Failing Women, Withholding Protection

HIV prevention with female condom

female condom to prevent HIV15 lost years in making the female condom accessible.

Oxfam Novib has been one of few organisations in the world investing in allowing the female condom to serve its purpose. I was fortunate to have the job of researching and writing this briefing paper for them.

They and the World Population Fund used it in their advocacy push at the 2008 International AIDS Conference. Find out more about their Universal Access to Female Condoms campaign here.



2008 marks 15 years since the female condom was invented, and, disgracefully, 15 years of failing to make them accessible to the women who need them. Despite the absence of any other female-initated form of protection, and unprecedented rises in funding for the response to HIV, female condoms remain inaccessible, and their contribution remains untapped.

The urgent need for access to female condoms is evident in the feminisation of the HIV pandemic, the large unmet need for contraception, and the pitiful progress towards meeting Millennium Development Goals 5 and 6 on maternal health and halting and reversing the spread of HIV.

Why provide female condoms, when male condoms are readily available, much cheaper, and provide a comparable level of protection?

  • Female condoms are a tool to assist women’s empowerment. Women who use female condoms report an increased sense of power for negotiation of safer sex, and a greater sense of control and safety during sex. It will be many years until women have any alternative femaleinitiated means of protecting themselves.
  • Providing both female and male condoms leads to more instances of protected sex and reductions in the incidence of sexually transmitted infections (STIs). Their additive effect, providing protection in instances which would not be protected by male condoms, makes them a costeffective form of HIV prevention.

Studies have repeatedly shown high levels of acceptability for female condoms. Some users prefer them over male condoms, as they offer more flexibility regarding the timing of putting them on and taking them off, and have a more natural feel. However, many donors and policy-makers remain sceptical that sufficient demand for them exists. Yet examination of femalecondom projects reveals significant demand, even though it is often deliberately suppressed and unintentionally undermined by stigmatisation and running out of stock. What is perceived as an issue of demand is actually one of supply. Expanding access to female condoms is held up not at the users’ end, but at the start of the chain: how much money donors and governments are willing to invest in buying female condoms, supporting female-condom programmes, and developing low-cost female condoms.

What is behind the failure to act comprehensively to create access to female condoms? Responses from donors and policy-makers to the female condom mirror the common reasons for not using a male condom: responses formed by ignorance, culture, denial, ‘poverty’, and conservatism. Added to this are overarching errors of a lack of leadership, a huge funding bias against existing forms of primary HIV prevention, failure to scale up programming, and failure to invest in strategies to lower the cost of female condoms.

Of course, some efforts have been been made in the past 15 years, which have accelerated since the launch of the United Nations Population Fund’s (UNFPA) global Female Condom Initiative in 2005. The rapid expansion of sales and free distribution in the few countries at the forefront of female condom programming demonstrates the massive unmet demand for female condoms. But there is so much more to be done. Worldwide, in 2007, roughly 423 male condoms were produced for just one female condom. Female condoms currently have a unit cost about 18 times higher than male condoms.

The levels of investment and programming needed to increase the choice of available female condoms, to lower prices and to expand production are highly feasible. Through collaborative action, donors, governments, civil society organisations and the private sector can begin the progress of achieving universal access to female condoms. Female condoms exist now, and concerted efforts to make them accessible must begin now.

Good Donorship in a Time of AIDS: Guidelines on Support to Partners to Manage HIV/AIDS in the Workplace

internal mainstreaming HIV

HIV in the workplace
Good Donorship in a Time of AIDS: Guidelines on Support to Partners to Manage HIV/AIDS in the Workplace

These guildlines were the outcome of an interesting process of research and negotiation with five Dutch donors.

In them I set out the sponsoring donors’ commitments to support their partners’ efforts to manage HIV in their workplaces in pilot projects in Uganda and India. I also presented the rationale and basic steps for organisations to do this.



Why have we developed these guidelines?

