FHI - Making Prevention Work Global Lessons Learned from the AIDS Control and Prevention (AIDSCAP) Project 1991-1997 Making Prevention Work 10. Crossing Borders: Reaching Mobile Populations at Risk

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10. Crossing Borders: Reaching Mobile Populations at Risk (See Below)

10. Crossing Borders: Reaching Mobile Populations at Risk

Most HIV/AIDS prevention efforts are defined by geography: they are designed, funded and implemented country by country or in regions within countries. But the epidemiologic and behavioral factors that drive the epidemic know no borders. In fact, mobile populations -- and those affected by transient traffic in the areas where they live -- are often at increased risk of HIV/AIDS. These mobile populations, in turn, can bring the epidemic from cities and towns to more rural regions when they return to their spouses and other sexual partners at home.

Mobile populations at risk of HIV infection include transport workers, miners and other migrant workers, military troops, refugees and women who trade sex in tourist and transient areas. Their risk stems from the experiences they share: separation from families and communities, language barriers, limited entertainment options, and easy access to alcohol, drugs and commercial sex.

Reaching mobile populations with consistent HIV/AIDS prevention messages and interventions is a formidable challenge. Cross-border and transient areas tend to have less developed health care infrastructures, including facilities for STD diagnosis and treatment, and mobile populations often do not know where or how to access the services that are available. The remote locations of most transient towns, the cultural and language differences among the populations who pass through them, and the generally higher crime levels and security risks encountered in cross-border environments make it difficult to carry out successful HIV/AIDS prevention programs.

Leading the Way

During the late 1980s the AIDSTECH Project (also funded by USAID and implemented by FHI) pioneered interventions with mobile populations in Tanzania, where it carried out a successful HIV/AIDS prevention project targeting truck drivers and their assistants and sex partners along the country's major transportation routes. AIDSCAP used the lessons from this experience in Tanzania to design interventions with transport workers in a number of African and Asian countries, including Zimbabwe, Ethiopia, India and Nepal.

Beginning in 1994, AIDSCAP expanded this early focus on drivers and truck routes to understanding sexual risk behavior among other mobile populations and developing effective interventions for them. A series of ethnographic studies supported by USAID's Asia and the Near East Bureau produced a wealth of information about the factors that promote the spread of HIV in border towns and port cities in Asia and the Pacific,^1-6 leading to the design of some of the world's first cross-border prevention projects.

In Indonesia, in a pilot prevention project that could serve as a model for other Asian port cities, a shipping company's management endorsed a comprehensive HIV/AIDS intervention, enabling outreach teams to work with Thai fishermen and their Indonesian sex partners in the city of Merauke. In the Lao People's Democratic Republic, AIDSCAP and CARE International used local festivals and other innovative communication strategies to raise awareness of HIV and increase condom use along the border with Thailand. In the Philippines, the Center for Multidisciplinary Studies on Health Development reached thousands of fishermen and their partners through interactive group sessions. And assessments along Nepali and Indian trucking routes led to successful collaboration between projects on both sides of the India-Nepal border (Box 10.1).

AIDSCAP interventions targeting refugees, miners and military troops have also yielded useful lessons about how to reach and influence mobile populations and their sexual partners. In Rwandan refugee camps in Tanzania, AIDSCAP sponsored the first large-scale early intervention against HIV and other STDs among refugees.⁷ In South Africa, where mining companies are beginning to develop prevention activities for employees who often travel across the country or from neighboring countries to work in the mines, AIDSCAP and Population Services International built upon the prevention efforts of the management of South Africa's large Welkom area mines to establish a condom social marketing project for miners and the community around the mines. Annual condom sales exceeded 249,000 in 1996 and had already reached 213,000 in the first four months of 1997.

In its work with the armed forces in Thailand, Cameroon and Zimbabwe, AIDSCAP found that the military hierarchy and its traditional role in educating young men offer ideal opportunities for HIV/AIDS prevention education. An intensive intervention that used Thailand's military structure and the prevailing social networks among soldiers was so successful in reducing risk behavior that it was adapted for use throughout the Thai military. In Zimbabwe, a local NGO called CONNECT worked with the Air Force and Army to conduct workshops on HIV/AIDS issues for commanding officers, train military personnel and their spouses as peer educators, and develop appropriate communication materials. And the AIDSCAP-sponsored Civil-Military Project on HIV/AIDS worked with civilian and military populations worldwide through the Civil-Military Alliance to promote collaborative HIV/AIDS prevention strategies.

