REGIONAL HIV AND AIDS PROGRAMME IN LATIN AMERICA AND THE CARIBBEAN ABC/GIZ/MS

REGIONAL HIV AND AIDS PROGRAMME IN LATIN AMERICA AND THE CARIBBEAN ABC/GIZ/MS

Regional HIV and AIDS Programme in Latin America and the Caribbean 1 Regional HIV and AIDS Programme in Latin America and the Caribbean ABC/GIZ/MS Summaries and lessons learnt 2007-2012

REGIONAL HIV AND AIDS PROGRAMME IN LATIN AMERICA AND THE CARIBBEAN ABC/GIZ/MS

Regional HIV and AIDS Programme in Latin America and the Caribbean ABC/GIZ/MS Summaries and lessons learnt 2007-2012

REGIONAL HIV AND AIDS PROGRAMME IN LATIN AMERICA AND THE CARIBBEAN ABC/GIZ/MS

Regional HIV and AIDS Programme in Latin America and the Caribbean 4 The Regional HIV and AIDS Programme in Latin America and the Caribbean – ABC, GIZ, MS Summaries and lessons learnt, 2007-2012.

PUBLICATION COORDINATION: ORGANIZATION: Claudia Herlt (GIZ) Olaf Horstick (GIZ) EDITORIAL COORDINATION (Correction, style and text): Claudia Herlt (GIZ) Olaf Horstick (GIZ) Wófsi Juri G. de Souza (ABC) Jonas Deusch (GIZ) Inga Söllner (GIZ) TRANSLATION: Rapport Traduções e Interpretações Ltda. Confluir Tradução e Interpretação Ltda - ME DESIGN and LAYOUT: DUO Design Serviços de Edição Gráfica Ltda - ME PRINTING: Gráfica XXX First Edition: 200 copies Photographs: Archives of the Regional HIV and AIDS Programme in Latin America and the Caribbean. Published and produced in Brasília, Brazil.

November, 2012

REGIONAL HIV AND AIDS PROGRAMME IN LATIN AMERICA AND THE CARIBBEAN ABC/GIZ/MS

Regional HIV and AIDS Programme in Latin America and the Caribbean 5 Acknowledgements List of abbreviations The GIZ Regional HIV and AIDS Programme in Latin America and the Caribbean: a summary I. Introduction 1. History of Brazil – Germany Trilateral Cooperation on HIV and AIDS 2. Principles of the cooperation as a basis for joint action 3. Triangular cooperation in the Regional HIV and AIDS Programme 4. Gender in the Regional HIV and AIDS Programme 5. Innovation and knowledge management in the Regional HIV and AIDS Programme II. Projects 2010-2012 1.

Sexuality education and HIV and AIDS prevention in schools 2. Strengthening of health systems in rural areas in Uruguay 3. Men´s health in Latin America III. Projects 2007-2009 1. The regional AIDS network of the Catholic Church / RELCALC-SIDA 2. Strengthening of the national HIV and AIDS response in Uruguay 3. Contributing to the Caribbean answer to the HIV and AIDS epidemic 4. Strengthening of the response to HIV and AIDS in MERCOSUR border regions 5. AIDS prevention for high mobility populations 6. Integrated health care delivery services in Ecuador, Peru and El Salvador 7. Monitoring and evaluation in the Dominican Republic, Ecuador and Panama 8.

Strengthening of civil society 9. Support of the Horizontal Technical Cooperation Group (GCTH) 10. Support of health research List of references Table of contents 7 9 14 16 16 17 21 22 23 24 24 26 28 30 30 32 34 36 38 40 46 52 54 56 58

REGIONAL HIV AND AIDS PROGRAMME IN LATIN AMERICA AND THE CARIBBEAN ABC/GIZ/MS

Regional HIV and AIDS Programme in Latin America and the Caribbean 6

REGIONAL HIV AND AIDS PROGRAMME IN LATIN AMERICA AND THE CARIBBEAN ABC/GIZ/MS

Regional HIV and AIDS Programme in Latin America and the Caribbean 7 “From South - South cooperation to trilateral cooperation and towards a horizontal approach” When the German Agency forTechnical Cooperation (GTZ as it then was) and the Brazilian National AIDS Programme took the first steps to work together in 2003, it passed unnoticed that they were, in fact, resuming a partnership born three decades earlier. In 1978, the Buenos Aires Plan of Action launched an initiative entitled Technical Cooperation among Developing Countries (TCDC), a concept that has since been extensively promoted by the G77.

The Millennium Development Goals (MDGs) launched in 2000 and accepted as an international framework for development activities, set tangible targets for national governments and development institutions. In the current global scenario of scarce funding and declining development cooperation from traditional donor countries, changes have had to be made. The traditional donor countries have set new criteria and increasingly demand improved effectiveness and sustainability of results. In this respect, the Paris Declaration in 2005 was a milestone, as signatory countries pledged to improve efforts and to abide by principles of harmonization, ownership, alignment, results, and mutual accountability.

The aim of the Accra Agenda for Action, signed in 2008, was to accelerate the rate of progress.

In parallel to this, new partners such as Brazil and the other BRICS (Brazil, Russia, India, China and South Africa), and emerging economies such as Mexico and Chile were taking up the concept of horizontal South - South cooperation. Building upon principles first enunciated in the TCDC, the essential elements of South - South cooperation consist of sharing knowledge and experiences. In such exchanges, the traditional concept of donor and recipient countries no longer applies: rather, exchanges of knowledge and experience occur horizontality, among equals.

In Brazil, a great expansion of South - South cooperation took place under the presidency of Luiz Inácio Lula da Silva (2002- 2009).