Breaking the silence: in many partnerships between Northern and Southern NGOs, HIV/AIDS is not discussed, or is discussed only in terms of the effects at community level. We want HIV/AIDS to be part of our dialogue with partners, and hope that these guidelines will lead to it being on the agenda, for both donors and partners. The guidelines may also help stimulate discussion within partner organizations.

Acting in solidarity: we are now in the late stages of developing and implementing workplace programs for our own staff, but are funding local partners which lack such programs. We believe we should actively open up dialogue and provide support to our partners, rather than be ‘concerned bystanders’, watching the impacts of HIV/AIDS on our partners but doing little to assist.

Getting our ‘heads out of the sand’: a recent CARE survey3 of 42 NGOs in Southern Africa found that, despite a HIV prevalence rate of around 25%, two thirds of the respondents said they did not think they had any HIV-positive employees! This vividly illustrates how managers may act like ostriches by ignoring difficult realities, a costly habit in the case of HIV/AIDS. These guidelines are about raising our heads, stating our commitments, communicating them to our partners, and helping them also to raise their heads.

Responding to demands from local NGOs: some donors expect better results from NGOs in high prevalence settings, or lower costs, as if HIV/AIDS does not exist. Research with local NGOs shows that instead of that lack of understanding, they want more openness, more support, and more clarity from their donors with regard to managing HIV/AIDS4 . These guidelines should go some way to meeting those demands.

Responding to demands from Program Officers: our Program Officers sometimes get requests from partners to fund their workplace policies. Some of them feel ill-equipped to deal with this new topic, and have asked for guidance. These guidelines should help them make decisions, and should ensure that partners’ requests are dealt with consistently within each of the Dutch donor NGOs.

Influencing others: other NGOs who work through partnership with organizations in the South are facing the same issues, but none have ‘grasped the nettle’ and developed guidelines on good donorship in a time of AIDS. We can share these guidelines with those development agencies, and so use them to stimulate their response. We expect that partners may also use these guidelines to influence their other donors towards ‘good donorship’ with regard to HIV/ AIDS.

Greater accountability: where local NGOs do not have budgets to cover employees’ health care costs, managers may cover the costs with money from other parts of their budgets. They are unlikely to tell their donors about this. These guidelines should increase communication and so accountability between us by providing clarity on what costs we are willing to fund, and by initiating dialogue between donors and partners, so that we can agree budgets to cover the financial costs of HIV/AIDS and other chronic diseases.

Support to Mainstreaming AIDS in Development

internal and external mainstreaming HIV

Support to Mainstreaming AIDS in DevelopmentSupport to Mainstreaming AIDS in Development: UNAIDS Strategy Note and Action Framework

Mainstreaming AIDS is a process that enables development actors to address the causes and effects of AIDS in an effective and sustained manner, both through their usual work and within their workplace.

Although not credited as such, I co-wrote this Strategy Note (minus the Action Framework) with Bob Verbruggen of UNAIDS.



Twenty years into the pandemic, there is now ample evidence for the complex linkages between AIDS and development: development gaps increase people’s susceptibility to HIV transmission and their vulnerability to the impact of AIDS; inversely, the epidemic itself hampers or even reverses development progress so as to pose a major obstacle to the achievement of the Millennium Development Goals.

The growing understanding of this two-way relationship between AIDS and development has led to the insight that, in addition to developing programmes that specifically address AIDS, there is a need to strengthen the way in which existing development programmes address both the causes and effects of the epidemic in each country-specific setting. The process through which to achieve this is called ‘Mainstreaming AIDS’.

The Rationale for Mainstreaming AIDS in Development

1) Mainstreaming aims at improving development practice so as to enhance its contribution to the response to AIDS:

  • By having development actors attend to both the immediate and the underlying determinants of people’s susceptibility to HIV infection:

HIV spreads “along the fault lines of failing development”, such as poverty, gender inequality, poor social services. Mainstreaming enables development actors to strengthen the way in which they help reduce the susceptibility to HIV infection of the people they serve. This implies that they also try to identify and minimize unintended negative effects of their own work, such as increasing gender inequality.

