HIV and AIDS awareness programs in remote areas of PNG: an evaluation of VSO Tokaut AIDS impact in the third year of activity.

Levy, Catherine

Introduction

The Tokaut AIDS Project funded by the Big Lottery Fund (UK) aims to improve the quality of life in two remote, rural target areas by lessening the impact of HIV&AIDS, through developing and supporting community-level responses to the problem, as well as supporting national-level structures. The Awareness Community Theatre (ACT) program is focused in the two districts of Raikos (Madang Province) and Jimi Valley (Western Highlands Province). The project utilizes Community Theatre, training and support at the community and school level to increase awareness of HIV&AIDS, and to promote positive attitude and behaviour change.

The main outcomes of the project are that rural community members make positive behaviour changes to reduce their risk, and particularly that of young people and women, of infection from HIV&AIDS and that persons living with HIV or AIDS in rural communities have an improved quality of life and are able to live as respected and productive members of society.

After a baseline research in 2005, and a first evaluation in 2006, this article features the second evaluation carried out in June 2007.

Within the scope of the project, the objectives of the present research were to assess the current level of awareness and knowledge around the threat of HIV&AIDS and how this level of awareness is affecting attitude and behaviour patterns, and to assess the current level of stigma attached to persons living with HIV or AIDS and how the awareness dispensed by the theatre performances and peer group discussions have altered the attitude and behaviour towards them.

The methods used for this phase of the evaluation were essentially qualitative, so as to gather the broadest possible sample of opinions, perceptions and beliefs expressed by those interviewed. Data were gathered through in-depth interviews: individuals (one hour) and focus groups of three to four participants (1.5 to 2 hours).

The sample was constructed on sub-sampling according to location, age and sex. In each community, an additional sub-sample of 'community agents' has also been interviewed to help assess their influence on their fellow villagers. Students and teachers have also been included in the sample, to gather information on the impact of the introduction of HIV&AIDS awareness material in the primary school curriculum. A total of 87 interviews were realized in Jimi, and 80 in Raikos.

Main results

Elements of community context

The Raikos district may be likened to a 'jigsaw puzzle', divided by linguistic diversity, a marked dichotomy between the (thin) coastline and the (more remote and traditional) hinterland. Clan rivalries (within the same village), and clan alliances or affinities, across neighbouring villages, contribute to make communication very difficult.

The presence of Lutheran Development Services is felt in their support of community-based initiatives, such as micro-finance scheme and coconut oil press cooperative.

All across Raikos, the initiation for boys encompasses talks about sex, warning about risk behaviour etc. The initiation for girls is not practised anymore, and appears to have been abandoned within the space of one generation. It used to encompass comprehensive sexual education (menstruation, sexual contacts, pregnancy and childbearing, taboos etc). This disappearance appears to leave women vulnerable, ill-informed, and not aware of their traditional negotiation rights.

The Lower Jimi constitutes one linguistic and geo-cultural area (one Mareng language is spoken in 28 villages). The Lower Jimi is turned towards the Kalam speaking area of Simbai, rather than towards the Highlands/Mount Hagen side. Koinambe is an Anglican mission supporting a hospital, a primary school, an airstrip with weekly connections to Mount Hagen and a radio medical evacuation service. The station thus stands in contrast with other parts of the Lower Jimi, where communities may have no school or aid post services, and where women particularly might remain confined to the exclusive perimeter of their house and garden, with little or no access to formal education. The greater the distance from their village to such centres as Koinambe or Tokban, the more strongly marked their lack of confidence and assertiveness in a generally male-dominated culture. Both areas are marked by remoteness and difficult access. Communities' prioritiy concerns are schooling, health, roads and communications.

The present results reflect the results of almost two years of continuous efforts and exposure in the Koinambe area of the Lower Jimi valley, and of nine months of presence in that particular part of the Raikos where awareness was carried out.

Knowledge about HIV and AIDS, transmission, prevention, services

Very much in line with the 2006 findings, the large majority of respondents find it difficult to explain the difference between HIV and AIDS, or just to explain HIV, and just like 2006 also, they appear to have very little or no interest in knowing about it. Some add that the troupe members most often appear to talk about 'HIV/AIDS', in one utterance. The Tokpisin words sikaids and sik nogut are most commonly used to designate the disease.

Both HIV and AIDS are commonly described as a binatang (Tokpisin for small insect), that lives in human blood or in human fluids, that 'hides' there for some time before killing the person that carries it; the exact length of time is not well determined by the respondents who can only say 'sampela taim' (some time) or 'longpela taim' (a long time). All respondents are able to say that it is a new disease and that there is no cure.

