AIDS action Issue 22 Page 1 2
Issue 22 September - November 1993
Promoting sexual health
The World Health Organization defines health as 'a state of physical, mental and social well-being', not just the absence of disease or pain. 'Sexual health' relates to this state of well-being in a person's sexual life - feeling comfortable and confident about sex and sexuality, being able to avoid sexually transmitted diseases (STDs) and unwanted pregnancies, ensuring fertility and safe pregnancies, and, indirectly, protecting the health of infants.
All these issues are inseparable for many people, including choosing when, and when not, to have children (family planning) and preventing infections. Despite this, few family planning and AIDS organisations meet people's sexual health needs. They often fail to help people to deal with problems in their sexual and reproductive lives, or to achieve satisfying and safe sexual relationships.
This special issue of AIDS Action, produced in collaboration with the International Planned Parenthood Federation (IPPF), shares the valuable lessons learned by family planning programmes which have responded to the challenge of HIV/STDs. They are developing sexual health programmes that promote a broader definition of safer sex - sex which is pleasurable, and safer from unwanted pregnancy, infections, and abuse.
This issue includes ways to help people to talk about sexual activities, sexuality and safer sex (including condom use), and outlines some training exercises in sexual health for AIDS and family planning workers. These workers need to overcome their own prejudices about sexual behaviour. They need to find out how people view sexual health, and what factors influence it. These factors may be economic ones, affecting contraceptive supply or availability of STD treatment. Cultural and religious factors also influence sexual health, affecting the status of women and their expectations, or attitudes towards young people's sexuality, contraception and abortion.
Workers need to involve people in developing programmes to meet needs in the community. This may involve challenging and changing attitudes and beliefs. But - with the risk of HIV, a life-threatening, sexually transmitted disease - the need to promote sexual health is becoming more urgent than ever.
With thanks to Dr Tony Klouda at IPPF's AIDS Prevention Unit
|HIV/STDS and family planning|
Making good connections
Combining family planning and HIV/STD prevention efforts makes sense because both are concerned with sex and sexual health.
Many sexually active women and they may also be worried about, or perhaps unaware of, the risk of infection with HIV or other STDs. Family planning services can play an effective role in HIV/STD prevention, because:
most clients are women aged 15 to 50, who (married or single) are among the most vulnerable to HIV/STDs
these services are sometimes the only type of health care used by women
workers already have some experience of discussing sexual activity (in relation to vaginal sex), and promoting sexual behaviour change.
Many family planning organisations are adding HIV/STD services to their work. They are also reaching adolescents, men and single women, as well as married men use family planning methods, women, and giving clients more opportunities to talk about sexual activities and relationships, and sexuality. They are trying to deal with issues that contribute to poor sexual health, such as inequalities between men and women, lack of inexpensive STD treatment, limited sexual knowledge, and harmful traditions and practices.
People are often more concerned about STDs with visible symptoms than they are about HIV, especially if AIDS is, as yet, uncommon. Discussing how to treat and prevent these STDs can provide an opportunity to talk about HIV. Even when family planning clinics and AIDS organisations cannot provide STD services, they can play an important role in STD control, by:
collaborating with STD clinics in setting up joint training and reliable follow-up and referral systems
II training staff to examine for STDs and to ask questions sensitively without embarrassment about sexual partners and practice (including same sex relationships and anal sex), and genital or lower abdominal symptoms
displaying information about HIV/STDs and giving people enough time and privacy to raise their concerns
explaining about STD transmission, prevention and treatment, and the importance of tracing and treating all potentially infected sexual partners
explaining to everyone the benefits of condoms in infection prevention - including people who are using another method of contraception
demonstrating how to use condoms properly and helping people to practise ways to persuade their partners to use them.
Approaches to integration
The following examples show how different family planning programmes have integrated HIV/STD prevention.
Training in response to needs
Planned Parenthood of New York City (PPNYC) in the USA serves about 40,000 women, men and adolescents each year, providing pre-natal care, STD and cervical cancer screening, gynaecological services and abortion, as well as family planning. About four years ago, an HIV/AIDS prevention programme was introduced. The first step was to train staff to deal with HIV/AIDS. They were already experienced in counselling clients on issues that are hard to talk about, such as sexuality, contraception and abortion. However they needed specific information, including help with overcoming fears about being infected. All staff attended a three-day course on HIV/AIDS, and then were supervised by senior staff until they were ready to begin discussing HIV with their clients. HIV counselling was difficult for some staff, especially because it was added to an already full caseload. Staff who felt stressed were encouraged to seek support from colleagues, senior staff or a personal counsellor. Overall, integration has been very successful, and HIV/AIDS education and risk assessment are now part of each initial and annual follow-up visit.