Most of these technical cooperation initiatives were in the form of exchanges of knowledge and capacity building. According to the Brazilian Cooperation Agency (ABC) the main aim of such cooperation activities was to forge ties between Brazil and other developing countries, by means of exchanges of technical knowledge and the strengthening of State institutions. Brazil is not a signatory of the Paris Declaration, which it considers too closely aligned with the vision and values of traditional donors. It does, however, subscribe to such values as promoting democracy and human rights in partner countries, alongside traditional donors.

With such values in common, much can be achieved through triangular (or South – South - North) cooperation between Brazil, a traditional European donor, and a third - developing - country. In view of the comparative advantages of each of the players involved, such an approach offers excellent prospects.

The fact that South - South cooperation and triangular cooperation are assuming a higher profile in international circles was evidenced by the United Nations High Level Conference on South - South cooperation, held in Nairobi, Kenya in 2009, and the latest High Level Forum on AIDS Effectiveness, held in Busan, Korea in December 2011. Different triangular cooperation approaches have been tried. Sometimes, such cooperation entails a financial contribution from a traditional donor, a technical contribution from an emerging country, and a project implemented in a third recipient developing country.

For projects under the Regional HIV and AIDS Programme for Latin America, the Caribbean (LAC) and Africa, the German Agency for International Cooperation (GIZ) at the behest of the German Ministry of Economic Cooperation and Development (BMZ) has partnered with the Brazilian Cooperation Agency (ABC) and the Ministry of Health of Brazil in a new approach, known as horizontal cooperation. Under this approach, three or more partners plan, implement, and evaluate each step of the project together. The common basis for such horizontal South-South-North cooperation in the field of HIV and AIDS is a demand driven approach, in line with experience accumulated under Brazil’s National HIV and AIDS Plan and Unified Health System (SUS) as well as facilitation, knowledge, and methodologies developed through German experience in the field of international cooperation projects.

Another feature of such cooperation is its multisectoral scope, since it encompasses such themes as health, education, a gender and human rights approach, and Acknowledgements

REGIONAL HIV AND AIDS PROGRAMME IN LATIN AMERICA AND THE CARIBBEAN ABC/GIZ/MS

Regional HIV and AIDS Programme in Latin America and the Caribbean 8 participation of civil society. Furthermore, it is underpinned by the assumption that systemic and countrywide approaches lead to better results and more sustainable outcomes. In effect, HIV and AIDS is the crosscutting theme that permeates an array of issues, including: strengthening of health care systems, based on the principles of the Alma Ata Declaration of 1978 and the Brazilian SUS experience of decentralisation; participation of civil society; health promotion and prevention programmes; and national strategies on men’s health and sex education.

Thus, horizontal cooperation is based upon a common understanding, on the part of cooperating partners that sustainable results can be achieved by learning from the national strategies of other countries. One of the main components for achieving such results is joint development of a practical monitoring and evaluation (M&E) system. For a number of countries in the LAC region, as well as African countries of the Portuguese Speaking Community (CPLP) the establishment of such a system has become a goal in itself. Within Latin America, South - South cooperation in the field of health has flourished, especially among the twelve countries of the Union of South American Nations (UNASUR).

The first initiatives of South - South - North cooperation were launched with support of the German International Cooperation Agency (GIZ, formerly GTZ), within the scope of UNASUR - SALUD. However, owing to termination of the programme in December 2012, further follow-up has been postponed. Nonetheless, it is foreseen that after December 2012, continuity will be given to all projects of the second phase of the Regional HIV and AIDS Programme. In ten countries of the LAC region, sexuality education programmes will proceed under the guidance of a joint committee, with assistance from UNESCO and UNAIDS.

Moreover, this is likely to serve as an example for implementation of regional initiatives in East and Southern African Countries, within the scope of an ongoing sexuality education project supported by German Ministry for Economic Cooperation and Development (BMZ) and UNESCO. Work will also proceed in the field of men’s health, in the form of a Brazilian bilateral project with Chile and with Ecuador.

Within the framework of its rural health reform programme, the Uruguayan government plans to expand the scope of trilateral cooperation activities to all departments of the country. Equipment and installations furnished through German Financial Cooperation (KfW) are an essential component of this programme. The Regional HIV and AIDS Programme, together with its Brazilian Partners, documented on the following pages, has provided unique experience for staff at all administrative levels in the participating countries over the past six years, and has produced a wealth of shared experiences and lessons learned.

This publication aims to contribute toward public debate on new approaches to international cooperation.The Hypotheses in the Boxes are lessons learnt but are also meant to stimulate discussions. Though well aware that not everything is perfect, we apologise for having omitted some of these valuable experiences. Of one thing we are certain, however: the key to success lies in identifying new ways of coping with the problems of this world, and in fostering mutual understanding. We thank the BMZ, the ABC and the Brazilian Ministry of Health, and all other partner governments and organizations, especially UNAIDS, DFID, UNESCO, UNFPA and PAHO for their many years of support.