The large majority of respondents say that the only diagnosis is through blood test. Besides these rational assertions, quite a few respondents, particularly away from the centers, and those who have had less exposure to the awareness campaign, are still looking for 'signs' such as bodily decay, weight and hair loss and diarrhoea, to recognize the disease.

The impact of the test is much commented upon: some say that having a blood test will make one think, whatever the outcome. If negative, the person will feel deep relief, and will probably behave 'more safely 'afterwards. If positive, there are two interpretations: one reaction in the sense to warn others 'Don't do as I have done'. Another one as 'I will die, and so will you.'

For the modes of transmission and concept of risk, all respondents are able to mention transmission through sexual contact. Some add that the virus is transmitted through unprotected sex. A very large majority of respondents spontaneously mention transmission through blood contact, in relation with open cuts (frequent in village life and garden work context), and the role of birth attendance, also common for women in remote villages. Danger of transmission is also associated with tattooing and sharing razor blades.

The transmission from parents to child is expressed more spontaneously in Jimi, where it is also expressed as 'papamama long pikinini' after the troupe changed it from 'mama to pikinini' in 2006. In Raikos, this type of transmission is more often mentioned in relation to breastfeeding and the dangers of virus transmission from an infected nurse to a non-infected baby. This newly acquired awareness has prompted a change in habit, as mothers are now reluctant to give their baby to another woman for nursing. Parent to child transmission remains however the mode of transmission that is the less clear and less present in the respondents' minds.

Respondents with less exposure to the awareness efforts still mention how wary they are of insect bites, and, to a lesser extent, of saliva, urine and excreta, and the sharing of plate, clothes and towel. Most of the respondents appear to request here further reassurance rather than straightforward information.

When asked about risk, about 'pasin i gat bikpela sans long kisim sik' (behaviour that give a chance to contract the disease), respondents mention unprotected sex and multiple partners, and the handling of fresh blood. Rape is mentioned as a risk circumstance by both men and women, although most of them add that this fact should be made better known, so as to more actively discourage rape.

Respondents are able to mention risk circumstances: discos and parties are mentioned first. Risk is also present in 'taun', as visits to town (Madang, Hagen) are associated with temptation and promiscuous behaviour. The visit of ship crew in Raikos villages, the sheer size of boat traffic along the coast, are identified by women and men alike as high risk circumstances, as well as the projected development of the Basimuk mine site up the coast from Biliau.

Risk is also very much present during times when cash circulates, as during coffee season, or at harvest of cocoa or copra. In analogy, the present campaign time for national elections is creating disturbances, with some candidates handing money in exchange of support. It is said that the danger lies as much with the men ready to spend their money (on women), as with the women, trying to attract men's money by proposing sexual favours.

Risk groups mentioned by respondents are young people in general (as seen by older respondents), the women victims of rape, the partners of promiscuous spouses, and, more generally, as seen by church goers, those who do not follow the Book, or God's words.

Finally, it is interesting to note that a number of young respondents, particularly students, display a good level of knowledge about HIV and AIDS, but without any experience of sex. All respondents say that there is no cure for the disease, if one accepts a few tentative mentions of bush cures or miracle cures, but without much conviction.

According to the dangers of transmission identified by each respondent, the modes of prevention or safeguard are said to be: use of condom, faithfulness to one partner who is faithful, abstinence, follow the Book. Other modes of protection mentioned are: staying close to their parents or listening to them (for the younger respondents), not going to parties, not going into town, stay away from fresh blood or wear rubber gloves. A large number of older informants (parents) mention compulsory blood check--and status disclosure- for young people intending to marry, openly asserting their intention to only give their marriage agreement if the potential partner tests negative.

Condoms are known to be available at Koinambe hospital (anonymously), and upon request at Biliau health centre (only men come and ask the officer in charge), and from the troupes' members. The feeling of trust towards the troupe members has developed to the extent that village men can go and ask female troupe members also for condoms, whereas previously they would have asked male troupe members only.

Findings in 2005 and in 2006 had shown that condoms were simultaneously strongly associated with 'sinful behaviour', on the one hand, but also with 'a new solution for a new disease' (and therefore strongly associated with use by young people), on the other hand. In 2006 condoms started being associated with the 'right to survival'. This trend is confirmed in the 2007 results, even if more clearly so in Jimi than in Raikos. In Jimi, the shift is subtle, from the dual 'pamuk (prostitute) vs safety' towards another duality: 'condom is the safest barrier' vs 'condom is not always safe, unfortunately it can break'. The result is a clear progress of the perception of condom as a practical part of 'modern life' (as in 'fighting a modern disease').