During a recent workshop, staff of The Gambia Family Planning Association listed the problems reported to them. These included lack of sexual satisfaction for men and women, problems in communication between partners, impotence, painful intercourse as a result of female circumcision, concerns about STDs and AIDS, side effects of contraceptives and infertility. Staff wanted to learn about helping people with these issues, and they have now been trained to include information about HIV/STDs in their counselling and education programmes, and to encourage the use of condoms as contraceptives.
HIV/STDS and family planning
Women at risk
Some programmes choose to raise the issues of HIV/STDs only with clients believed to be at risk. This often includes single people or women who have problems with becoming pregnant or miscarriage, or who have STD symptoms. However, this approach leaves out other people who may be at risk, such as many married women. It may be better to encourage every client to think about whether he or she is at risk, especially in areas where HIV or other STDs are common.
One organisation in Zambia found that most women were at risk because their partners had other lovers. Although the women were worried, they did not feel able to ask their husbands to use condoms. Women who did were often accused of infidelity and threatened with rejection. The organisation then started a group where women could develop ways of approaching the subject of condoms with their husbands, rehearse what they would say and support each other. The women felt that they were being made responsible for safer sex, and asked staff to talk to men, in workplaces, for example. So, in small groups, men discussed the issues and became more aware of the risk of HIV to themselves and their families. A drama performed by the women for the men brought home the need for action.
In Ghana, the Planned Parenthood Association established Daddies’ Clubs in workplaces, where men could meet to discuss family planning and child rearing. Discussions now include HIV/STDs and options for safer sex, and condoms are distributed. Anyone who wants to talk in more depth is invited to come for one-to-one counselling. This allows people to think about risk privately and to decide if they want to discuss their concerns.
More than sexual health
Rural women in Mexico often have no access to health care or family planning, so the family planning association, Mexfam, is training community health workers to run groups with female farm labourers. Health education covers a wide range of issues: sex education, family planning, reproductive health and pregnancy, child health, water and sanitation, and energy-saving strategies. Low self-esteem, domestic violence, sexuality and STDs are also discussed. Both barrier and hormonal contraceptive methods are supplied, but demand for condoms is increasing. The women are very enthusiastic, and the men are also showing some interest in discussing the issues.
Thanks to Gill Gordon and Peter Gordon of lPPF’s AIDS Prevention Unit, for collaborating on 011 the articles in this special issue. Thanks also to Jeanne Kolinoski, PPNYC, 26 Bleecker St, New York, USA and Gabriela Rondriguez, Mexfam, Juarez 208, Tlalpan CP, 14000 Mexico DF.
One-to-one confidential counselling can provide a valuable opportunity for a person to understand their own vulnerability to infection, and to make informed choices. If you are counselling someone, ask questions in ways that do not offend, threaten or frighten and check that the person feels able to talk about difficult topics. Ask yourself: ‘How would I feel if I were asked that question!’
Begin with open questions (without a yes or no answer) to allow the person to bring up their concerns. It is best to have a conversation rather than writing down the answers while you are talking.
Examples of helpful questions
What do you know about HIV/STDs?
How would you know if you had an STD?
What questions do you have about HIV/STDs?
What are your worries about HIV/STDs?
Now that you know about how HIV/STDs are transmitted, do you think you might be at risk in any way?
Are you in a stable relationship? How long have you been with that person?
Do you ever have any other sexual partners?
Have you ever thought or known that your partner has others? Are they men or women?
Do you or your partner travel and stay away from home sometimes?
Do you use family planning? Have you ever used condoms?
Have you ever had an STD before? When was that?
Do you have any signs and symptoms of an STD now?
Have you ever thought or known that a partner might have an STD?
Have you/your partner ever had any problems with getting pregnant when you want to?
Have you/your partner(s) ever had a miscarriage or stillborn child?
After the person has explored all the issues, with you providing information when needed, you can talk through ways to reduce their risk.