We also thank all of our colleagues who, with so much dedication and trust, made this work possible for the well being of all peoples of the region. Brasilia, November 2012 Dr Claudia Herlt Programme Director GIZ Regional HIV and AIDS Programme

REGIONAL HIV AND AIDS PROGRAMME IN LATIN AMERICA AND THE CARIBBEAN ABC/GIZ/MS
Regional HIV and AIDS Programme in Latin America and the Caribbean 9 List of abbreviations A ABC (pt.: Agência Brasileira de Cooperação) Brazilian Cooperation Agency AISA (pt.: Assessoria de Assuntos Internacionais de Saúde) International Health Advisory AOP Annual Operations Plans ART/V Antiretroviral therapy/drugs ASICAL (es.: Asociación para la Salud Integral y Ciudadanía en América Latina y el Caribe) Latin American and Caribbean Association for Integrated Health and Citizenship APLAFA (es.: Asociación Panameña para el Planeamiento de la Familia) Panamanian Association for Family Planning B BMZ (dt.: Bundesministerium fuer wirtschaftliche Zusammenarbeit und Entwicklung) German Ministry of Economic Cooperation and Development Brazilian Ministry of Health:
  • DAB (Departamento de Atenção Básica)
  • DARA (DiretoriadeArticulaçãodeRedesdeAtençãoàSaúde)
  • SGEP(SecretariadeGestãoEstratégicaeParticipativa) Brazilian Ministry of Health:
  • DAB: Department of Primary Healthcare
  • DARA: Coordination for Healthcare Networks
  • SGEP: Secretariat for Strategic and Participatory Management C CARICOM Caribbean Community CEDAPS (pt.: Centro de Promoção da Saúde) Health Promotion Centre CEDEP (es.: Centro Paraguayo de Estudios de Población) Paraguayan Centre of Population Studies CEDES (es.: Centro de Estudios de Estado y Sociedad) Centre of State and Society Studies CEDRO (es.: Centro de Información y Educación para la prevención del abuso de Drogas) Centre of Information and Education for the prevention of drug abuse CHART (es.: Red Regional del Caribe de Capacitación de VIH y SIDA) Caribbean Regional VIH y SIDA Training Network CHRC (es.: Consejo del Caribe de Investigación en Salud) Caribbean Health Research Council COASCE (es.:CoordinadoradeONGsdelasAméricassobreSIDA,CárcelyEncierro) CoalitionofLatinAmericaNGOsonAIDS,PrisonandIncarceration

Regional HIV and AIDS Programme in Latin America and the Caribbean 10 CONAVIH (es.: Comisión Nacional para la Prevención y Control del Virus de Inmunodeficiencia Humana) National Committee for Prevention and Control of HIV CPLP (es.: Comunidad de los Países de Lengua Portuguesa) Community of Portuguese Speaking Countries CRN+ (es.: Red del Caribe Regional de Personas viviendo con HIV/Sida) Caribbean Regional Network of People Living with HIV and AIDS CRNM CARICOM Regional Negotiating Machinery CVC Caribbean Vulnerable Communities D DFID UK Department for International Development F FIOCRUZ Oswaldo Cruz Foundation FLACSO (es.: Facultad Latinoamericana de Ciencias sociales) Latin American Social Sciences Institute FMP Manuel Pérez Foundation G GCTH Technical Horizontal Cooperation Group GIZ (dt.: Gesellschaft fuer internationale Zusammenarbeit) GIZ: Fusion of GTZ, DED and InWEnt German Agency for International Cooperation H HIV Human Immunodeficiency Virus HSS Health System Strengthening I ICTC International Centre for Technical Cooperation (Brazil) ICW International Community of Women living with HIV/AIDS IDB Inter-American Development Bank K KfW (dt.: Kreditanstalt fuer Wiederaufbau) German Financial Cooperation

Regional HIV and AIDS Programme in Latin America and the Caribbean 11 L LAC Latin America and the Caribbean LACCASO (es.: Consejo Latinoamericano y del Caribe de Organizaciones No Gubernamentales con Servicio en VIH/SIDA) Latin American and Caribbean Council of NonGovernmental Organizations with HIV and AIDS services LACEN (pt.: Laboratório Central de Saúde Pública do Distrito Federal) Central Public Health Laboratory of the Federal District LGBTI Lesbian, gay, bisexual, transgender and intersexual M M&E Monitoring and Evaluation MDG Millennium Development Goals MINSA Ministry of Health (Peru) MoH Ministry of Health MS Ministry of Health (Brazil) MSM Men who have sex with men MSP Ministry of Public Health (Uruguay) MSPAS (es.: Ministerio de Salud Pública y Asistencia Social) Ministry of Public Health and Social Assistance N NAP National AIDS Plan O OECS Organization of Eastern Caribbean States OEI (es.: Organización de Estados Iberoamericanos para la Educación, Ciencia y la Cultura) Organization of Latin American Countries for Education, Science and Culture

Regional HIV and AIDS Programme in Latin America and the Caribbean 12 P PAHO/WHO Pan American Health Organization/World Health Organization PANCAP Pan Caribbean Partnership against HIV & AIDS PCI International Cooperation Programme (Brazil) PEM (es.: Plan Estratégico Multisectorial) Strategic Multisectoral Plan PEN (es.: Plan Estratégico Nacional) National Strategic Plan Peruvian Ministry of Health:
  • DGSP (Dirección General de Salud de las Personas)
  • ESNITSS (Estrategia Nacional Prevención y Control de las ITS, VIH y Sida)
  • CENSI (Centro de Salud Intercultural)
  • DGE (Dirección General de Epidemiología) Peruvian Ministry of Health:
  • DGSP: General Directorate of People’s Health
  • ESNITSS: National Strategy for Prevention and Control of STIs and HIV and AIDS
  • CENSI: Intercultural Health Centre
  • DGE: General Directorate of Epidemiology PHC Primary Healthcare PLWHA People living with HIV/AIDS PN-AIDS National AIDS Programme PPL (es.: Personas privadas de la libertad) People deprived of freedom PPNN (es.: Policía Nacional) National Police R REDLA+ (es.: Red Latinoamericana de Personas viviendo con VIH o SIDA) Latin American Network of People living with HIV/AIDS REDLACTRANS (es.: Red de Latinoamérica y el Caribe de Personas Trans) Latin American and Caribbean Network of Trans-People REDTRASEX (es.: Red de Trabajadoras Sexuales de Latinoamérica y el Caribe) Latin American and Caribbean Sex Workers Network RELARD (es.: Red Latinoamericana de Reducción de Daños) Latin American Damage Reduction Network S SENPLADES (es.: Secretaría Nacional de Planificación y Desarrollo del Ecuador) Ecuadorian National Planning and Development Secretariat SNiS (es.: Sistema Nacional Integrado de Salud de Uruguay) National Integrated Health Programme (Uruguay) STI Sexually Transmitted Infection SUS (pt.: Sistema Único de Saúde) Unified Health System (Brazil)

