Sports a tool to combat HIVAIDS, but also a right

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Sports a tool to combat HIVAIDS, but also a right



    Marleen Bosmans

    Ghent University International Centre for Reproductive Health

    In a world where HIV/AIDS is increasingly infecting and affecting the poor, young and female, growing attention is paid to the development of innovative approaches aimed at enhancing the effectiveness of the interventions to halt the further spread of the pandemic. The ABC approach (abstinence, faithfulness and condom use) is still at the core of many HIV/AIDS prevention programmes targeting youth but doubts remain about whether this approach has really contributed to better protection of young men and women against HIV/AIDS, particularly in an environment where sex and sexuality is a taboo. Sport has been identified as a new and important resource for reaching youth whose prior concerns and interests are not necessarily how to protect themselves from HIV/AIDS. Sport has moreover been recognized a right of all men and women without discrimination grounded on the principles of dignity and equality. This paper explores how sport can be used as a rights-based tool that may facilitate the access of vulnerable youth male and female - to

    HIV/AIDS information, education, care and treatment.

The looks of HIV/AIDS: poor, young and female

    The fight against the spread of the HIV/AIDS pandemic has become one of the major

    st century in the fight against poverty and for development. challenges of the 21

    Worldwide HIV/AIDS has become the leading cause of death and the most important

    1contributor to the burden of disease among adults aged 15-49 years (WHO). Although

    HIV/AIDS is not a poverty disease, there is a very close relationship between poverty and vulnerability for HIV/AIDS. This is particularly the case for African countries where 40 percent of the population survives on less than US$ 1 a day. In general, poverty levels are relatively higher in AIDS-affected countries, although the countries with high HIV-prevalence rates are not necessarily countries with the worst poverty indicators. The


    South African region, for example, is economically the most advanced one of sub-Saharan Africa, it nevertheless contains seven countries with HIV-prevalence rates higher than 20 percent: Botswana, Lesotho, Namibia, South Africa, Swaziland, Zambia and Zimbabwe. These countries show high levels of income/consumption inequality with one

    2third of the population living on less than US$ 1 a day.

    Poor populations, unskilled workers and people with a low educational level have become increasingly more vulnerable to HIV infection and are disproportionately affected by the pandemic. At an early stage the pandemic mainly affected the wealthier and better-educated populations who had greater mobility and the economic resources to pay for casual sex. As information and knowledge about HIV/AIDS became more widely available these groups started changing their behaviour and to better protect themselves from getting infected. Risk behaviour among the better-off has largely become a matter of power and choice. The poor and less educated populations, however, have become relatively more vulnerable. Risk behaviour among these populations is not only a matter of lack of access to information, education and health services, but also of poverty and lack of power that may compel them into sexual behaviours and practices that put them at

    3risk. Most of the estimated 40 million people infected with HIV have never been tested, either because there are no health services, or because the stigma associated with HIV/AIDS is too high to take the risk of knowing. Besides, most of the infected have little understanding of the disease and their knowledge is often very limited or even

    4erroneous (UNESCO, 2004).

    Most AIDS-affected countries have young populations and half of the yearly 5 million newly infected people are young adults between the ages of 15 and 24 years. Several studies in South Africa found that particularly poor young people run high risks of being infected with HIV/AIDS. Young people start having their first sexual experience at an ever younger age but often lack the knowledge and the skills to protect themselves. Young people receive conflicting messages about sex and sexuality, adhere to myths and cultural beliefs that may even increase their risk for HIV/AIDS and do not tend to acknowledge the disease to be a problem that may affect there personal lives or their


    5 A study in 34 countries in sub-Saharan Africa immediate environment (Hartell, 2005).

    indicated that in none of the countries more than half of the young people between the

    6ages of 15-24 years were aware of critical prevention and transmission methods.

    HIV/AIDS is not only young and poor, it is also female. Initially the pandemic mostly affected men, but now almost half of the HIV positive people are women. In sub-Saharan Africa 67 percent of the 8.600.000 newly infected young people are female (UNFPA,

    72003). Poverty and gender discrimination lie at the centre of women’s and girls’ increased vulnerability. Poor women and girls have less access to information, education and health services than men. Often they are lack the social and economic power and the negotiating skills to refuse sex or to demand condom use. Adolescent girls and young women are particularly vulnerable to sexual violence and exploitation what increases their risks of being infected by HIV. Practices such as early and forced marriage expose them to additional risks instead of creating a protective and safe environment (UNFPA,

    82003, 2005).