Safer sex and condoms
Giving people more choices
Many factors affect how men or women can reduce their risk - AIDS Action explores some options.
Counsellors, educators and trainers need to feel comfortable about encouraging people to discuss options for protecting themselves and their partners against STDs and HIV. People need to make their own decisions based on how they assess their personal level of risk. This is affected by their ability to change their situation, and their feelings, values and needs. Options include no sex (abstinence), staying with one sexual partner, and having sex with fewer partners. However these options may not be possible for everyone. The last two may not be free from risk.
Safer sex - including condom use - gives people more choices. As well as greatly reducing the risk of HIV/STDs, safer sex also prevents unwanted pregnancy. Safer sex refers to sexual contact that does not involve semen, vaginal fluids and blood (including menstrual blood) entering another person's body or coming into contact with broken skin.
Safer sex activities include
Non-penetrative sex-massaging, touching, or kissing and licking your partner's skin; stimulating your own or your partner's genitals with your hands (masturbation); stimulating the penis between the partner's thighs (thigh sex) or their arm and body (armpit sex); kissing on the mouth and deep kissing (tongue sucking).
Penetrative vaginal or anal sex using a condom.
Oral sex (mouth contact with male or female genitals). This is much less risky than unprotected penetrative vaginal or anal sex. Avoid this if either partner has sores on their genitals, mouth or lips. The risk is even lower if a condom is used for oral sex with a man, or piece of latex (dental dam) is placed over a woman's genitals.
Emphasise the benefits
It is important to present safer sex and condom use in a positive way. Ask people to think of safer sex activities which they would feel able to suggest to their partners or promote to others. If you are working with a group, you can use the exercise to start a discussion about condoms (see box). Emphasise the benefits of condoms: when used properly, they are very effective contraceptives, as well as protecting against HIV and STDs (in anal and vaginal sex).
They lower the risk of pelvic inflammatory disease and cervical cancer for women. Unlike most other contraceptives, they have no side effects. Some men find that the tightness of a condom helps them to maintain an erection.
Make sure you give people opportunities to discuss their worries. Remember that women especially need confidence and skills to negotiate safer sex.
Practice makes perfect
Men and women have more confidence about condoms, and are less likely to experience problems such as breakage if they practise how to use a condom correctly, using a model penis made of wood, rubber or clay.
Tips for condom use
Condoms should be stored in a cool, dry, dark place. They should not be used if they feel brittle or sticky, or after the expiry date (usually printed on the packet).
Put the condom on when the penis hard, before it enters the partner or touches their genitals.
Place the condom (with the rolled-up rim facing outwards) on the end of the penis with one hand. With the other hand, pinch the tip of the condom (to remove any trapped air). Continue to squeeze the tip while unrolling the condom to cover the penis.
Lubrication helps to prevent condom breakage. If a condom breaks during sex, it should be taken off immediately and a new one put on.
Take the penis out soon after ejaculation, but before it becomes soft. While withdrawing, hold the rim of the condom firmly against the penis to prevent leakage.
Slide the condom off without spilling any semen. Do not use it again. Tie a knot in it, and dispose of it safely.
Why don't people use condoms?
Ask participants (in small groups) to list the reasons why people in their community don't use condoms. Meanwhile, write these headings on large sheets of paper: knowledge; feelings; skills; physical reasons; cultural reasons (religion, gender, age); lack of resources/economic reasons; and other. In the large group, ask people to read out their reasons and decide which heading to put them under. Then ask:
what can you learn from these lists?
which issues are already being dealt with, and how?
when and why do people use condoms?
how will you find out more about people's reasons for using or not using condoms?
what else might encourage more use of condoms?
Safer sex and condoms
Sex and lubrication
A man is able to have sexual intercourse only when he is sexually excited and his penis is hard. Arousal in women produces vaginal secretions which can act as a lubricant during penetrative sex. When women become sexually stimulated (by stroking, kissing, and touching their genitals) they often want and enjoy intercourse much more. However, women can have penetrative sex whether they are aroused or not. But if they are not, it can feel painful and dry (especially if their partner is wearing a condom).
Lubrication during vaginal and anal intercourse reduces friction so condoms are less likely to break. If natural lubrication is not possible or enough, spermicides or water-based lubricants, such as glycerine or KY jelly, can be used. Sensation and pleasure for men can be increased by putting a little lubricant inside the tip of the condom. Some condoms are lubricated already. Oil-based or greasy lubricants such as vaseline or butter should never be used because they damage condoms.
