-economic impact andaddress special situations

F. Strengthen HIV/AIDS-related researchand development and developmechanisms for follow-up,monitoring and evaluation

G. Mobilise ResourcesH. Strengthen commitment, action and

joint accountability of the broaderUN system

With these strategic objectives,UN-HABITAT in cooperation withUNAIDS is mainstreaming HIV/AIDS intoits work programme of 2006-2007.

UN Strategic Framework on HIV/AIDSand UN-HABITAT’s response

HIV/AIDS and the Human Settlements Sector



From several sectors work on HIV/AIDS response andinterventions several issues have been learnt which poseas challenges to the Water and sanitation Trust Fund.These include:

• The need for political commitment at the highest levelis crucial for effective prevention and impactmitigation of HIV/AIDS

• It is now acknowledged that HIV/AIDS is adevelopment problem that has implications for allpublic and private entities and not just for the healthsector

• The people affected by HIV/AIDS may have animportant function in breaking the silence and toshow that they can continue to live a productive life,care for their families and contribute to communityactivities

• Water, sanitation and hygiene education services arekey for HIV/AIDS prevention and impact mitigation.

• The greatest challenge is that within this area, there islimited evidence-based research findings availableand limited experiences from water and sanitationfield operations.

• Software side of water and sanitation programmes,such as pro-poor governance, gendermainstreaming, human values-based education,income generating activities (IGAs), that result inbehaviour change, empowerment and povertyalleviation also address key issues of HIV/AIDS

Areas of Impact Mitigation

• Staying healthySafe water supply and acceptable sanitation helpeliminate diarrhea and skin diseases which arecommon opportunistic infections.

• Home based careAs caring for people living with AIDS withincommunities is now regarded as an essentialelement in the continuum of care, it calls for areliable water supply and good sanitation areindispensable for bathing, washing, cleaningand disinfecting the home environment, as wellas water for taking medication. Together withthis, hygiene education must be integrated intraining for home based care

• Infant feedingAs an alternative to breastfeeding, bottle-feedingis suggested depending on affordability, culturaland social acceptability. In such a situation, safewater, sound sanitation practices and hygieneare needed to prevent the baby from falling ill.

• Labour savingDue to accessible water supply to householdsaffected by HIV/AIDS

• Water for productive useWater can be a source for income generatingactivities and for softening food for those patientssuffering from mouth ulcers or thrush.

Lessons learnt and challenges



• Strengthen core competencies ofWater and Sanitation Trust Fundand build on comparativeadvantage.

• Carry out water and sanitationprogrammes work in a way thatthey address the causes andconsequences of HIV and AIDS.Ensure that all the pro poorcommunities have a continuoussupply of safe water within theirvicinity. This has a doublepositive effect of reducing thevulnerability of the women/girlswalking long distance in searchof water and also safe water tobe used for taking medications.

Health care of people affected by HIVand AIDS also need the core servicesof water and sanitation as apreventive and mitigating condition.

• Start with assessing andanalysing water and sanitationsituation level and quality ofservices, poverty, gender, etc Thiscalls for a strategic mapping ofall the vulnerable groups in thecommunity that may be broughtabout by the scarcity of the same.

• Start with understanding HIV/AIDS then move to health anddevelopment nexus.

The wider correlation betweenHIV/AIDS and the developmentchallenges that it posses call forimmediate consideration andunderstanding and not merelyfocusing only on HIV/AIDS Healthcare of people affected by HIV andAIDS also need the core services ofwater and sanitation as a preventiveand mitigating condition.

• Focus on risk and vulnerability,not on AIDS per se.

• Use phases of HIV/AIDSprogression to guide analysisand action.

Plan for the future implications andmitigation in addition to establishingrobust preventive measures, as wellunderstanding the probable financialmedical implication once the staff orcommunity are in need of the sameas their body get weakened by thevirus.

• The dealing with HIV epidemicneeds the unrelentingcommitment of leadership at thehighest levels- from the head ofstate, relevant ministries to thecommunity.

• Differentiate Internal and ExternalStrategy.

• Internal: HIV/AIDS WorkplacePolicy for water and sanitationservice providers.

• External: Mainstreaming HIV/AIDS into strategic planning,programming and operations ofa water and sanitation serviceprovider and its relations withcustomers

• Avoid duplication and developlinkages with ongoing HIV/AIDSInitiatives within the UN and atUN-HABITAT.

While it is true that HIV/AIDS nowcovers all parts of the world, specialconsiderations in terms of strategicresponse has to be put in place thatnotes the variance on regionalnational and even to the communitylevel.

Strategic focus on prevention of highrisk groups and 5 to 15 year olds(long-term strategy) must be givenpriority.