HIV/AIDS Prevention Programmes for Youth

    Protecting young people, and particularly young women and girls, against HIV/AIDS becomes a huge challenge. The promotion of abstinence, fidelity and consistent condom use, is the credo of the so-called ABC approach which is at the core of many of HIV/AIDS prevention programmes targeting young people. The main goal is to encourage young people to delay their first sexual experience, to reduce the number of sexual partners and to use a condom when having sex. The implementation of this approach, however, is quite complicated as vulnerability for HIV/AIDS is determined by a combination of several cultural, political, social, economic and legal factors. Early sexual experience is not only a matter of choice but also related with a series of contextual factors such as household poverty, access to education, access to health care, place of residence, ethnicity, gender and legal protection (Hallman, 2005). Some cultures allow girls to be married as soon as they reach puberty. Several studies indicate that for many girls their first sexual experience was forced and against their will. Although the


    protection of women and girls against sexual and gender-based violence (SGBV) has been recognized as a prior concern for reducing their vulnerability for HIV/AIDS, the concept of SGBV is still easily reduced to the act of rape. Many other forms of SGBV , such as making use of the sexual services of girls living in the street and trying to survive as sex workers, or forced marriage, may be accepted, tolerated and even justified

    9Moreover, sex, sexuality and condom use are difficult (Bosmans, Temmerman, 2005).

    topics to discuss, even with your partner or friend. A variety of studies indicate that in many societies it is socially unacceptable for girls to raise the issue of condom use and that they may even face risks of physical, emotional and economic violence when they dare to do so.

    It remains unclear to which extent the ABC approach has actually contributed to safer sexual behaviour of adolescents and youth. Research in South Africa, for example, found that peer pressure, curiosity, coercion (particularly for young girls) and material gain were some of the main reasons why the HIV prevalence among the South African adolescents remains so high: 15,6% of the South African youth between the ages of 15 and 24 years is infected with HIV. Increased knowledge and awareness about HIV/AIDS has not necessarily been translated into substantial changes in the sexual behaviour of young people. Overall, adolescents did not practice safer sex and more than 50% of the sexually active adolescents has never used a condom (Hartell, 2005).

Sport: an Innovative Approach

    The cry for improving the impact of HIV/AIDS education and prevention programmes to stop and even curb the spread of the pandemic among young people, sounds louder and louder. Campaigners worldwide are looking for innovative approaches of how best to reach groups who are most at risk and how to increase the effectiveness of the interventions. Sport has been identified as a key tool in the fight against HIV/AIDS among youth and adolescents. The assumption is that sport may facilitate their access to the HIV/AIDS message because sport is not only a favourite pastime, but is also


    considered to be a good way of promoting respect for diversity, tolerance, non-discrimination and solidarity.

    On 1 June 2004 the International Olympic Committee (IOC) and the Joint United Nations Programme on HIV and AIDS (UNAIDS) signed a Memorandum of Understanding (MoU) in Lausanne, Switzerland, on the use of sports to raise awareness about HIV/AIDS, particularly among the sport community. The MoU had two major objectives: 1) to exchange regular information and lessons learned in order to enhance the role of sport organizations in the fight against AIDS at community and national level; 2) to

    10 The organize AIDS awareness activities with coaches, athletes and sports personalities.MoU is totally in line with the philosophy of the Olympic idea of the IOC and its previous commitments to promote peace, to preserve human dignity, to combat discrimination, to promote sustainable development and to support education and culture. The declaration of the Fifth World Conference on Sport and Environment (Torino, Italy, December 2003), the so-called “Torino Commitments on Sport and Environment”,

    emphasized the role of sport in addressing “social and economic priorities such as the fight against poverty and the spread of HIV/AIDS; and in the promotion of social justice,

    11human well-being and gender equity.”

    In June 2004, HIV/AIDS experts from UNAIDS, the National Red Cross and Red Crescent Societies and the National Olympic Committees from 13 sub-Saharan countries were brought together at a workshop in Johannesburg, South Africa, to identify ways of how sport could be used to raise awareness among the public, and particularly among young people, about HIV/AIDS and to fight the stigma and discrimination associated

    12with it (Gomo, 2004). Sport was identified as an important tool to break down barriers, to promote self-esteem, to teach life skills and healthy behaviour. Athletes are called to act as role model for young men and women. At the XXVIII Olympic Games in Athens August 2004, 11.000 athletes were given HIV/AIDS awareness cards and red ribbons in their welcome kits. In many countries the National Olympic Committee has undertaken activities for organizing awareness raising campaigns, trainings, seminars and advocacy


    activities on the issue, alone or in partnership with other national or international organizations.