In 2006, an old Kompiai leader had said that he preferred to advocate condoms to the young ones, and later to advocate change in behaviour, rather than see them die without any chance of changing behaviour. This comment finds an echo in 2007 in various forms, this time also from women: a woman in her 40s in Jimi said that she would take it as a sign of her husband's care for her if she were to find condoms in his bag or if he were to suggest that they use it when engaging in sex. A Mama Group leader (and devoted Lutheran church goer) in Raikos does not personally like condoms, but absolutely supports them, to keep the young ones alive. In Jimi again, young men readily recognize carrying condoms around in their pockets. Even some young women are said to carry them, as a protective measure if they are approached by a man outside the village. A peer educator in Jimi has taught his own teenage sons how to use condoms.

It remains nevertheless that condoms are still very new, and that a number of respondents still need to work at feeling comfortable with them. Male condoms remain by far a male affair, in both men and women's minds. There are a lot of questions and curiosity about female condoms, as the condom that women would be most likely to handle. Some women say they have never seen a condom, and quite a few men say they do not know how to use them. There are complaints about condoms taking away the feeling of pleasure, or fear that it might damage the woman's skin. The issue of disposal remains an important one, with complaints of careless or improper disposal, both in Jimi and Raikos. Furthermore, its negative image is still present as associated with 'loose behaviour', multiple partners, and relationships outside marriage, and it is still blamed by some respondents for encouraging 'pasin pamuk' (prostitute behaviour).

It is important to note that a number of younger respondents in Raikos, both males and females, express their belief that their village is safe from the disease, that HIV and AIDS are still confined to town, or at the most to a few specific places of the Raikos coastline. Consequently they do not feel the need to use condoms. We have not met this type of comments in Jimi.

Access to services (blood test and counselling): Koinambe respondents know that they can take a blood test in Hagen or Kudjip. 'Remote' Jimi respondents are not so sure, and wonder if they could take it in Koinambe hospital. In Raikos, most respondents know that the test can be taken in Madang (although they hesitate about where exactly in Madang). The supposed cost of the test varies, from free to 100 Kina. Most respondents however add that they could not afford the transport costs to Hagen or Madang anyway.

For counselling services, apart from the community agents, no respondent had any clear idea what the word counselling--nor the concept- refers to. A number of respondents, however, ask about advice in relation to blood test. These respondents are enquiring about counselling without knowing about the concept.

In Koinambe, the interviews with the two hospital nurses who have received training in counselling, have shown that, even though they have advertised for the service being available, they have received few responses. Both nurses' general impression is that patients are either unaware of what counselling is about, or are reluctant to come to the hospital, as if it were an admission of their fears--or of their positive status. Further discussion with the troupe members, with Mother's Union members in Jimi, and with village health volunteers in Raikos indicate that they all partly fulfil this function of counselling already, as a number of villagers have contacted them in turn for questions and advice of sensitive nature. At this stage of the interview, a number of respondents express their fear by requesting compulsory testing and subsequent public disclosure of the status.

Sources of information and impact of Tokaut AIDS

The main sources of information about HIV and AIDS are the theatre troupe's performances and peer group discussions. Other sources of information include the hospital, the school, the parents, church and community leaders and members who have received training, and, more remotely, contact with town, radio and newspapers. Posters and booklets in Mareng local language (created by VSO Tokaut AIDS and distributed in April 2007) are also spontaneously mentioned by most respondents in Jimi.

Respondents underline how much they appreciate the drama pieces presented by the troupe, and generally show an accurate remembrance of their content. They explain how it made them look at their own situation and behaviour, and at its impact on people around them, innocent like their children or like those of infected people. The choice of vocabulary in Tokpisin is mentioned in Raikos as an example where the troupe have corrected and improved themselves, in order to not offend the audience. (From using 'kok', 'kan' and 'koap', to 'bol bilong man', 'rot bilong karim pikinini', and 'bungim bodi').

The methods of Image and Forum theatre have had a further impact on the whole community by creating a space for expression open to all its members. The first beneficiaries are said to be the women, especially in those areas where women do not usually speak up in public. The older women speak up more easily than the young ones. The very fact that women are given an opportunity to speak up in public is still commented upon. Both male and female respondents express their satisfaction at being able to 'change the story', for good (through interventions during Forum theatre sessions).