AIDSCAP was also able to reach the female partners -- both commercial and casual -- of mobile men. For example, an AIDSCAP-supported study conducted by the African Medical and Research Association identified the most acceptable and cost effective ways to provide confidential STD services to women living along the Tanzania-Zambia truck route.^8,9 In South Africa, in conjunction with the national AIDS program, the project reached out to the sexual partners of miners with education and a condom social marketing project in the mining communities. AIDSCAP also supported pilot efforts to help the wives and other steady partners of mobile men protect themselves from infection -- a difficult challenge because these women often live far from the original intervention sites .

But perhaps AIDSCAP's greatest contribution to strengthening HIV/AIDS prevention for mobile populations has been its role in raising awareness of the magnitude of the problem and in advocating for interventions that cross borders, particularly in Asia. The results of AIDSCAP's assessments of HIV risk among mobile populations and the experiences from subsequent interventions were disseminated through position papers and other publications, presentations at international and regional meetings, and smaller workshops and meetings. As a result of these efforts, several international organizations and donors, including UNAIDS and the British and Australian aid agencies, have agreed to support AIDSCAP cross-border projects once the project ends or have used AIDSCAP findings to design new projects. And government officials who participated in meetings that AIDSCAP organized to encourage support for cross-border activities are beginning to recognize the importance of facilitating such cooperation to slow the spread of HIV/AIDS.

Lessons Learned

Cross-Border Interventions

Mobile populations encounter increased opportunities for HIV-risk behavior in border towns and port cities.

Formative research conducted by AIDSCAP in nine countries revealed that border towns and port cities offer individuals greater access to inexpensive commercial sex and alcohol than other urban and trade areas.^1-6 The remote locations of border towns also isolates individuals from their regular social networks, which typically regulate individual behavior. As a result, mobile populations in cross-border environments, where men greatly outnumber women, have more opportunities to engage in risk-taking behavior.

Consistent and complementary prevention strategies and messages, implemented on both sides of a border, can greatly enhance the effectiveness of HIV prevention programs.

AIDSCAP's experience working with NGOs in neighboring border towns in Nepal and India shows that consistency and collaboration are the keys to implementing an effective cross-border project (Box 10.1).

Similarly, community-based organizations implementing AIDSCAP-supported projects in Haiti and the Dominican Republic exchanged ideas, shared resources and established networks with counterpart groups working with Haitians and Dominicans in New York, Florida and Massachusetts. A brochure listing referral services in both countries is just one of the ways in which the organizations from the Dominican Republic and New York plan to reinforce HIV prevention messages and provide services to a mobile Dominican population that frequently travels between the two countries.

Intergovernmental authorization and support are preferable, but not required, for assessments and HIV/AIDS prevention interventions across borders.

Blanket authorizations from all countries involved would, of course, be most desirable, but require long-term policy dialogue. In the meantime, prevention activities can proceed while program managers and sponsors simultaneously seek broader support for cross-border action.

The AIDSCAP-sponsored cross-border activity in Nepal and India, for example, began in 1995 through the collaborative efforts of two NGOs (Box 10.1). In 1996, AIDSCAP convened a three-day workshop for representatives of governments, NGOs and private industry from India, Nepal and Bangladesh to share lessons learned from the project and to encourage further collaboration among prevention projects in border zones. UNAIDS is providing funding for a series of workshops to continue this dialogue, as well as support for the India-Nepal border project after the AIDSCAP Project ends. And Family Health International is planning additional cross-border interventions in India, Nepal and Bangladesh.

10.1 The India-Nepal Partnership: A Model Cross-Border Intervention
Dhaaley Dai, a cartoon condom figure, wards off HIV with a shield in the border town of Birgunj, Nepal. "Wear condoms. Drive away AIDS," reads the message on billboards and posters. Just a few hundred meters away in Raxaul, India, another condom figure spreads a similar message in Hindi.