Regional HIV and AIDS Programme in Latin America and the Caribbean 13 T TCP Technical Cooperation Project TCDC Technical Cooperation among Developing Countries U UNAIDS Joint United Nations Programme on HIV/AIDS UNASUR Union of South American Nations UNESCO United Nations Educational, Scientific and Cultural Organization UNFPA United Nations Population Fund UNGASS United Nations General Assembly - Special Session

Regional HIV and AIDS Programme in Latin America and the Caribbean 14 The GIZ Regional HIV and AIDS Programme in Latin America and the Caribbean: a summary for phase 1 (2007- 2009) and phase 2 (2010- 2012) Since the mid 1990s, the spread of HIV and AIDS in Brazil has been stabilised, through a successful programme involving comprehensive, multisectoral, integrated approaches throughout the entire health care system and involving all sectors of society.

In the process, Brazil has acquired experience that it is now sharing with other countries, mostly in Latin America and Africa, but also in other regions of the world. Germany has joined forces with Brazil in spreading this knowledge to other countries, by contributing its extensive technical experience of development issues, through triangular cooperation in specific projects. During the first phase, the government of the United Kingdom supported the projects financially, DFID being an important like-minded partner of GTZ.

The overall approach entails country demand driven definition of priorities, followed by joint development and implementation, and is often described as horizontal or triangular cooperation, South - South cooperation or South – South - North cooperation. The outstandingfeatureofthisapproachisnegotiatedcollaborationamong multiplepartnerstocreatesynergies,andbuildingupontheparticularstrengthsandcomparativeadvantagesofeachpartner. Gender and health equity are crosscutting themes in such cooperation, with a special focus on marginalised groups and on populations most affected by HIV and AIDS. Another key feature is HIV mainstreaming, whereby the Regional Programme seeks to ensure that HIV and AIDS programmes are integrated into health care systems, with the net effect that national health systems are strengthened.

  • Knowledge management and innovation have also been a key element, as evidenced by the experiences of the Regional Programme 2007 - 2012 documented in this publication. All activities and goals were oriented by the experience of Brazil’s National AIDS Plan and Unified Health System (SUS). Activities included 1. Health services
  • Improvement of access to health services
  • Management of health facilities
  • Networking for exchanges of knowledge and experience 2. Health personnel
  • Support for long-term personnel planning
  • Training and further training of health personnel 3. Health information
  • Information systems for health facilities
  • Platforms for health education and information 4. Governance
  • Decentralisation
  • Good governance
  • Participation of civil society Projects and results 2010 - 2012 By the second phase of the Programme, vertical approaches to HIV and AIDS had been abandoned; and comprehensive, systemic, countrywide approaches had been adopted to address the HIV/AIDS epidemic.

Sexuality Education Argentina, Chile, Peru, Paraguay, and Uruguay drew up or enhanced their national policies on sexuality education, and the themes of sexuality education and HIV prevention were incorporated into national curriculums. Intersectoral committees were established to oversee implementation of these policies and, by 2011, they were reaching over 80,000 teachers and 1.5 million students. To ensure sustainability of the project, a Latin American Network for Sexuality Education was established, with support from UNAIDS/UNESCO/ UNFPA and GIZ. More recently, Bolivia, Colombia, El Salvador and Guatemala have also joined the initiative.

Regional HIV and AIDS Programme in Latin America and the Caribbean 15 Integrated health care services in rural areas In Uruguay, integrated approaches were developed for provision of rural healthcare services, thereby improving access to enhanced primary healthcare, including HIV and AIDS prevention and treatment. The drafting and implementation of strategic plans and establishment of monitoring systems has contributed toward strengthening the national health system. Men´s health Ecuador, Chile, and Uruguay are currently defining a strategy for men’s health, with a focus on high-risk behaviours, HIV prevention, and access to healthcare, maintaining a gender perspective, with the aim of reducing early mortality.

Projects and results 2007 - 2009 RegionalAIDSNetworkoftheCatholicChurch/RELCALC-SIDA The aim of the project was prevention of HIV in remote areas, by means of strengthening the catholic church’s regional network for HIV and AIDS prevention and restructuring its regional executive secretariat in Porto Alegre. Twenty two Latin American countries participated in this initiative. Cooperation partners in this project were the AIDS Pastorate, the Brazil based International Centre for Technical Cooperation (CICT), GIZ and DFID. StrengtheningoftheNationalResponsetoHIV/AIDSinUruguay In Uruguay, the ICTC, alongside the Uruguayan Ministry of Public Health (MSP), GTZ and DFID developed a national action plan and adopted other measures to strengthen its national STI, HIV and AIDS programme.