    In 2005, the IOC and UNAIDS published a toolkit for the sport community on the

    13prevention of HIV/AIDS (IOC/UNAIDS, 2005). The development of the toolkit is one

    of the results of the implementation of the IOC Policy on HIV/AIDS that does not only

    stress that the IOC has a moral obligation to actively engage in the fight against HIV/AIDS, but also that the IOC will play a leading role in committing efforts and mobilizing resources within the Olympic movement. The toolkit is designed to be used in training programmes for young people, sportspeople and sport personnel with the aim to increase their “AIDS competence” and their capability of communicating properly about HIV/AIDS. The kit gives clear and accurate answers to a series of questions about HIV/AIDS: what is HIV/AIDS, how is it transmitted, how to prevent it, where and why to test, where to go for care and treatment, etc. The kit also pays attention to the effect of sport on HIV and the effect of HIV on sport, how to minimize the risks of HIV transmission on the sport field and how to start working on HIV/AIDS with different age groups.

Using Sport as a Rights-based Tool

Sport and Breaking the Taboo about Sex

    When talking about sport and HIV/AIDS, the focus is mainly on how to use sport as a tool for creating awareness, improving knowledge and changing attitudes to HIV affected people. The experiences are still very recent and it is probably too early to assess their effectiveness and the impact on the sexual behaviour of young people. Automatically, however, one refers to experiences with other HIV/AIDS information and education programmes for youth, such as programmes organized for in-school youth. These programmes usually have several components, such as life skills training, HIV/AIDS information (often provided by teachers, nurses or doctors), peer education programmes (basically on campus), sensitisation activities (for example on the World AIDS Day) and


    condom distribution (where allowed). In spite of the close interrelatedness between HIV/AIDS and sexual behaviour, many HIV/AIDS life skills training programmes, however, do not or insufficiently - address the issue of sex, sexuality and sexual health, “the purpose of which is the enhancement of life and personal relations, and not merely

    counselling and care related to reproduction and sexually transmitted diseases” (ICPD,

    14 A rights-based approach also implies the recognition of the right of all men and 1994).

    women “to attain the highest standard of sexual and reproductive health”, a “state of

    complete physical, mental and social well-being” in “all matters related to the

    reproductive system, its functions and processes” (ICPD, 1994). This means that all men and women, including adolescent boys and girls, have the right to a safe, sound and enjoyable sexual life free of discrimination, coercion and violence, both inside and outside marriage.

    In many societies talking about sex and sexuality is still a big taboo, particularly because sex is associated with all kinds of values and moral norms and belongs to the intimate and private sphere of the lives of men and women. The approach to HIV/AIDS is often determined by ideologically driven values or inspired by religious beliefs that do not allow young people to have access to accurate information in such a way that they are capable of taking informed decisions and making realistic choices to protect themselves

    and their partner. HIV/AIDS information and education is often very technical and taught in isolation and not as part of a wider sexual and reproductive health framework that also deals with issues such as family planning, (un)wanted pregnancies, sexually transmitted

    15infections, SGBV (Boler,Jellema,2005). Many HIV/AIDS educators do not feel at ease

    talking about sex and do not succeed in overcoming these barriers as they lack the skills to 1) reflect upon their own sexuality and relation with their partner; 2) to talk about it with their partner; 3) to talk about it in public; 4) to respond properly to the questions that young people ask them in order to guide them and enable them “to deal in a positive and responsible way with their sexuality” . (ICPD, 1994; Brennan, Bilukha, Bosmans M.,

    161718Dahal, Jha, 2005; Bosmans, 2005).


    Section 7 of the IOC toolkit clearly points out that coaches or presenters of HIV/AIDS information should become comfortable with their own sexuality in order to be able to respond honestly and factually to questions of curious young people and to really interact with them. Although the toolkit acknowledges that this may involve a lot of introspection and raise a lot of questions, it does not provide modules for really tackling the issue. (IOC, 2005). Experiences in Colombia with programme officers, field workers, health workers, teachers, artists, adolescents and their parents, who were involved in a SRH/HIV/AIDS programme of UNFPA (United Nations Population Fund), learned that reflection on their own views on sexuality and their own sexual practices were basic and essential, though very difficult and challenging steps to take. The participants qualified the approach as “excellent” and “revolutionary.” They were not only impressed by the high quality of the information given, but also by the impact the trainings had on the quality of their personal lives what allowed them to look at, talk about and working on sexuality and sexuality related issues such as HIV/AIDS in a more respectful and non-judging way (Bosmans, 2005).