It is important to address practices that increase risk. In some countries women use herbal preparations or a cloth to dry their vaginal secretions. This can increase vaginal tearing (and the associated risk of infection) and condom breakage. Another practice is having anal sex to avoid pregnancy. Encourage both women and men to discuss: if and why practices like these are common; if and why women/men prefer it; whether the practice could increase risk of HIV/STDs; and the options for making it safer.
Condoms are contraceptives too
AIDS workers need to take into account that many people already use family planning, and this may affect their decision about using condoms. People may need to use condoms as well as, or instead of, another form of contraception. The most effective methods are sterilisation (for men and women), IUDs (intra-uterine devices) and hormonal contraceptives (the pill and the injectable), but they do not prevent HIV/STDs. The condom is the only protection against all STDS, including HIV. Other barrier methods, such as the diaphragm, used with a spermicide, protect against some STDs and cervical cancer.
Issues to think about
Some men and women may want to use a condom and another method, especially if either partner is HIV-positive and they are concerned about risk of pregnancy.
HIV-positive women and those at risk of HIV/STDs are advised not to use IUDs, because vulnerability to infection may be increased. Oral contraceptives may further weaken the immune system of HIV-positive women.
It may be difficult for someone who has been sterilised to suggest condom use to a regular partner if they are reluctant to discuss HIV/STDs.
Getting pregnant usually means having unprotected penetrative sex. People who are HIV-positive (or who think they might be) need counselling about possible risks and options. They can then decide what to do.
Condoms are often associated with occasional sex outside marriage. Mentioning infection prevention could mean implying that a partner has been having other relationships. Sometimes women may find it easier to suggest using condoms as contraceptives (because they have no side effects).
Some couples decide to use condoms only if they have sex outside their relationship. They may use another method of family planning if they wish to avoid unwanted pregnancy in their own relationship.
It is usually women who take responsibility for contraception, often relying on methods not used at the time of intercourse and sometimes without their partner's knowledge. Condoms are one of the few methods controlled by men who therefore need to agree to preventing pregnancy, as well as infection.
Women who are past the menopause can no longer get pregnant. But older men and women may risk infection if they have unprotected penetrative sex.
CDC Update, 1993. Barrier protection against HIV infection and STDs. JAMA 270, no 8: 933. Single copies are free until August 1994 from CDC National AIDS Clearinghouse, PO Box 6003, Rockville, MD 20849-6003, USA
A leaflet on condom use, with instructions (or adapting the words and pictures (or different audiences, is available free in French and English from DST/GPA, WHO, CH-1211 Geneva 27, Switzerland.
See AIDS Action issue 13 for information on negotiating condom use.
Tips for training
Talking about sex
Family planning and AIDS workers are often asked for advice on sexual health issues. To help them respond. They need:
basic information about recognising and treating STDs, preventing HIV/STD infection, and the benefits of condoms
to feel comfortable talking about sexual activities and relationships, and about HIV/STDs
communication and counselling skills to help people decide whether they are at risk and to discuss their concerns openly.
The following are suggestions to help workers (during training) and people in the community (during workshops or one-to-one sessions) to feel more relaxed and confident.
People often find it difficult to talk about sexual activities, relationships, and their feelings about sex, especially behaviour that is not widely accepted such as sex outside marriage, same-sex activities or anal sex.
Ask people if they want to talk in single sex or mixed male and female groups, or both, during a workshop.
Make sure that people know that the session is confidential and cannot be overheard. Ask permission to talk about sensitive Issues, explain the purpose of the discussion and acknowledge embarrassment.
Listen to people's concerns about sexuality and follow their lead in the use of language and ideas. People may not be as shy as you think. In one Muslim village, when a family planning worker was using very polite language, an elderly traditional birth attendant used an explicit term. Participants applauded her, and quoted a local saying: 'If you are too shy to say the words, you will hurt the idea.'
Group Exercise: ask people to list the medical and local names for different kinds of sexual activity and for male and female genitals. Ask them in pairs to talk about how they feel about the words. Then ask them whether the names have positive or negative meanings, and in which situations they would be appropriate or unacceptable.
Role play helps people become more aware of their values and feelings, and to practise talking about difficult subjects.