This initiative included participation of civil society and HIV self help groups, using a human rights based approach in the national HIV and AIDS policy. One of the main objectives was HIV prevention in border regions. Contributing to the Caribbean Response to the HIV epidemic ThefifteenmembercountriesofCARICOMandPANCAPdrewupa work plan to strengthen PANCAP’s STI, HIV and AIDS programme, with a special focus on human rights and participation of civil society and of HIV self help groups. The project, which included participation of FIOCRUZ, CICT, GTZ and DIFD, PAHO and WHO, also addressed improvement of monitoring and evaluation systems.

Strengthening of the response to AIDS in border regions of MERCOSUR The CICT, GIZ and MERCOSUR, in an alliance with seven municipalities on the borders of Argentina, Bolivia, Brazil, Venezuela, Colombia, Paraguay and Uruguay set up bi-national committees to respond to the spread of HIV and AIDS in especially vulnerable boarder regions. Binational work plans and joint activities for HIV prevention were among the outcomes of this project. AIDS prevention for high mobility populations in Peru The aim of the project was strengthening of HIV prevention for high mobility and indigenous populations in Peru, given that studies have drawn attention to the high vulnerability of these groups.

Technical cooperation between the Ministry of Health of Peru, CICT, DFID and GIZ provided support for decentralisation of HIV prevention services into the interior of the country, with a view to reaching these populations.

Integrated health care Between 2007 and 2009, within the scope of the Regional HIV and AIDS Programme in Latin America and the Caribbean, GTZ, in cooperation with Ministries of Health, CICT and DFID, carried out a project for strengthening the response to STIs and HIV and AIDS,throughprovisionofintegratedhealthcareservicesinthree Latin American countries: Ecuador, El Salvador and Peru. Monitoring and Evaluation During the same period, GIZ, CICT and DFID, together with the national AIDS programmes of Ecuador, the Dominican Republic and Panama, were engaged in a project for implementation of monitoring and evaluation systems.

Furthermore several minor projects were supported, especially in health research and strengthening civil society. In conclusion, in the two phases of the Regional HIV and AIDS programme numerous activities have been successfully supporting the national responses to HIV and AIDS, using a health

Regional HIV and AIDS Programme in Latin America and the Caribbean 16 1. History of Brazil – Germany Trilateral Cooperation on HIV and AIDS The very successful triangular cooperation against HIV and AIDS has been developed through grants of the German Federal Government, with the Ministry for Economic Cooperation and Development (BMZ), executed by the German International Cooperation (GIZ, formerly GTZ), from 2003 to 2012.

2002: First contacts: After the Barcelona AIDS conference, Brazil’s national AIDS programme and GTZ discussed prospects for a joint cooperation with other countries.

2003-2005: PCI: First trilateral cooperation initiatives with 5 Latin American countries within the scope of Brazil’s International Cooperation Programme (PCI) 2005:The Brazilian Government, together with UNAIDS founded the International Technical Cooperation Centre (CICT) for international cooperation on AIDS. January 2006 to December 2006: The trilateral cooperation with CICT extended its scope to other countries January 2007 to December 2009: The HIV and AIDS Regional Programme: In the first phase, the trilateral cooperation extended to over 20 countries, in support of national strategies for combating AIDS.

A total of 11 trilateral cooperation projects and 3 multilateral regional projects were carried out - the latter with more than 5 countries participating. Institutional support for the Horizontal Technical Cooperation Group (GCTH) and the CICT. Cooperation with UNAIDS. Partnership with the UK Department for International Development (DFID) 2009: Following an external evaluation, the CICT was nationalised and the national AIDS programme (PN-AIDS) incorporated into the Ministry of Health (MoH). January 2010 to December 2012: During the 2nd Phase of the Regional Programme with new partners, the Brazilian Cooperation Agency (ABC) and the International Health Advisory (AISA) of the MoH, the concept of trilateral cooperation was further refined.

In line with state of the art healthcare practices, the programme focused on strengthening health care delivering systems, incorporating HIV and AIDS as a crosscutting programme within primary care. The triangular cooperation was extended to include countries in Africa, (South/South and trilateral cooperation) based on the Heiligendamm G8 and G5 processes, with UNAIDS, UNESCO, UNFPA and PAHO as partners 2012: Merging of DED, GTZ and InWEnt into GIZ.

December 2012: Closure of the Regional HIV and AIDS Programme due to a funding decision of BMZ. However, the principles determined by the Regional Programme continue with an institutionalised South - South collaboration of the Brazilian counterparts and other countries in Latin America, the Caribbean and Africa. 2003-2012:Total German Government Grant: EURO 11.350,00 I. Introduction

Regional HIV and AIDS Programme in Latin America and the Caribbean 17 2. Principles for cooperation as a basis for joint action The principles for the triangular cooperation as developed in the Regional Programme are based upon accumulated experience of South - South cooperation.

These principles underpin actions during each project phase (planning, implementation and evaluation). These principles are: 1. All projects should be demand driven and country led 2. All projects should be aligned to national policies and the strategic planning of partner countries. 3. The beneficiary country shall lead the cooperation process in each project phase 4. Each step of the project shall be subject to agreement of all partners (Brazil, Germany and partner countries) 5. All projects shall include and use local and regional knowledge and experiences. External knowledge and experiences may serve to complement local knowledge/experiences provided they strengthen local initiatives and strengthen sustainability 6.

All projects shall aim to strengthen and consolidate health systems of partner countries From the experience in the Regional Programme a step-bystep process has been developed and applied for the projects in the triangular cooperation: A. Choosing projects A.1. Selection process Project selection shall always be driven by demand for cooperation from the partner country. In view of the high demand for healthcare cooperation projects with Brazil and the German Cooperation, it has become necessary to assess demands, to select those that can be addressed and, more specifically, choose those to include in the trilateral cooperation.