Sport, HIV/AIDS and Dignity

    Human dignity and equality are basic principles on which a rights based-approach to HIV/AIDS is grounded (OHCHR/UNAIDS, 1998). Particularly when targeting highly vulnerable groups who are often stigmatised and discriminated against by the society, rebuilding dignity and self-esteem is essential for really drawing their attention for the HIV/AIDS message. The experiences with adolescents and young women displaced by war and armed conflict in Colombia and Sierra Leone learned that HIV/AIDS is not an issue of prior concern to them, although they ran high risks of being infected with HIV. HIV/AIDS prevention programmes were embedded in programmes and activities that called their attention and responded to their direct interests such as arts (theatre, dance, music, painting, etc.), vocational skills training and income generating initiatives. Through these activities they started feeling like full citizens again as they gradually regained their self-esteem and the respect of their community. Regaining self-esteem and


    the sense of citizenship allowed them to be receptive for SRH/HIV/AIDS messages and empowered them to refuse unwanted sexual contacts.

    The preservation of human dignity, the recognition of the practice of sport as a human right and the elimination of any form of discrimination are fundamental principles of

    19 In line with these principles the sport community has already Olympism (IOC, 2004).

    clearly committed to changing attitudes of discrimination and stigmatisation, associated with HIV/AIDS to understanding and acceptance. A fully rights-based approach, however, would also imply that this commitment should be reinforced by measures taken in order 1) to improve the access to sport of youth - young men/women, boys and girls - who are particularly vulnerable for HIV/AIDS or disproportionally affected by it but are often discriminated and stigmatised because of their low socio-economic status; and 2) for creating of supportive and enabling environments that allow these youth to (re)build

     20their dignity (OHCHR/UNAIDS, 1998).

Sport, HIV/AIDS and Gender

    A rights-based approach inevitably implies a gender-based approach to HIV/AIDS, also in sport. In May 1994 the first international conference on women and sport was

    21organized with support of the IOC in Brighton, United Kingdom (IWG, 1994). At the

    conference 280 delegates from 82 countries agreed upon the creation of the International Working Group on Women and Sport (IWG). The IWG recognizes the right of all women and girls without discrimination to have the opportunity to participate and to be involved in sport activities. The IWG also committed to promoting the creation of safe and supportive sport environments for women and girls and the elimination of all forms of harassment and abuse, violence and exploitation (IWG, 1994). At subsequent conferences in Windhoek 1998 and Montreal 2002 the issue of women and sport and how sport can contribute to the elimination of discrimination against women, the promotion of gender equality and equal development opportunities for women and girls was further

    2223elaborated (IWG, 1998, 2002). The 2002 conference in Montreal, organized under

    the theme “Investing in Change”, insisted on the importance of developing self esteem


    and self confidence among women and girls through sport and launched a call for “sport and physical activity as health promotion, to develop awareness of the power of sport in avoiding risk behaviours like early sexual activity and teenage pregnancy, substance abuse, HIV/AIDS (…)” (IWG, 2002).

    The challenge will be how to put these principles into practice, particularly within the context of HIV/AIDS. The IOC toolkit acknowledges the lack of social and economic power of women and girls to negotiate relationships based on abstinence, faithfulness and use of condoms. The kit equally recognizes the taboos that surround the issue of rape and other forms of sexual violence. Examples are given of how HIV positive sportswomen out themselves and support HIV/AIDS prevention, but so far the issue of gender has not really been mainstreamed as a basic strategy in using sport as a tool for HIV/AIDS prevention. Guidelines and practical tools for promoting gender-equity within the sport community as an integrated part of its commitment to fight HIV/AIDS will be essential if sport really intends to contribute to enhanced protection of women and girls from HIV/AIDS. Likewise the implementation of the commitments to protect women from violence and exploitation will need to be fully integrated into any HIV/AIDS prevention programme.

Sport, HIV/AIDS and Access to Health Care

    Information and education are two key-components in the organization of HIV/AIDS prevention programmes that are grounded on a rights-based approach. Facilitating access to health services, such as voluntary counselling and testing, treatment and care is the third key-component (OHCHR/UNAIDS, 1998). The elaboration of this third component in the toolkit is rather limited. How can the availability of sport health services be used to improve the accessibility to HIV/AIDS counselling and care? What kind of health referral systems can be set up? How can the youth friendliness of the sport health services been improved? What is the role of the sport doctor in case of sexual violence? How can the sport doctor become a person of confidence? What about the training of sport doctors in HIV/AIDS and other SRH related issues? What about the monitoring and supervision of


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