The use of a slightly modified Dhaaley Dai in India (pretests revealed that members of target audiences there did not identify with the traditional Nepali shield and did not like the condom's muscular limbs) is just one example of the close collaboration between two AIDSCAP-sponsored organizations on opposite sides of the India-Nepal border. By adopting similar strategies, methods and materials, the Nepali NGO General Welfare Pratisthan and the Bhoruka AIDS Prevention (BAP) Project in India were able to create complementary HIV/AIDS prevention programs for transient border populations.

This collaboration grew out of AIDSCAP's research on HIV risk behavior along trucking routes in India and Nepal and the Transport Corporation of India's (TCI's) interest in protecting its workers from HIV/AIDS. Through its Bhoruka Public Welfare Trust, TCI had already opened a network of 15 STD clinics throughout India. In 1995, with technical assistance from AIDSCAP, the Trust opened a similar clinic in Raxaul and began linking it to GWP's prevention activities across the border.

Raxaul was chosen as the site for the cross-border intervention because it is the most important entry point into Nepal from India and because of its proximity to GWP's activities in Birgunj. Both border towns are located at "zero points" where a number of major highways converge. About 2,000 truck drivers pass through these points daily, often stopping to load and unload trucks and to rest before continuing their drive.

At every stage of the project, the Indian and Nepali staff of the two projects worked together to ensure that project goals, strategies, evaluation indicators, messages and services were consistent on both sides of the border. And because the projects had adopted similar approaches, outreach workers from India and Nepal found it easy to coordinate their activities. Staff from BAP, GWP and AIDSCAP reviewed communication strategies, materials, training curricula and condom social marketing strategies developed for the Nepal program and adapted them for the BAP Project in Raxaul.

Frequent visits and communication among field staff were also important to successful collaboration. The GWP team in Birgunj and BAP staff visited each other regularly, and BAP personnel participated in staff training activities at GWP's Hetauda field office, just an hour's drive north of the border.

BAP Project Manager Atanu Majumder noted that his staff had learned a great deal from GWP's outreach workers. "We didn't have the experience of how to work with sex workers, so we are grateful to GWP," he said. "Our staff has gone there and worked with them. They have taken us to the field and showed us how to interact with sex workers."

The two teams also organized several joint events, including a World AIDS Day Rally at the border. But the most important part of the collaboration was the joint STD referral system. Because people were often reluctant to visit the highly visible and well-known STD clinic in Birgunj, GWP staff used bilingual referral cards to direct men and women in need of STD services to BAP's general clinic just across the bridge.

Such visible cooperation helped both groups gain credibility and support within their communities. It also meant that the target audiences of the transport workers and their sex partners received the same messages on both sides of the border -- a successful way of reinforcing the idea that HIV knows no boundaries and ensuring access to consistent prevention options.

Women

Reaching the spouses and regular partners of migrant workers, business travelers and military personnel with HIV prevention activities is possible and essential in order to slow the spread of HIV.

It is difficult, but not impossible, to reach the regular partners of mobile men when they do not live at the men's place of employment or along the transportation routes. For example, AIDSCAP-supported research conducted by the Indian Institute of Health Management Research in the Jaipur region of India successfully engaged truck drivers and their wives in a dialogue about HIV/AIDS and other STDs, which resulted in a greater awareness about the epidemic and an increased willingness among participants to discuss sexual matters with their spouses. The study results will be used to design an education and counseling intervention that will target both groups.

In Zimbabwe, AIDSCAP's intervention with the National Army and Air Force trained not only the military men but also their spouses as peer educators. Women's involvement ensured that both members of a relationship received the same messages and were aware of the same risks, which was particularly important because men in the Zimbabwe National Army are not permitted to live with their spouses.

Refugees

Effective HIV/AIDS prevention interventions are possible in refugee camps.

Refugees are vulnerable to high-risk sexual behavior that can lead to HIV infection because of family disintegration, general trauma and stress, rape and violence, lack of access to condoms, the breakdown of HIV/AIDS prevention interventions, and increased impoverishment of women, whose only option may be to exchange sex for money or food. But to people who have been displaced by war, civil strife or natural disasters, HIV/AIDS may seem a distant threat as they struggle to survive. Therefore, when AIDSCAP launched the first large-scale early HIV/AIDS and STD intervention in a refugee camp, no one knew whether project staff could engage camp residents in efforts to protect their long-term health.