During a planning workshop, held by ABC, Ministry of Health and GTZ in March 2011, criteria for cooperation in the field of health were defined. If a project fulfils agreed criteria for cooperation, firstly Brazil examined whether it is suitable for trilateral cooperation with Germany. If so determined, GIZ assesses whether the project complies with guidelines established by BMZ, and whether it is eligible for such cooperation. 1. Demand for technical cooperation from the partner country YES YES YES YES 2. The project complies with the agreed scope of cooperation? 3. Brazil (ABC/AISA) considers if it is suitable for a trilateral cooperation approach.

4. Germany (GIZ) considers if it participates in the trilateral cooperation project Joint preparation of the technical cooperation project Selection process for joint cooperation projects

Regional HIV and AIDS Programme in Latin America and the Caribbean 18 A.2 Joint project preparation – ABC, MoH,GIZ If all of the parties are in agreement that a trilateral approach is appropriate, a cooperation project is drawn up with the partner country, defining objectives, strategies, goals and inputs to be provided by each of the partners. During planning workshops the partners have the opportunity to discuss details of the project. It should be underlined that this process must be perceived as an integral part of joint cooperation. A.3 Cooperation with other players in international cooperation During this phase possibilities for cooperation with other players, such as UN agencies, should be assessed.

Such cooperation can help to streamline cooperation activities and ensure that partner countries derive the maximum benefit from actions carried out.

B. Establishment of a management structure Once agreement has been reached and a formal Technical Cooperation Project (TCP) signed, a management structure should be established to conduct joint work processes. This structure should include a coordinating committee and a technical committee: The Coordinating Committee Members (management level): Ministry of Health of partner country, ABC, AISA, GIZ. Responsibilities:
  • Provide strategic guidance for the project and decide on any changes that may be needed
  • Approve Annual Operations Plans (AOPs)
  • Evaluate annual and final outcomes of the project
  • Resolve problems at the policy level, when necessary The Technical Committee Members (technical staff): Ministry of Health of the partner country, AISA, GIZ Responsibilities:
  • Prepare Annual Operations Plans (AOPs)
  • Coordinate technical cooperation with the technical departments of the Brazilian Ministry of Health and with those of partner countries during project implementation
  • Constantly monitor progress of the project
  • Prepare project documentation
  • Regional HIV and AIDS Programme in Latin America and the Caribbean 19 Coordinating Committee Members: MoH of partner countries, ABC, AISA, GIZ
  • Provide strategic guidance for the project and decide on any necessary changes
  • Approve annual operations plans (AOPs) for the project
  • Evaluate annual and final outcomes of the project Technical Committee Members:Technical staff responsible for the project at the MoH of partner countries, AISA, GIZ
  • Prepare AOPs
  • Coordinate technical cooperation necessary for project execution
  • Monitor progress of the project
  • Document all phases of the project Technicalareas inBraziland intheother country
  • Support preparation of the AOP
  • Implement activities
  • Monitor and evaluate activities and processes
  • Document activities

Regional HIV and AIDS Programme in Latin America and the Caribbean 20 C. Project execution The project shall be carried out jointly: All parties will be informed about all activities and frequent meetings will be held. Progress and setbacks will be monitored and assessed and, if necessary, the strategy will be reviewed. To this end, the coordinating committee will hold regular meetings to evaluate processes, adjust strategies (if necessary) and resolve any policy problems that may arise; whereas the technical committee shall promote constant exchanges of information. Wherever necessary, joint workshops and missions will be held, however, not all activities need be carried out with the presence of all partners.

What is important however is that throughout project execution the process shall be monitored jointly at all times.

D. Monitoring A monitoring and evaluation plan shall be drawn up and agreed by all parties, and revised and adjusted by the technical committee, as may be necessary. Other players will be involved in monitoring as the need arises. Results shall be disclosed by the coordinating committee on a regular basis. E. Evaluation The coordinating committee shall assess progress no less than once each year. Moreover, at least one evaluation workshop shall be held each year, with participation of all relevant players. Triangular cooperation has the potential for overcoming geographical and cultural differences when the countries working together share similar cultural traits and values.

Regional HIV and AIDS Programme in Latin America and the Caribbean 21 3. Triangular cooperation in the Regional HIV and AIDS Programme Triangular cooperation between Brazil, Germany and other countries of Latin America and the Caribbean or African partners is one of the principal features of the Regional HIV and AIDS Programme for Latin America and the Caribbean. The term is often used interchangeably with South - South Cooperation or, more specifically, South – South - North Cooperation. Under triangular Cooperation, as applied in this programme, partners develop projects together, define common objectives, implement activities and prepare a framework for monitoring and evaluation, benefiting from the comparative advantages offered by each partner.

With the Regional HIV and AIDS Programme, based on the experience of Brazil’s integrated, multidisciplinary national AIDS programme and its extensive experience in the implementation of its own Unified Health System (SUS), third countries in Latin America, the Caribbean and Africa have had the opportunity to address the challenges of HIV and AIDS through strengthening their health care systems within their own local contexts. Knowledge transfers from Brazil to other countries have been optimised by combining the knowledge of local contexts and needs provided by the third country, with Brazilian technical expertise, complemented by German experience of developing, facilitating, monitoring and evaluating strategic international cooperation processes.