Group Exercise: In pairs, one person acts out a role (examples below) to which the other person responds.
A young man asks: What exactly is safer sex?
A woman says: ‘I want to use condoms but what shall I do when I want to get pregnant?
A woman is worried about using condoms as contraceptives.
A man says he tried using a condom but it broke, and his partner didn’t enjoy sex with it
A man who has had a vasectomy feels he could not suggest using condoms to his wife
After the pairs have talked for five feedback on what they found useful, and what was not helpful. Ask their partner to say what they found difficult and what they did well. You can also use role play to help people find ways to talk about safer sex with their partner(s).
To start discussions, use drama, pictures, stories, agony aunt letters (anonymous letters either made up or taken from newspapers or magazines) and puppets or masks.
In a group, avoid asking people to speak about their own experience (unless they choose to). Instead, ask general questions about what other people might think, feel or do:
What worries do men/women have about sex?
How do you think young people try to avoid pregnancy when they don’t have access to contraceptives?
What are some of the reasons why men/women have sex outside marriage? In which situations do men have sex with minutes, ask the role player to give men?
Tips for training
Participation is the key
These two training exercises enable AIDS and family planning workers to feel more confident in communicating about sexual health issues.
These characters were developed for a training course in India and were described using flannelgraph pictures. You can adapt the characters for different situations, making sure that you provide plenty of detail about them, and include behaviours that people may find difficult to talk about.
Vijay is married to Sangita and they live in a poor neighbourhood. He is a lorry driver, often away from home, and has affairs. Vijay knows about AIDS, but doesn't believe it is a risk. He has had an STD several times, which he treated with drugs from the market He thinks about using condoms with his wife, but he doesn't know how to suggest it.
Sangita was sterilised after having two children. She works in a factory and sometimes feels so depressed that she gets drunk with a neighbour and they have sex. She often suffers from vaginal discharges and pain, as do her workmates. She does not go to the doctor because she is embarrassed and treatment is expensive. The women heard a talk about AIDS at work, but one woman was beaten when she suggested using condoms to her husband.
PramilIa is 16 and works as a maid in a rich household. Her elderly employer puts pressure on her to have sex with him. She is having an affair with Vijay, and his attention makes her feel special. They tried to use condoms once, but they were in a hurry and sex was painful. She now takes the contraceptive pill. One day she would like to get married and have children. She knows nothing about STDs or AIDS.
Krishna is homeless, and lives on the street He sometimes accompanies Vijay on his journeys, and helps with the manual work. Vijay is kind to him and sometimes they have sex which makes Krishna feel close and wanted by another human being. He once heard on the radio that homosexuals get AIDS but he didn't know what either word meant.
Participants are first asked to discuss each person's sexual health needs. After this, they are asked to do role plays to help the characters express their needs, and consider their options for action. The role plays can include: counselling the characters individually; counselling Vijay and Sangita together; talking with a group of women (including Sangita) from the factory; talking with a group of street children (including Krishna).
Hints for role playing
Ask open questions such as: ' What makes it difficult for you to use condoms?'
Clients may find it useful to hear what others in a similar situation have done
Neighbours and friends can be useful supporters
Neither women nor men should be made totally responsible for changing their situations
Talking with couples may help them to talk with each other
People who share a common problem can find it useful to talk in groups
People's feelings are as important as what they know
Hints to help participants
Work alone or in pairs
Speak a local language and be the same gender, age, religion as the people they talk to
Establish rapport before discussing the topic and stress confidentiality
Move from the general to the specific
Be informal and friendly and share personal experiences (but only if these are genuine)
This exercise needs a whole day to prepare, to do the fieldwork and to discuss what happened. It helps workers to think about different people's needs, knowledge, feelings and attitudes.
Participants are asked to talk with people (individuals, couples and small groups) in nearby streets, shops and eating places. Before starting, they discuss how they will: introduce themselves; explain the purpose of the conversation; encourage people to speak to them; ask open-ended questions; and listen to what they say.
Examples of some open questions about HIV/STDs are:
What do you know about diseases passed through sex?
Are these diseases a problem in your community? Who for?
How can people avoid these diseases?
What obstacles make it difficult for people to do this?
What can people do about this?
When they return participants are asked to describe: what happened; what they learnt; what they felt they had done well; what problems they had; what impact they felt the session had; and what they would do next in the town. Participants at these workshops have felt that this exercise was one of the highlights, despite the fact that they were nervous about doing It beforehand.