The peer group discussions have added a sensitive opportunity to ask questions and get answers or further precisions on delicate and private topics. Comments on these sessions make it clear that the cultural taboo usually attributed to speaking about sex in public actually applies to talking about sex while the other sex is listening. It is acceptable for women to talk about sex amongst themselves, or for men to do so amongst themselves. The taboo lies in the other sex being able to hear what is being said.

As a confirmation of 2006 results, women reiterate that the discussions have given them for the first time the opportunity to ask questions, and function as their 'skul', sometimes the only one they are able to attend.

The aspect of growth of the relationship between the troupe and the villagers is underlined in both Jimi and Raikos: with each visit, mutual trust develops, the troupe is perceived as (more) reliable, and the audience's confidence grows to allow them to ask questions, or simply intervene during forum theatre.

Aftermath: after the theatre troupe leaves the village ...

After the troupe leaves the village, the population keeps on talking about the issues they have raised, although the daily routine and the workload, especially for the women, does not leave much place for long discussions.

The older community members, especially the parents, talk a lot about it, more particularly because they worry so much about their children's behaviour. Parents, both mother and father, are often mentioned to sit down with their children at family dinner and talk about the dangers of the disease. Not only parents mention these sessions (as they did already in 2006), some children now do also. The sessions do not however appear to have developed into real conversations: parents initiate them and do most of the talking, children listen. The content of these various warnings, however, appears to still be quite vague, as' Stap gut' or 'Stap isi' (Tokpisin for 'Remain quiet, do not behave stupid'), 'Stap wantaim mama na papa' (Stay with your parents), 'No ken raun planti' (Do not stray far away'). Only a few fathers say to have given their sons more explicit information about the use of condoms, and a few mothers to their daughters about 'not touching men'.

Among themselves, the boys and the girls, in separate groups, talk about the risks of contracting the disease, and look at each other with distrust, each group blaming the other for spreading it. And everybody looks with distrust at those people coming in from outside, from taun, as possible carriers. Generally, boys appear to be more outspoken than girls, just as they were marginally more open during the interviews. Girls appear as less inclined to talk than boys, especially the girls that pride themselves of 'behaving well'. In Raikos particularly, the girls' present lack of sexual education appears in stark contrast to the one that was given traditionally upon the girl's first menstruation, and may be thought to leave the girls more vulnerable to harassment and abuse, as is reported to be the case.

The communication cross-generation functions also in the opposite direction--from children to parents- in the case of children from remote villages getting information at school, then passing it on once back in the village--usually to the restricted audience of the family circle, and almost exclusively as a summary on the modes of transmission and of prevention.

The students talk about the issue inside the classroom, and outside. In both Jimi and Raikos, teachers and students report that students 'warn each other', in the form of 'jokes' about risky behaviour, and also correct each other's knowledge about HIV and AIDS.

The communication cross-gender appears somewhat more developed than last year, with a number of men reporting their wife's comments about the dangers of transmission, a sign they have at least heard them.

Awareness and contact with a person living with HIV

Both Bismark Range Tieta and Kunai Paia Tieta have produced a play called 'Stigma and Discrimination', which has been presented to the villages upon the third visit. The play uses the Forum Theatre technique that proposes a script to the audience, in which the person living with HIV and AIDS is badly treated as well as his family. The audience is then given the opportunity to 'correct' the play, then to further discuss the issue with their peers in group.

Although it appears that no person with HIV or AIDS has stepped out openly to disclose their status, the general impression in both areas is that the disease is among them, not outside anymore. This assertion is much clearer in Jimi, where respondents are able to give precise examples of several people who died of AIDS in the last year. Also, two interviews mention that a couple have just recently disclosed their status in Kompiai. At least two respondents have personally cared for an infected person, and one has given one shelter in his house for one night. Such clear examples are not given in Raikos, where respondents merely refer to a speech given by the officer in charge of the health centre, informing them about the presence of HIV in the Raikos. But they add that they themselves have not seen anything.

In both areas, respondents are very aware that voicing suspicion about somebody's status may land them into trouble. This dread makes the Jimi respondents lower their voice and look around when they broach the subject, but they speak nevertheless. In Raikos, in at least two interviews, the informant openly chose to not disclose information. In both cases, they were referring to a woman who died early in 2007. She had been officially diagnosed with womb cancer, but was suspected of having also contracted HIV during an apparently very active sexual life with multiple partners, mostly from outside the village. The woman, living in the centre of the village, is reported to have been well looked after by the community up to the time of her death, even in the last phases of her illness.