  • By having development actors take into account the impact of AIDS and adjust their work accordingly:

AIDS disproportionately hits the most vulnerable groups, and affects the capacity of development actors themselves: it thus deepens existing development problems. Through the process of mainstreaming, development actors analyse and address the impact of AIDS both on their own capacity and on the people they serve, now and in the future.

2) Conversely, mainstreaming is about gradually incorporating national responses into national development processes in order to ultimately equip countries with the capacity to reverse and contain the epidemic. Through the process of mainstreaming, national responses are being institutionalized within national development instruments and processes: this will ensure the sustainability of AIDS programmes and strengthen national coping capacity, thus allowing them to achieve lasting results.

Mainstreaming and the National Response

Considering the above, mainstreaming and national responses are inseparable:

  • While all development actors, including international development agencies, need to mainstream AIDS in their work, it is not possible for any of them to respond to the complexity of the causes and effects of AIDS by itself. The intended system-wide impact of mainstreaming can only be achieved if the respective efforts complement and reinforce each other.
  • Inversely, for national responses to achieve their ultimate goal of containing the epidemic, they need to address the development-related causes and effects which fuel it through effective mainstreaming processes. Indeed, while HIV prevention work is necessary to inform and motivate people to protect themselves, it cannot overcome deeply-rooted societal causes of susceptibility; similarly, treatment, care and support programmes can reduce the impact of AIDS on affected households, but cannot address the underlying reasons for their vulnerability.

From the above, it is clear that putting in place “specific” AIDS programmes and mainstreaming AIDS in development is not a matter of “either/or”. One of the facets of the exceptionality of AIDS is indeed its character of long-term emergency, which commands a response representing a continuum, from a response attempting immediate relief to a more in-depth developmental response, addressing the societal factors of susceptibility and vulnerability.

Mainstreaming HIV/AIDS in Development and Humanitarian Programmes

mainstreaming hiv aids in development programmes

Mainstreaming HIV /ADIS in Development and Humanitarian Programmes

Aids on the Agenda – lite

AIDS on the Agenda is quite a long book, so in 2004 Oxfam produced this cut down version of it.

You can download it for free or buy a hard copy from Oxfam publications.


AIDS depends for its success on the failures of development. If the world was a fairer place, if opportunities for men and women were equal, if everyone was well nourished, good public services were the norm, and conflict was a rarity, then HIV (Human Immunodeficiency Virus) would not have spread to its current extent, nor would the impacts of AIDS (Acquired Immune Deficiency Syndrome) be as great. We now know that the spread of HIV and the effects of AIDS are closely linked to development problems such as poverty and gender inequality. Development and humanitarian agencies should be doing more to respond to the challenges posed by HIV/AIDS. This book suggests a way in which they can do so through their existing work without necessarily establishing special programmes of HIV prevention or AIDS care.

This book is a shorter, simplified version of AIDS on the Agenda (Holden 2003), a book which can be ordered from Oxfam GB, or downloaded for free from here. The ideas in the two books are the same; but this version, we hope, is accessible to a wider range of readers: those who actually do development and humanitarian work, in addition to those who manage it and fund it. Unlike AIDS on the Agenda, this book does not feature quotations and case studies; instead it presents general lessons learned – mainly from the experiences of non-government and community-based organisations (NGOs and CBOs) working in the parts of Africa that are worst affected by HIV/AIDS. AIDS has changed the world. This book is about the changes that we need to make in order to do effective development and humanitarian work in a world of AIDS.

Part 1: The case for mainstreaming HIV/AIDS

Chapter 2 considers the two-way relationship between under-development and the causes and consequences of HIV/AIDS. It shows how the disease can make gender inequality worse, and claims that HIV/AIDS is a long-term development problem with no obvious solution.

