A short history

After the break-up of the Soviet Union the transition process to a new social and economic order in the successor states, was accompanied by severe economic and social hardship. Nowadays, vulnerable groups are still left without social or medical assistance. In addition, epidemics in combination with a deteriorating health-care system, have made infectious diseases another focus of attention. The break-up of the Soviet Union also influenced the neighbouring countries. Formally, Mongolia was an independent state, but the country used to have strong political, social, cultural and economic links with the former Soviet Union for seven decades. With the collapse of the union, Mongolia was also affected and is at present going through a transition period, in many respects similar to the other former soviet republics.

AIDS, the incurable disease

AIDS is caused by the Human Immunodeficiency Virus (HIV), which affects the immune system, thus making the patient vulnerable to any infection. The HIV virus can only be transmitted by sexual contact and exposure to blood or tissues of an HIV infected person. Once infected, a person remains a potential source of HIV infection for the rest of his/her life; he or she may unknowingly contribute to the spread of the disease. Expensive drugs may prolong life expectancy, but so far no cure has been found. AIDS is still considered 100 percent fatal.

HIV/AIDS in Mongolia

Mongolia is one of the few countries not heavily affected by HIV/AIDS. Only two HIV cases have been reported so far in the country; one person died this year. But the present HIV/AIDS epidemic in the two neighbouring countries of Mongolia, Russia and China, has alarmed Mongolian authorities. The more, since the number of sexual transmitted diseases (STDs) has increased dramatically in Mongolia since 1990, which indicates the increased level of risky sexual behaviour. Syphilis rates among blood donors have risen by a factor of ten in five years. Similarly, over the last ten years syphilis among pregnant women has increased in 5 times and gonorrhoea increased 60 times (source: National STD/AIDS Centre).

Talking about sexual health is not easy

In close collaboration with the Ministry of Health and Social Welfare, MSF conducted a survey of young people about reproductive health issues. The MSF survey was carried out in the capital Ulaanbaator and in the central province Tov Aimag, among more than one thousand young people aged 15 to 25. The survey asked people about their knowledge and attitudes towards HIV/AIDS, STDs, contraceptive use and about what media they use to get their information. Among the most interesting survey results, it was revealed that there was a high awareness of HIV/AIDS, with 98% of respondents having heard about the disease, and almost the same number regarding HIV/AIDS as fatal.

Also, 80% of those surveyed, who were sexually active and not married, said they would be glad if their partner offered to use a condom. However, almost 80% of these unmarried respondents said that during their last sexual contact, they did not actually use any means of contraception. The respondents expressed their embarrassment to buy condoms and have difficulty in talking to a partner about using a condom. Also, 23% rated sharing toilet facilities and 17% rated coughing/sneezing as being highly risky to transmit HIV. Such misunderstandings can lead to unfounded fear and prejudice against HIV/AIDS.

Raising awareness

By using a condom one can protect oneself against an HIV-infection, but emotional and cultural factors as well as sexual attitudes often hamper such prevention. Using mass media structures to increase people's knowledge of the way the virus is transmitted, their awareness of risky exposure and the ways to protect oneself can be very effective. Campaigns all over the world have shown that a policy of instilling fear in people does not alter their behaviour. An open, informative approach, however, has proven to be effective. As the survey results show, young Mongolians are generally well informed about HIV/AIDS, know the main transmission ways, and that the disease is still considered fatal.

However, it appears that Mongolia is not using this advantage effectively: young people often realise the danger of AIDS in general, but find it extremely difficult to talk about this subject, take personal responsibilities towards gathering information and take precautions to protect their sexual health. Mongolian health authorities are realising the danger of HIV/AIDS for Mongolia and see the need for prevention activities, but lack experience and funding. Different (non) governmental organisations have developed small scale initiatives, but so far no comprehensive prevention campaign has been developed.

The programme

The AIDS prevention program in Mongolia consists of three components, aiming to raise people's awareness and increase their knowledge. 1. The launch of an effective HIV/STD campaign model, with the purpose of increasing the level of knowledge and awareness amongst young Mongolians regarding the practice of safe sex. 2. The establishment of an information centre in close co-operation with the non-governmental organisation 'AIDS/Infoshare Russia'.

The Information Centre will distribute up-to-date information about HIV/STD issues among health professionals and other relevant institutions and organisations in Mongolia. 3. The training of health professionals in counselling of people before and after an HIV test. This will be done in close co-operation with AIDS/infoshare Russia. The program is developed in close co-operation with Mongolian health structures and (inter)national (non) governmental structures. It is intended to serve as a model for preventive activities in the future, to be adopted for long-term use by the authorities and local (non)governmental organisations.

The campaign

In August 1998, Mongolian health authorities and the United Nations Program on AIDS (UNAIDS) approached the MSF office in Moscow for practical assistance in developing AIDS/STD prevention campaign in Mongolia. In March 1999 MSF opened its office in Ulanbataar, the capital of Mongolia. By involving international specialists and knowledge, wide-ranging international experience was used in the design of the first Mongolian campaign.

A survey was carried out to define the level of knowledge and awareness among young Mongolians between 15 and 25 years. Focus group discussions and in-depth interviews with the target group and their parents gave more detailed insight in the Mongolian cultural setting. Target group discussions based on different concepts eventually led to a message and a design that was well appreciated and understood by the target group.

The campaign has been designed by a Mongolian design agency "Studio". Initially the campaign has been designed for the Mongolian urban youth, who is in close contact with mass media structures. In a later stage the campaign materials will be used in rural areas of Mongolia as well. The campaign consists of three 30 seconds video commercials, a radio commercial, printed advertisements, leaflets and outdoor and/or public transport advertising. The campaign will picture a condom followed by the slogan "...- a healthy and wise choice". Since the use of words like 'condom'and 'sex' is still very sensitive in Mongolia, MSF chose not to use these words directly.

Information Centre

Without the involvement of professional health care workers, (non) governmental organisations and other relevant structures, a campaign against the spread of HIV is not likely to succeed. The availability of updated, accurate and reliable information on HIV/AIDS/STD prevention and care is one of the important goals of the HIV/AIDS prevention program. A special Information Centre will be set up in Ulanbataar to fill this need. The establishment of an Information Centre is carried out together with five regional information centres in Russia. Three more centres are planned to be established in Ukraine, where MSF is developing an AIDS prevention programme as well. A network between the Mongolian, Russian and Ukrainian Centres will be developed and information exchange will be the key.

Counselling

Health professionals play an important role in the prevention of HIV/AIDS. Through their contact with patients, they can play an effective role in determining who is at risk and providing these individuals with counselling and information that may prevent the spread of HIV. In the past the approach from the health sector has been involuntary testing or testing without the informed consent. Presently, testing for HIV/AIDS is performed on pregnant women and blood donors, as well as those persons considered at high risk, such as persons diagnosed with a STD. In 1998, over 45,000 HIV tests were performed, with no new cases detected. Often no pre- and post HIV test counselling is offered and privacy of tests results is not guaranteed. The programme will provide training for health professionals regarding pre- and post HIV-test counselling and the prevention of sexually transmitted diseases.

Six Mongolian trainers will become the leading trainers in the follow up training sessions for medical and para-medical staff. The programme will be supported by return training's, site visits, newsletters and other materials developed. It is foreseen to embed this training program in the curriculum of the medical faculty of the University of Ulaanbaator and thus to ensure knowledge of counselling for future Mongolian health professionals.