In both Jimi and Raikos, there are requests to 'lukim long ai bilong mi' ('See with my own eyes') a person with HIV. Expectations are really more of seeing a person with AIDS and showing signs of disease. Or respondents still cannot get reconciled with the facts that HIV can really NOT be seen.

Impact on attitude and behaviour

All respondents were able to report some change, even if small, and give concrete examples of these changes, on a personal or on a community level. Open communication is an obvious change in both areas touched by Tokaut AIDS. People have learned or are learning to use the correct words, and to get rid of their 'traditional' shame of talking about the topic.

Some examples of change given by respondents may be dramatic, as two examples of strong opponents to the Tokaut AIDS 'Tok Stret' (straight talk) policy--one teacher in Koinambe, one young community member in Biliau who have gradually (but within months) been won by the arguments, and have operated such a turnaround that they now spontaneously speak up in public in favour of the actions against HIV/AIDS, including using the direct language that made them shrink earlier.

Quite a number of respondents give examples of personal changes: according to their former behaviour, the may talk more openly (parents, church goers), have reduced their partners to one (whether they are married or not), have chosen to abstain (young men), use condoms (young men, some young women). On the side of non-sexual transmission, care may be taken with blood (rubber gloves are fetched at the local hospital), or one avoids giving one's baby to another woman for nursing. One female respondent gives as an indicator for change the lesser number of court cases for adultery.

A general perception of (mostly older) respondents is that the young ones have not changed, or not changed enough. The older people express that they themselves feel safer, either because they were behaving safely before, or because they have understood the need to control risky behaviours. But to them the young people are still too daring. These affirmations contrast with the young respondents', who appear to be quite aware of the danger, and willing to check their behaviour.

Attitude and behaviour towards a person living with HIV or AIDS

Attitude regarding a person living with HIV or AIDS brings up simultaneously mixed feelings of fear, anger, pity, compassion, rejection and more . Respondents do not appear to make here a difference between looking after a person living with HIV and a person living with AIDS. In their comments they appear to envisage almost exclusively the person with AIDS, as the one needing almost medical attention.

When it comes to caring for a person living with HIV or AIDS, both areas appear to have well memorized the lessons given by Tokaut AIDS troupes: when asked how to look after a person living with HIV or AIDS, all respondents start a litany that sounds like: 'Lukautim ol, givim gutpela kaikai, givim marasin, wasim ol, hamamasim ol, no ken mekim ol wari ...' (Tokpisin for' Look after them, give them good food, give medicine, wash them, be loving to them, do not make them to worry ...'). Fear is still expressed on the level of non-sexual transmission.

Jimi overall express a moderate fear, quickly rationalized by the clear knowledge about transmission: 'as there are only three ways to contract the disease, I should be safe'. This confidence is apparent in the lack of request for care centres, as opposed to the findings in 2006: last year, the numerous requests for care centres were meant to create a space for the physical exclusion of persons living with HIV or AIDS. This year, the only requests for care centres come from community agents, and aim at creating a counselling or resource centre for persons living with HIV to drop in, not to receive medical help, nor to stay permanently. This progress is remarkable, even if restricted to the areas that have had continuous exposure to awareness for the last two years. As a counterexample, we received several testimonies of the type of incidents happening outside the area of activity of Bismarck Range Tieta: in Tabibuga, a person suffering from AIDS was lowered into her coffin in the last stages of her illness, but before she died. The coffin was then closed after she died, and her funeral was expedited.

Most of the Jimi respondents explain spontaneously that they would follow the custom of looking after a sick family member, although they initially express upset at them not having behaved 'properly', despite warnings (Note that the length of HIV period is not taken into account by respondents here). Church goers would look after them 'as Christians do'. There is mention that there might be blame on sangumah (black magic) in more remote, less informed areas. A lingering feeling of shame is expressed, as the spread of HIV appears to be still linked to 'pasin nogut' ('improper behaviour').

Generally, Jimis appear as having rather well integrated and accepted the presence of the disease in their midst, and to be reassured enough by the awareness work to be able to cope with it. If fear is still present, beyond any doubts, we did not encounter any of the panicky expressions of fear expressed in the first year, and to a lesser extent, in the second year, but well expressions of fear as concerns and precautions to be taken not to be infected. The accent is more strongly now on prevention, including requests for blood tests, particularly for potential marriage partners (and this, even more strongly from parents).