In the light of outstanding outcomes achieved in these and previous projects, the concept of knowledge transfer has, in itself, attained significant value and potential. Moreover, in view of the recent international consensus in favour of encouraging and supporting South - South dialogue and the new aid effectiveness agenda, the need for a more inclusive dialogue between cooperation partners has become evident, in line with the spirit of the Paris Declaration, the Heiligendamm Process, the Accra Plan of Action 2008, and the 8th Millennium Development Goal. Triangulation is currently viewed as a new approach for combining the strengths of so-called traditional donors and the partners of South - South cooperation.

Furthermore, the importance of joint participation in the formulation of public policies can hardly be overstated, it being a necessary step for institutional capacity development.

An example of Synergies: Country 1: Technical expertise, with an integrated, multisectoral approach, in response to the HIV and AIDS epidemic Country 2: Local knowledge, setting of priorities, logistics Country 3: Expertise in international collaboration, project design, monitoring and evaluation Country 1 Country 2 Country 3 Synergies The concept of triangular cooperation

Regional HIV and AIDS Programme in Latin America and the Caribbean 22 4. Gender in the Regional HIV and AIDS Programme In view of its relevance for health, behaviour, risk factors and exposure to disease, gender is a crosscutting theme in all planning for health under the Regional HIV and AIDS Programme.

Indeed, a gender perspective underlies development of all interventions for protecting the population against HIV and AIDS, since the most vulnerable populations are also, historically and globally, among the most stigmatised and discriminated against, owing to gender issues and roles. When addressing gender themes, the Regional Programme acknowledges that gender is not limited to the dichotomy of men and women: but rather, that certain categories (lesbian, gay, bisexual, transgender and intersexual - LGBTI) cannot be included into either of these two. Respect for gender diversity and for the rights of such minorities is crucial when addressing such themes.

Acknowledgment and respect for gender diversity is of special importance in the healthcare context. A broader concept of gender and the mainstreaming thereof enables inclusion and acceptance of the special needs of LGBTI population facing marginalisation in many other contexts. Furthermore, mainstreaming of gender themes in healthcare, as promoted under the Regional Programme, is acknowledged to be one of the most effective strategies for achieving gender equity. By promoting gender as a crosscutting theme, the Regional Programme consolidates a gender perspective into formulation, monitoring and analysis of policies, programmes and projects, thereby ensuring equal access to healthcare services for all women, men and LGBTI individuals.

However, a mainstreaming strategy does not preclude initiatives directed specifically towards any one of these groups. The Regional Programme has corroborated the fact that, among its partner organisations and in government bodies of the countries of the Latin America and Caribbean region, women conduct most operative services, whereas men occupy most executive and decision-making positions.This in itself, and the need to promote change in power relations within workplaces, is a strong argument for maintaining a gender focus in all activities, programmes and projects sponsored by GIZ in the region.

In all work carried out under the Regional HIV and AIDS Programme in countries of the region, a gender perspective, coupled with a human - rights approach and combating of discrimination on the basis of sexual orientation or diversity, have always been at the centre of efforts to bring about changes in mores and attitudes, and in breaching the near monopoly of men over decision-making on public-policy issues. Nonetheless, the role of the Regional HIV and AIDS Programme in promoting men’s health should not be overlooked. Surveys have revealed that, in the Latin America and Caribbean Region, life expectancy for men tends to be some 8 years lower than for women.

To address this discrepancy, in partnership with the Brazilian Government, the Regional Programme has launched triangular cooperation projects for men’s health, so as to ensure that pathologies typical of men receive the same priority at health care services as those relating to the health of women, children and adolescents.

In summary, gender issues, gender equity in health care, gender diversity, and respect for the rights of LGBTI minorities are a crosscutting theme that permeates all aspects and strategies under the Regional HIV and AIDS Programme. Working on gender issues means adapting to the needs of men, women and LGBTI

Regional HIV and AIDS Programme in Latin America and the Caribbean 23 5. Innovation and knowledge management in the Regional HIV and AIDS Programme Innovation and knowledge management are among the crosscutting themes of the GIZ Regional HIV and AIDS Programme. Both are considered integral components of the programme, since innovation is based on new knowledge, and new knowledge cannot be translatedintopracticeexceptbyaprocessofinnovation. Among a number of innovative processes that have been pursued throughout the programme, the following two stand out:
  • On a strategic level, the emergence of triangular cooperation, whereby partners contribute through a synergistic process, according to their particular capacities, represents a new approach to international development activities. This innovative cooperation approach was embraced by countries interested in pursuing cooperation under the programme and by the Brazilian Cooperation Agency (ABC) of the Ministry of External Relations and the International Health Affairs Advisory (AISA) of the Ministry of Health
  • On a technical level, though the programme was targeted at HIV and AIDS, since 2005 activists worldwide have advocated that responses to the epidemic should not take the form of isolated vertical programmes, but rather, should be integrated into existing healthcare services and should encompass health promotion, preventive and curative strategies, in the form of horizontal programmes. The Regional Programme adopted this innovation in 2010, and has since focused on systematic approaches and strengthening health care systems while, at the same time, enhancing the quality of services targeted specifically at HIV and AIDS.

Experience acquired during the various activities and projects conducted under the programme has contributed towards knowledge management, one of the crosscutting themes of the programme. Knowledge management was already a strong component within GIZ, which considers itself a learning organisation. Documentation of experiences was thus an important part of the work and, alongside sharing of information and making knowledge available to all parties, contributed toward the success of project management.

Documentation of the programme entailed production of: 1) peer reviewed reports; 2) peer reviewed conference contributions; 3) best practice guidance; 4) regular reporting to funding agencies and partners; and 5) this final publication.