• High Prevalence Environments.• Gender prevalence of HIV.• Women and girls are vulnerable

to sexual violence (and thus HIV)when collecting water and fuel.

Strategic Considerations



Strategic entry points of interventionStrategies for addressing HIV/AIDS

1. Normative ActivitiesDevelopment of pro-poorand gender sensitivegovernance frameworks,including policy options,norms, standards andmanagement toolkits forthe urban WATSAN sector

Prevention

Human Values-based Water,Sanitation and HygieneEducation

Positive Living

Pro-poor water governanceframework provides anopportunity to involvePLWHA and a platform toensure their needs in termsof water and sanitation areaddressed.

Treatment Support Impact Mitigation

A pro-poor governanceframework allows vulnerablegroups and survivors, such aswidows/ers, orphans and theelderly to participate indevelopment processes in ameaningful manner.

Private sector and the urban poor: This framework enables an HIV/AIDS workplace policy forwater utilities, small-scale independent providers and community-based systems which cangreatly enhance conditions for care and treatment of PLWHV and impact mitigation.

Mainstreaming HIV/AIDS issues into Rights-based approaches to water can greatly contribute tothe protection of rights of PLWHA and survivors, such as orphans and widows.

Rainwater Harvesting is astrategic tool for support toPLWHA to supplement theincreased need for water.

Rainwater Harvesting is astrategic entry point forimproving the livingconditions of orphan headedhouseholds, as it supportsshelter improvements andopportunities for incomegeneration

• There is a need to mainstream HIV/AIDS issues into all activities such as pro-poor governance, sanitation for the urban poor,urban catchment management, water demand management, water education in schools and communities, advocacy-raisingand information exchange of the Water for African Cities Programme Phase II

• The Water for Asian Cities Programme is a low prevalence region, where the main focus should be on awareness raisingand preparedness for the increase of HIV/AIDS in the region.

2. Operational Activities:Facilitate pro-poor, gendersensitive investment throughregional WATSANprogrammes

(Advocacy, awarenessraising, value-based watereducation, capacity buildingand training, and gendermainstreaming anddemonstration activities)

Mainstreaming HIV/AIDS into Urban Water Demand Management will allow utilities to betterunderstand the changing profile of water users, sick, widows, orphans and elderly. It will alsoprovide utilities to address the need of PLWHA for increased water and improved sanitation.

Urban Catchment Management as a bio-structural intervention is a new promising area, whichcan contribute to alleviating the impact of HIV and AIDS.

Environmental Impact Assessment Guidelines also focus on social impacts, particularly theurban poor, and should include considerations of impact assessment on PLWHA and survivors,such as orphans and widows.

The improved water andsanitation provision throughthe Lake Victoria and MekongInitiatives will contribute to theimproved living conditions ofPLWHA and also reducevulnerability.

3. Replicable Model-settingInitiatives:Provide strategic support topro-poor, gender sensitiveinitiatives at the local levelwith a focus on participatoryinvolvement of localcommunities.

Both LVWATSAN and MEK-WATSAN Initiatives provideunique opportunities forsupporting work on orphanheaded households andhome based care.

4. Monitoring Activities:Monitor progress towardsWATSAN targets.

The ongoing monitoring process can include an element on HIV/AIDS and contribute to the better understanding of the impactof insufficient water and sanitation on HIV/AIDS (vulnerability) and the impact of health on the performance of the water andsanitation sector.



• Pro-poor governance• Sanitation for the urban poor• Water Demand Management• Urban Catchment Management• Gender mainstreaming

The first step for developing a strategicframework for addressing HIV/AIDS isto formulate an objective within theframework of the overall developmentgoals of the Water and Sanitation TrustFund.

“To support developing countriesimprove access to safe water andhealthy sanitation thus preventingtransmission, provide care and supportand mitigate the impact of HIV/AIDSwith a special focus on the poor andvulnerable in urban areas”.

In order to achieve this, the followingfive strategic directions will support thisobjective:

Strategic Direction 1:Awareness raising, Human values education,advocacy

To raise awareness and advocate onhow to address HIV/AIDS through waterand sanitation initiatives amongst WSIBstaff, national policy makers, boardmembers and CEO’s of water andsanitation service providers andcapacity-building institutions

This is to convince decision makers thatAIDS is relevant and that they can dosomething about it in theirorganisations. In addition it targetscapacity building institutions with a viewto building their capacity and ormaking them put a priority to the HIV/AIDS component in their capacitybuilding programmes. It will explore theinvolvement at the highest level policymakers as well as policy implementerswithin the relevant authorities.