In Raikos, we met reactions comparable to the ones encountered last year in Jimi: fear is still the first and strongest reaction when talking about contact with a person living with HIV or AIDS. This fear may start to be rationalized by arguments drawn from newly acquired knowledge about transmission and prevention, but it is still dominant. The audience says about the drama 'Stigma and Discrimination', that they have been at the same time deeply touched by the mistreatment of the person with HIV and their family (and deeply touched in part because they recognized themselves in the play!), while being reassured by the factual information about transmission, and about care. A few respondents recall a young man in a neighbouring village who is suspected to have suffered from the disease. He had food thrown at him, no real care, and finally died. After seeing the play, a number of villagers talked about him, to deeply regret their behaviour.

Fear of a person living with HIV or AIDS, and reluctance to look after them is more openly expressed by young people, while older ones may feel reassured by their own knowledge, and also be more used and willing to look after community members:

The general feeling in Raikos is that more work is needed, more exposure to awareness, and maybe more direct experience with persons with HIV. There are here requests for a care centre that would 'accommodate' (i.e. segregate) persons living with HIV and AIDS.

Women's sexual negotiation capacity

Sex still remains a difficult topic to discuss openly, with lots of embarrassment and references to the fact that it is traditionally taboo to talk about it (in public). On the level of sexual negotiation capacity, there are remainders of women's traditional sexual negotiation capacity, especially at times when she is bleeding (menstruation, after giving birth), but also, to a lesser extent for the younger generations or in the 'centres', while she is pregnant or breastfeeding. The more remote, more traditional areas appear (little surprisingly) to better protect women in that respect. It is regretted by older women in Raikos that the traditional sexual education to young women has completely disappeared. This absence leaves a definite gap in the women's knowledge, and in the upholding of customs and consequent sexual negotiation ability.

Both in Jimi and Raikos, older respondents underline that women's abuse is largely a modern thing, rather than traditional. This type of remarks should be interpreted as complementary to the comments on how some women carry condoms in their billums, 'in case' they meet a man on the road. They remind of comments heard in Sepik (2005) and in Jimi (2006), by older women suggesting to younger ones to wear female condoms when going out or on the road, 'in case they get raped'. These precautions should be interpreted as a tentative to protect a woman who finds it hard to refuse a man's advances, rather than point to a woman in pursuit of opportunistic sexual pleasure. Generally women appear to gain self-confidence and assertiveness as they get older and as they bear children, which gives them status within the community.

When a married woman refuses sex to her husband, he may have different reactions. He may be understanding and accept; this is more likely if the relationship is a few years old or if the partners are older, but is not said to be the norm. Quite commonly, it seems, he would turn his frustration out on his wife, or on the children and household. Or he may walk out and look for another woman or another wife. Alternatively he may challenge his wife and tell her that, if she refuses, that means she has a lover. Reports often mention here that it is easier for the woman to give in, rather than face the possible consequences.

When a non-married woman refuses sex to her boy-friend or to her lover, she may use her newly acquired knowledge--and assertiveness, to stand up to the man. She may successfully use the argument of not wanting to get infected (together with not wanting to get pregnant). It is reported however that men use the argument of the condom to get over this type of reluctance. Some male respondents admit to having forced women (plural?) into sex, which matches women's accounts of having been forced, or having heard of women being forced. Support for the women's cause may come from the church and community leaders. Some young people also show the path to respect and understanding within the couple. There are isolated reports of women's sexual resistance (in words or acts) and the support that women start giving each other.

In Raikos, parents and older respondents are concerned with the number of young women having sex with men, preferably older ones. There are questions about how men get to 'bribe' these women (the English word is used). Women are also reported by men to be eager to experiment with sex. There is a high number of teen age pregnancies, although apparently less so among the girls still at school. The women themselves point a finger to the women who are said to 'sleep around' and put in the same bag at least one example of a young girl of fifteen who found herself pregnant by a married man and says she was raped rather than consenting.

Among the other young women interviewed in Biliau, only one admitted to have sexual relations, while all the other ones claimed to know nothing about sex. The general feeling among interviewers was that, contrary to the Jimi respondents, the young female interviewees in Biliau did not want to talk openly about this particular topic. It may be also that they are genuinely uninformed about sexual matters. In both cases, they would benefit from more openness, as a requisite to successful sexual negotiation ability. The issue of women's sexual negotiation capacity for safer sex appears to be the one that is progressing most slowly within the Tokaut AIDS efforts, and this may not be surprising, considering that this issue is not addressed directly by the drama yet, rather comes in as a peripheral issue, and that it reaches much deeper within the community's structural foundations. Most men would still need to be made to think about--then believe--what their own benefits would be to give their women more sexual choice.