AIDS action Issue 22 7 Page 8
Letters / Sexual health resources
Nurses fight AIDS
We were interested to read about nurse training and occupational safety in issue 19. The National Association of Nurses and Midwives in Uganda carried out a ‘train the trainer’ programme with the International Council of Nurses in 1990-91. Nurses gained a great deal of confidence, and now work with the motto: ‘Fight AIDS, not people with AIDS.’
Occupational safety was a major issue because gloves and syringes are in short supply. Some nurses are now involved in training TBAs and traditional healers, and in running home-care and counselling programmes for their patients.
C Nakayenga, Uganda NANM,
PO Box 8322, Kampala, Uganda
Coping with stress
Since setting up TASO over five years ago, we have been training counsellors for our seven centres and for other organisations. Managing stress has always been an important part of providing a good service and caring for our staff.
During their six months training, counsellors learn about dealing with stress and burn-out.
Every month counsellors meet to discuss their work, stressful issues and solutions, as well as positive experiences and future plans.
Counsellors are free to take a break, or even a day off, between sessions.
Every year a three-day stress management workshop is held for counsellors, run by external facilitators. Topics include: what stresses you?; signs and symptoms of stress; dying and grieving; and marriage problems and solutions.
Counsellor supervisors receive extra training and are available to help colleagues with problems.
Staff are encouraged to involve themselves in activities unrelated to AIDS.
Peter Ssebbanja, TASO, PO Box
10443, Kampala, Uganda
Thank you for sending me AIDS Action - I am very grateful for your efforts. In November 1992, I started a club for fellow prisoners, with the help of the Anti-AIDS Project and other organisations here in Zambia. About 30 of us meet twice a week for an hour, with permission from the prison authorities. I am also translating some materials into our language, Bemba, and distributing newsletters and booklets throughout the prison.
Maximum Security Prison, PO Box 80915,
Sexual Health Resources
Talking AIDS - a guide to community education and mobilisation in HIV/STD prevention (£2/US$4 English, French, Spanish. Arabic and Portuguese).
Preventing a crisis - describes ways to integrate HIV/AIDS prevention and family planning (£4/US$8: English, French, Spanish, Arabic and Portuguese).
Counselling and sexuality - a set of four videos and a manual for training in counselling skills in sexual health and relationships (£50/US$100 English and Arabic).
All about AIDS - developed in the Caribbean, giving information about HIV/STDs, safer sex and contraception using stories, cartoons and quizzes (£1/US$2: English).
The above are available from IPPF Distribution Unit PO Box 759. Inner Circle, Regent’s Park, London NW1 4LQ UK.
Women and HIV/AIDS - includes information on HIV/STDs, safer sex, condom use and contraception (£5.50 to readers in developing countries: English, French and Spanish).
Readers without access to foreign currency should contact AHRTAG for a free copy.
Flannelgraph on family planning, STDS and AIDS - five sheets of pictures printed on flannel and a manual with information and ideas for participatory education sessions (£20/US$35: English).
Turning the tide - safe motherhood: a district action manual by Dr Marie - Therese Feuerstein includes a section on HIV, conception, pregnancy and delivery (£7.50: English).
The above ore available from TALC PO Box 49, St Albans, Herts, AL1 4AX. Send an international money order, eurocheque or UNESCO coupons, adding 60% for airmail or 30% surface mail for postage.
Managing editor Kathy Attawell
Executive editor Nel Druce
Design and production Ingrid Emsden
Editorial advisory group Calle Almedal, Nina Castillo, Professor E M Essien, Dr Sam Kalibala, Ashok Row Kavi, Dr Ute Küpper, Professor Keith MacAdam, Dr Tuti Parwati Merati, Dr Claudia Garcia Moreno, Dr Chandra Mouli, Dr Anthony Pinching, Dr Peter Poore, Barbara Wallace, Dr Michael Wolff
Publishing partners ABIA (Brazil) Colectivo Sol (Mexico) ENDA (Senegal) Consultants based at University Eduardo Mondlane (Mozambique)
AHRTAG's AIDS programme is supported by FINNIDA, HIVOS, ICCO, Memisa Medicus Mundi, Misereor, Norwegian Red Cross, Oxfam, Save the Children Fund, SIDA and WHO/GPA.
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