Strategic Direction 2:HIV/AIDS Work place policies for serviceproviders

To build capacity in water andsanitation service providers, both formaland informal (small scale independentproviders, community systems) todevelop and implement HIV/AIDSworkplace policies

This is attributed to water andsanitation service providers and largelyto their limited knowledge on their roleas well as inadequate capacity that theyhave. For the small independentproviders and community watermanagement systems, there is anurgent need to equip them with skillson areas of cost effectiveness andmaking use of the local resources forproductivity and healthy living in theface of AIDS epidemic.

Strategic direction 3:Mainstreaming HIV/AIDS into projects andstrategies

To mainstream HIV/AIDS into the pro-poor and gender sensitive normativeand operational activities of the workprogramme of the Water and SanitationTrust Fund, focusing on awarenessraising and advocacy, human values-based education, capacity building,networking and partnerships

The strategy will look into ways ofenabling and prioritisingmainstreaming into the entire waterand sanitation sector so that the sectorcan effectively and efficiently contributetowards prevention, care and impactmitigation caused by HIV/AIDS.

Strategic direction 4:Specialised/focused HIV/AIDS interventions

To develop strategic partnerships withspecialized HIV/AIDS programmes andinterventions and to support HIV/AIDSinitiatives focusing on vulnerable groups,

such as women, children and elderly(focus on orphans and vulnerablechildren (OVCs) and home based care)

This underscore the linkages andbenefits that exist by working inpartnerships thus complimenting thework already established by other HIV/AIDS specialized programs. It alsoconsiders the roles of the sector inaddressing the needs of the vulnerablegroups of –women, children and theelderly.

Strategic direction 5:Increasing knowledge base

Increasing the knowledge base on howwater and sanitation can reducevulnerability and the impact of HIV/AIDSon the sustainability of water andsanitation projects through appliedresearch and strategic partnerships withongoing work in this area

This last strategic objective focuses onfuture programming. It considersresearch and best practices that thatcan be replicated in other areas orregions so as to quickly respond andaddress the ever changing needs of thepopulation and household changes asposed by AIDS. It considersstrengthening the work to be done toreduce vulnerability through routinemonitoring and assessing of the impactof interventions.

Objective of Developing a Strategic Framework

Awareness raising, Human values education, advocacy

Increasingknowledge base

Specialised/focusedHIV/AIDSinterventions

Mainstreaming HIV/AIDS into projects andstrategies

HIV/AIDS Work placepolicies for serviceproviders



Action Plan



Strategic Objective 1 Priority

To raise awareness and advocate how to address HIV/AIDS through water andsanitation initiatives amongst WSIB staff, national policy makers, board members andCEO’s of water and sanitation service providers and capacity-building institutions

1.1 Building a common Undertake situational analysis of the HIV/AIDS situations Mediumunderstanding in organisations

1.2 Awareness raising Raise awareness and provide information’s about HIV situations, Shortits broad implication to the business.Developing a detailed public awareness, advocacy andinformation-sharing component in collaboration withother stakeholders.

1.3 Lobbying and Lobby through the relevant ministers to make: Short toadvocacy at the HIV/AIDS a priority in their ministerial work. Mediumhighest level Meet with the MCOW, Council of ministers for both Mekong

and Lake Victoria regionsIn agreement with the relevant ministries, to develop Pro-poorurban water governance frameworks

3


To build capacity in water and sanitation service providers, both formal and informal(small scale independent providers, community systems) to develop and implementHIV/AIDS workplace policies.

2.1 Conduct pilot Undertake pilot demonstration on three selected utilities Shortdemonstration in as a fast track initiative.two to three utilities

2.2 Assessment Assess the work currently being undertaken by the Mediumof the ability to deal water utility and sanitationwith HIV/AIDS

2.3 Provide technical Help to draw up workplace HIV/AIDS intervention policies Mediumsupport to water that will include:and sanitation – Staff awareness and addresses risky behaviours/factors:service providers – Staff health policies, particularly addressing treatment/ support

and impact mitigation-organisational commitment onHIV/AIDS issues.

– Financial planning and budgets to deal withHIV/AIDS related issues and costs

– Create a forecasted plan for the human resource changesand absenteeism.

– Establish a peer education system

2.4 Sustainability of Make the utilities understand that they stand to loose in the Mediumthe water and absence of a long term plan and strategy that addressessanitation utilities their internal aspect and at the same time focusing on the consumers.

Education for water usage and managementHelp develop skills on energy saving techniques for waterand sanitation

2.5 Training Training and capacity building programme will be developed to Shortaddress needs expressed by countries, such as water demandmanagement, community based quality testing, sanitation,pro poor governance.