What is being said however, by both men and women, is that women are better protected by the men's changes in behaviour as a consequence of increased awareness on HIV/AIDS. While these changes are increasing women's safety, they do not readily increase their sexual negotiation capacity.

Impact on a community level

A general effect of the epidemic, and of information about it, is to bring the community members closer together--in fear of 'strangers'. Examples of change on a community level concern mainly the behaviour of church and community leaders, their personal commitment, the depth of their outspokenness and the decisions they may have taken that affect the community. Respondents mention how their leader may have decided to ban parties and disco's, how they are speaking openly at community gatherings or in church, how they broach related topics, such as drugs and alcohol that make the users lose control, and bring themselves and other community members in danger.

In Jimi, as part of the impact of Tokaut AIDS one young leader mentions the depth of the change he has undergone on a personal level--becoming more aware of his responsibilities, and deciding not to take a second wife as he was planning to do, then working further on advocacy in his own community.

In Jimi and Raikos, marijuana creates problems, together with stim and gambling in Jimi, and jawa (1) in Raikos

Bismarck Range Tieta and Tieta Paia theatre troupes

Bismarck Range Tieta and Kunai Paia Tieta are seen as the bodies who literally 'opened the eyes' and the mind of their audience. Both troupes are seen as assets for the community, as the experts and the local references in terms of protection against the spread of HIV.

Their contribution takes the form of information AND counselling, that they give mostly during the times when they practise 'advocacy' in restricted family circles. Numerous examples are given by troupe members of occasions where they are asked for advice and support in confidential information or even practical interventions (speak in a school, accompany somebody for an STI test, act as referee in difficult situations between husband and wife...) They are said to literally 'jump up' at any opportunity for peer education. Comments are made about the necessity--for the credibility of their efforts- to stick to a strict 'code of conduct' in terms of responsible behaviour, alcohol management and safe sex. In this view, troupe members are closely scrutinized as role models.

Suggestions: what should happen with Tokaut AIDS in your community?

Generally, respondents display very little critical sense when asked what they would wish from the troupes. They basically stick to expressing their gratitude and satisfaction at the troupes' efforts and performances.

The main suggestions are:

* The troupe should keep on visiting the community, to update the information and reach the youth as they grow. Areas of importance are, besides transmission and prevention, the diagnostic blood test, and care for persons living with HIV and AIDS.

* The troupe should visit the neighbouring areas, to reach those neighbours that are still ignorant, and so put them into danger by risky behaviours.

* Give more time to the Forum theatre sessions, so that more community members have a chance to speak, particularly women.

* Check the troupe's behaviour as 'role models' and follow their code of conduct.

* Give people more, thorough, sexual education and bring in the open such issues as the difficulty of talking about sex, and the consequences, such as endemic rape, STI's, unwanted pregnancies, spread of HIV. Relate this to issues that are fuelling the epidemic: drugs, drink, women's lower status.

* Bring out the 'positive': help the community see the positive changes they have already achieved. Praise the good changes and the role models. (Use community-centred indicators to monitor the change)

* Train the members as counsellors and in home-based care (troupe members, women's group members).

Conclusions and recommendations

The 2007 evaluation sees the emergence of the picture resulting of over two years of continuous presence and exposure, reinforced by the Anglican Church support, in Koinambe and surrounding area. This picture may be summarized in a quote from a Koinambe teacher: 'They have learned to live with the idea that HIV and AIDS are amongst them'.

All places in Jimi and in Raikos are not evolving at the same pace: the communities that benefit from proximity to the centre, exposure to awareness, repetition/synergy of messages (from the theatre troupe, the church, the school, the health centre ...) display greater awareness and self-confidence to engage against it than the other villages.

The research team reports increased comfort of respondents during the interviews: even women who do not speak Tok Pisin overcome their shyness to answer the questions with the help of an interpreter (Jimi).

The appreciation of the Tokaut AIDS interventions is clear and unequivocal: for the content of the drama, for the forum theatre and peer discussion techniques, for the repeated visits and the consequent trust that is allowed to develop between the community and the troupe, for the involvement of the leaders, the church, and the teaching staff.