All documentation was distributed in printed form and electronically via the Internet. Furthermore, all information was stored in databases of the GIZ document management system (DMS). Information exchanges took place through regular meetings of technical groups and also through national and international conferences, and addressed a number of issues, including HIV and AIDS, general healthcare, and monitoring and evaluation.

The high visibility achieved by the programme internationally, and especially in countries of the Latin America and Caribbean region, bears witness to its capacity to generate and disseminate new knowledge and contribute toward innovation. Global challenges of HIV and AIDS require international responses, guided by best practices and implemented through South – South (S-S) or South – South – North (S-S-N) cooperation, under which equity is guaranteed in all actions and cultural adaptation is a key element

Regional HIV and AIDS Programme in Latin America and the Caribbean 24 1.

Sexuality education and HIV and AIDS prevention in schools Context Project execution Research shows that comprehensive sexuality education fosters behaviours that reduce risk factors for HIV transmission. Providing students with information and education helps them acquire the life skills needed to reduce their vulnerability to HIV infection and is the theme of a pledge assumed under the UNGASS Declaration of Commitment on HIV/AIDS in 2001.The importance of strengthening sexuality education programmes and HIV prevention in schools, and of addressing discrimination, social exclusion and stigmatisation of HIV positive children and adolescents was recognised at the “Cairo+10”event, in 2004.

In the Mexico City Ministerial Declaration on “Educating to Prevent” in 2008, Ministers of Health and of Education of Latin American and Caribbean countries agreed to promote comprehensive sexuality education, with a gender sensitive, non discriminating focus, taking into account a diverse range of manifestations of sexuality, with a view to strengthening the autonomy of adolescents and young adults on human rights related subjects. The declaration also highlighted the importance of a multisectoral response.

The project was launched with a seminar at which representatives of the Ministries of Health and of Education and members of civil society organisations in the 6 partner countries agreed to a set of common objectives, strategies and guidelines for the implementation of sexuality education and HIV prevention policies. Based upon this consensus, each country developed its own national work plan. During the project execution phase (2007 - 2009) each country established a multisectoral management committee for sexuality education, including representatives from the Ministries of Health and of Education and members of civil society organisations, responsible for the implementation of the project at the national level.

The committee received support from a national consultant, selected by national authorities and contracted with funding from GTZ/UNAIDS/CICT. National policies and work plans were drawn up and implemented, and progress was monitored through regular regional workshops. The work continued during the consolidation phase, in 2010, featuring reflection on the strengths and weaknesses of implementation. In 2011, Colombia, Bolivia and Guatemala joined the project, whereas El Salvador joined in 2012. Since 2011, a regional network or“Community of practice”known as CoPSexEd has been developed to facilitate continued technical exchanges of experiences between countries.

  • South - South cooperation mechanisms have been adopted and have proven efficient tools for mutual support, given that many of the countries involved faced similar challenges with regard to HIV prevention in schools. Historical and cultural proximity has facilitated exchanges of scientific and technological knowledge, experiences, and lessons learned. Horizontal technical cooperation activities have also stimulated development of new and innovative tools for HIV prevention in schools. II. Projects 2010 – 2012 Duration 2007-2012 Objectives
  • Strengthening Public Policy for sexuality education
  • Strengthening sexuality education programmes and HIV prevention in schools
  • Harmonization of public policies and strengthening of linkages between health and education sectors Cooperation Partners Brazilian Ministry of Health, the Ministry of Education, UNAIDS, UNESCO, UNFPA, and initially the Brazil-based International Centre forTechnical Cooperation (ICTC), after 2009: ABC, Ministry of Health. CEDEP (Paraguay), FMP (Uruguay), CEDRO (Peru), CEDES (Argentina), OEI (Chile) Participating countries Argentina, Brazil, Chile, Paraguay, Peru and Uruguay. Since 2011: Bolivia, Colombia, Guatemala and, since 2012: El Salvador

Regional HIV and AIDS Programme in Latin America and the Caribbean 25 Results Currently, all participating countries have included sexuality education and HIV prevention as part of the school curriculums and are planning to follow up with these programmes, either with national funding or by incorporating sexuality education into programmes sponsored by the Global Fund. Between 2007 and 2011, an estimated 83,000 teachers were trained, and sexuality education reached more than 1,500,000 pupils in the participating countries. Further outcomes of the programme were: (a) greater donor harmonization, resulting from participation of international and multilateral partners in national and regional management committees; (b) multisectoral harmonization, achieved through the setting up of multisectoral management committees, proved crucial for coordination of the entire process, which in turn led to coordinated actions based on common objectives in the field of sexuality education and HIV prevention in schools, at the same time enhancing efficiency and strengthening national capacities to address challenges posed by the HIV pandemic; (c) through nationally led implementation, ownership of the processes was enhanced; (d) a horizontal cooperation approach to technical cooperation between countries was supported by international and multinational stakeholders; (e) implementation of the regional South - South cooperation project has caused Ministries of Education to assume control over sexuality education and HIV prevention in schools.

This is a major change since, traditionally, Ministries of Health have led the response to AIDS. However, in view of the multisectoral impact of the epidemic, involvement of Ministries of Education is crucial for a stronger and more effective national response. Thus, stronger national policies on HIV and AIDS prevention have had the effect of assisting in increasing access to sexuality education.

Regional coordination of countrywide implementation has resulted in stronger national responses. Multi-sectorial approaches once achieved contribute to sustainable results. For effective HIV Prevention the Ministry of Education needs to take the lead in evidence-based teaching on HIV and AIDS.

REGIONAL HIV AND AIDS PROGRAMME IN LATIN AMERICA AND THE CARIBBEAN ABC/GIZ/MS
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