Chapter 3 explores what mainstreaming means, by setting out the four main terms used in this book: • AIDS work • integrated AIDS work • external (programmatic) mainstreaming of AIDS • and internal (organisational) mainstreaming of AIDS. It identifies similarities and differences between them, and gives practical examples of what the terms mean for development and humanitarian organisations.

Chapter 4 addresses the question ‘Why mainstream HIV/AIDS?’. It considers some of the problems that may arise if development and humanitarian organisations fail to take AIDS into account in their ordinary work. It also responds to some objections to the idea of mainstreaming HIV/AIDS, and describes two problems which development organisations may meet when they do AIDS work.

Chapter 5 draws together all the elements of Part 1. It presents a ‘web’, showing four levels of influence on HIV transmission, and different kinds of response, both direct and indirect.

Part 2: Ideas for mainstreaming HIV/AIDS

Chapter 6 provides some general strategies for initiating and sustaining mainstreaming, and proposes some guiding principles. Chapter 7 offers ideas for mainstreaming HIV/AIDS within the internal operations of development and humanitarian agencies, and Chapters 8 and 9 offer suggestions for external mainstreaming in development and humanitarian programmes respectively. Chapter 10 presents an overview of the issues and challenges involved in promoting and adopting the strategy of mainstreaming, and the book concludes with Chapter 11.

AIDS on the Agenda: Adapting Development and Humanitarian Programmes to Meet the Challenge of HIV/AIDS

Managing and mainstreaming HIV

managing and mainstreaming HIVAIDS on the Agenda: Adapting Development and Humanitarian Programmes to Meet the Challenge of HIV/AIDS

My book on HIV mainstreaming written for policy-makers, managers, and programme staff in development and humanitarian agencies. AIDS on the Agenda was one of the first publications on this subject. Many of the definitions which I developed back then are now widely used.

You can download the entire book for free or buy it from Oxfam.

See also Mainstreaming HIV/AIDS in development and humanitarian programmes for a cut down version of this book.


This book is concerned with AIDS (Acquired Immune Deficiency Syndrome), but not with specific responses to it. If you are looking for advice about work that is focused exclusively on the problem of AIDS – home-based care, medical treatment, voluntary counselling and testing, condom promotion, or AIDS education – then you need a different book. But if you are concerned about the devastation that AIDS is causing, and you believe that more needs to be done, and by more people, than can be achieved by AIDS-specific work alone, then read on. You will find ideas based on experiences of adapting mainstream development and humanitarian work to address the problem of AIDS indirectly, along with ways in which organisations can respond from within to protect their employees and their business. AIDS has changed the world; this book is about the changes needed for effective development and humanitarian work in a world of AIDS.

This book considers the dual challenge for development and humanitarian organisations of ‘mainstreaming’ HIV and AIDS, which consists (i) of making changes to the internal management of their organisations, with a view to limiting the impacts of AIDS on their employees and their work, and (2) adapting their external work in order to take account of the causes and consequences of AIDS. In arguing that mainstreaming HIV and AIDS is a task for all organisations involved in development and humanitarian work, this book aims to stimulate thinking and debate about ways in which organisations can respond to AIDS without necessarily also doing work specifically focused on AIDS.

It is organised in three parts:

Part I: Mainstreaming HIV/AIDS in development and humanitarian programmes: background and rationale

Chapters 1 to 6 offer a general introduction to the global threat of AIDS and the international community’s response to it, and present the arguments for mainstreaming as an additional strategy.

Part II: Experiences of mainstreaming AIDS

Chapters 7 to 9 address the reality of work on the ground, and the lessons that emerge from the case studies.

Part III: Ideas for mainstreaming AIDS

Chapters 11 to 15 present practical ideas for agencies seeking to mainstream HIV/AIDS into their work.


The Resources section at the back of the book provides further practical ideas for mainstreaming AIDS, in the form of a series of ten user-friendly Units, designed to stimulate readers to think how they might introduce mainstreaming into their own organisations.