On the level of awareness, respondents report an increased awareness of transmission and prevention methods. On the side of prevention, respondents identify risk behaviour and risk circumstances, including some driving forces of the epidemic, such as difficulty of access to cash and women's lower status. Condom's perception continues to evolve in the direction of 'a modern solution to a new disease', and a (short-term) method of protection (while still retaining its negative association with 'unacceptable behaviour', as underlined by some Churches).

The impact on attitude and behaviour is the expression of a 'rationalized fear', that reflects the integration of knowledge on transmission and prevention. Most respondents are able to give examples of change, whether at a personal or a community level, including their own personal change. Such changes are identified by both young and old respondents, by men about themselves, by some women about themselves or about their partner.

Attitude and behaviour towards a person living with HIV: respondents express confusion between the perception of a person living with HIV and a person living with AIDS, the latter being prevalent. Interviews give the impression that respondents have learned by rote about the care for person with HIV. Behaviour change has been tested in a number of practical cases in Jimi. In other places, particularly Raikos, it remains a theoretical knowledge that needs to be tested by the reality of persons living with the disease. Most often, respondents refer to the Melanesian tradition for the care of a sick family member, and apply it to HIV and AIDS. Fear is expressed, if rationalized and reduced, at this stage, to risk of non-sexual transmission, and stigma is expressed indirectly: 'I would not hurt a person living with HIV, but I would not allow my child to marry one'

Women's negotiation capacity makes slow progress, mainly for unmarried women or outside marriage. Signs of change towards women's assertiveness are the mentions that they now talk in public, during interviews, and the fact that men are acknowledging women's voices. Isolated examples are given of women's resistance in words and in acts. Most vulnerable are young women, especially those that do not have access to education, nor have borne children yet. While women enjoy a somewhat better protection against the spread of HIV, it appears to be as a consequence of men's behaviour changes rather than of their own empowerment. Women's status within the view of a community affair depends on the community norms, not on an outsider's point of view. For women's status to change, the whole community has to look at their norms, reevaluate them and agree on changes. Only then can individual behaviour changes be sustained inside the community.

The void left by the breakdown of traditional structures should be identified in areas where it plays a part in the driving forces of the epidemic, particularly women's protection and status. Reviving specific traditional structures may help tackle current problems and engage the community.

The difficulties associated with remoteness, i.e. terrain, large territory, isolated communities, language and illiteracy have to be kept in mind to understand the size of the Tokaut AIDS challenge in the areas. While there is a clear need for more awareness efforts, preference should be given to advance 'strategically' in a given geographical level, where the 'natural' resonance of present action is best felt, in the areas neighbouring to the ones presently visited, and towards which the present community 'naturally' turns.

Successful awareness is based on repetition but also on unified voices: it is particularly crucial to seek to align the voices of influence within the community, such as the voice of the local churches.

The acceptation of the presence of HIV in the area is made obvious through the requests for information, not about transmission and prevention anymore, but about blood test, counselling and care for person living with HIV or AIDS. Such topics should be emphasized in the upcoming awareness visits. 'Natural' counsellors identified within the community should get training to fulfil their role they have started to fulfil or might be expected to as the epidemic spreads (troupe members, teachers, church leaders, women's groups ...)

Theatre, and particularly Image and Forum theatre, and peer group discussions have proven to be strong, efficient introductions. The programme should contemplate community engagement tools such as 'community conversations' for deeper community changes and consensus. Such tools continue to recognize the necessity to work on the 'driving forces' of the epidemic: lack of education, women's status, community's perception of masculinity, access to cash, and breakdown of traditional values.

At this level, Tokaut AIDS may help the community decide what 'they' want to look like, not what an outside model should dictate. To function better, the community should learn to capitalize on their strengths to support behaviour change: 'Do not tell us how to do, help us find out for ourselves how we will function better as a community'. Community-developed indicators would help the community assess its own progress and would serve as a base for further action, based on information and guidance provided by Tokaut AIDS.

(1) Stim and jawa both refer to local home-made brew made of mashed bananas and sugar left to ferment with yeast. The result is a potent alcoholic drink, cheap and very popular, mostly among young men, but not solely. A young man of 16 died of over-consumption of the beverage in a Raikos village just prior to the research team's arrival.

Catherine Levy has a doctorate in linguistics from the University of Brussels. She conducted her research in the Awar language on the north coast of PNG. She has been involved in HIV/AIDS-related social research and adult literacy since 2005. Her projects include the creation of HIV/AIDS awareness material in Mareng language (Jimi Valley, WHP), research into optimisation of distribution and use of this material in 25 Mareng-speaker villages.

Email: levied@scubamadang.com.pg