To mainstream HIV/AIDS into the pro-poor and gender sensitive normative andoperational activities of the work programme of the Water and Sanitation Trust Fund,focusing on awareness raising and advocacy, human values-based education,capacity building, networking and partnerships

3.1 Program Work towards ensuring that the all aspects and program cycles Mediumdevelopments incorporate HIV/AIDS as a component.

3.2 Integration Work towards integral analysis of HIV/AIDS in relation to Mediumorganisational mission/mandate beyond 5 five year period.

3.3 Targeted Special attention must be given to the youth, elderly and women, Mediuminterventions at the same time understanding that the types of interventions

might differ or change depending on

3.4 Gender Developing a detailed gender mainstreaming strategy to Mediummainstreaming. be applied to the local level.

Action Plan




To develop strategic partnerships with specialized HIV/AIDS programmes andinterventions and to support HIV/AIDS initiatives focusing on vulnerable groups,such as women, children and elderly (focus on orphans and vulnerable children (OVCs)and home based care).

4.1 Strategic Undertake a partner mapping exercise through stakeholder MediumPartnership analysis to determine the what activities are done by others in

the focused area

4.2 OVCs, elderly Link up the ongoing initiatives of UN-HABITAT’s lake Victoria region Shortand women Water and Sanitation Initiative, by providing safe drinking watersupport and sanitation to AIDS child orphan headed households.

4.3 Support to Encourage partners to address HIV/AIDS in their workplaces and Mediumpartner in their programs. Provide necessary links to technical supportorganisations as well as funding where necessary.


Increasing the knowledge base on how water and sanitation can reducevulnerability and the impact of HIV/AIDS on the sustainability ofwater and sanitation projects through applied research and strategic partnershipswith ongoing work in this area

5.1 Piloting of projects To spearhead demonstration and piloting of new and innovative Mediumapproaches to service provision that specifically target theurban poor and other vulnerable groups

5.2 Continuous Have in place, a system that encourages research and development, Mediumresearch showcasing best practices within the water and sanitation sector

especially in the areas of impact mitigation and prevention

5.3 Monitoring and Explicitly and routinely assessing relevance of activities to those MediumImpact analysis affected by HIV/AIDS

5.4 Perfecting the The water and sanitation sector should retain its focus on its core Mediumcore service business and determine how to support WATSAN development

in ways that are relevant to people affected by HIV/AIDS whilebearing in mind that the agency itself is/will be affected byillness and death.

Action Plan



Acknowledgements

Strategy for addressing HIV/AIDS Issues in Water and Sanitation Activities has been prepared under the overallsupervision and co-ordination of Mr. Andre Dzikus, Programme Manager, Water for Cities Programmes, Water,Sanitation and Infrastructure Branch, UN-HABITAT. A comprehensive strategy document was prepared by LynetteInjette Ochola with inputs from Mr. Samuel Sakwa and Mr. Charles Ogutu. This was reviewed by Dr. KulwantSingh and Mr. P. S. Mathur for preparing an abridged version as a brochure.

The special inputs and many suggestions for the Strategy were also provided by Dr. Dinesh Mehta, OIC, UrbanDevelopment Branch, the staff of the Water, Sanitation and Infrastructure Branch and Dr. Paul Dover, RegionalAdvisor, SIDA HIV/AIDS Team for Africa.

Programme Contact Persons:

Kalyan RaySenior AdvisorOffice of the Executive DirectorUnited Nations Human SettlementsProgramme (UN-HABITAT)P.O. Box 30030, Nairobi, KenyaTel: (254-20) 7623039Fax: (254-20) 7623588E-mail: [email protected]

Bert DiphoornChiefWater, Sanitation and Infrastructure BranchUnited Nations Human SettlementsProgramme (UN-HABITAT)P.O. Box 30030, Nairobi, KenyaTel: (254-20) 7625420Fax: (254-20) 7623588E-mail: [email protected]

Kulwant SinghChief Technical AdvisorWater for Asian Cities ProgrammeRegional OfficeEP 16/17, Chandragupta Marg,Chanakyapuri, New Delhi -110 021, IndiaTel: (91-11) 42225019/42225022Fax: (91-11) 24104961E-mail: [email protected]

Andre DzikusProgramme ManagerWater for Cities ProgrammesUnited Nations Human SettlementsProgramme (UN-HABITAT)Water, Sanitation and Infrastructure BranchP.O. Box 30030, Nairobi, KenyaTel: (254-20) 7623060, 7625082Fax: (254-20) 7623588E-mail: [email protected]

Documents

Strategy For Addressing HIV/AIDS in Programme Activities