The pilot project, managed for AIDSCAP by Care International in the Benaco camp for Rwandan refugees in Tanzania, proved that HIV/AIDS prevention programs can be effective in a refugee setting. Using a comprehensive strategy that included peer education, educational entertainment, condom distribution and promotion, and STD services, the project trained thousands of peer educators, reached hundreds of thousands of refugees with prevention messages, motivated thousands of them to seek counseling and STD treatment, distributed 1.5 million condoms in less than a year, and reduced the number of people who reported having more than one sex partner (Box 10.2).

10.2 Rwandan Refugees Mobilize to Prevent HIV/AIDS
In 1992, a staggering 30 percent or more of Rwanda's urban population was infected with the virus that causes AIDS. When genocidal civil war sent hundreds of thousands of people fleeing the country two years later, HIV inevitably followed them into hastily constructed refugee camps in neighboring Tanzania and Zaire.

With families separated and communities torn apart, the daily hardships confronting refugees living in overcrowded camps often overshadow the threat of HIV. But those same day-to-day struggles put refugees at increased risk of contracting HIV/AIDS and other STDs. Commercial sex is common, alcohol consumption is high, and condoms are rarely available. Women and youth -- particularly those separated from their families -- are at risk of rape, other forms of violence, and HIV.

The Benaco camp in Tanzania, home to quarter of a million people, became the site of the first early HIV/AIDS intervention for refugees in August 1994, when AIDSCAP and CARE launched prevention activities that were gradually expanded to three other refugee camps. An assessment conducted for the project by John Snow, Inc., found that more than half the respondents perceived themselves to be at risk of HIV infection.

The project began by training about 100 volunteers as community health educators to teach camp residents about HIV/AIDS prevention, distribute condoms and encourage them to seek treatment for STDs. PSI, which managed condom distribution for the project, also trained special condom promotion teams and peer educators. And CARE trained counselors to conduct health education sessions about HIV/AIDS and STDs for patients awaiting treatment at outpatient clinics run by the African Medical Research and Education Foundation (AMREF). The remarkable degree of collaboration that occurred among these and other organizations working in the camps was the key to the project's success.

In response to needs identified by the community, the project expanded. For example, a home-based care component was added for those already sick, "Adolescent Health Days" were held to acquaint teens with the health services available to them, and a women's crisis team was created to provide social, legal and medical support to those who experienced sexual violence.

Empowerment -- taking control of one's own health -- proved a powerful message in an environment riddled with uncertainty. Refugees also responded to messages urging them to seek STD care to ensure future fertility.

Sports events were perhaps the most effective medium for reaching youth with HIV/AIDS prevention messages. Weekly events at the community sports complex drew thousands. During half-time, performers conveyed HIV/AIDS messages through traditional dance and music, and PSI and CARE staff distributed condoms.

The AIDSCAP/CARE project in the Tanzanian camps proved that it is possible to involve refugees in HIV/AIDS prevention, training 2,173 peer educators and reaching more than 700,000 people. A survey conducted after the first year of the project found that about 80,000 people had sought counseling and STD treatment as a result of project efforts and the number of people who reported having more than one sex partner had dropped. But with continuing unrest throughout the world and the growing international threat of the HIV/AIDS epidemic, the pilot project's most valuable legacy may be a greater understanding of how to help refugees prevent HIV transmission.

Income-generation projects can help reduce the risk of HIV infection among women and young girls in refugee camps.

Relief agencies usually avoid creating income-generating activities for refugees because they fear that such activities would encourage people to stay in camps indefinitely. Their objective is to provide temporary relief to displaced people until they can be repatriated or resettled. But in refugee camps where single women and girls are at high risk of acquiring HIV infection because many must exchange sex for food and other basic commodities, income-generating projects are essential for HIV/AIDS prevention, giving participants a means of supporting themselves without threatening their health. In Benaco, women benefited from income-generating activities such as produce-growing cooperatives sponsored by other NGOs working in the camp.

Structural changes in the environment of a refugee camp can play an important role in HIV/AIDS prevention.

Environmental changes may be easier to make in these temporary settlements than in more settled communities, and they can help prevent HIV transmission as well as improve the quality of life. For example, in the Benaco camp in Tanzania, relief officials learned that rapes often occurred in the large communal latrines, which were located a short distance from the camp and shielded with pieces of plastic. Replacing the latrines with smaller, four-family structures close to people's tents helped protect women and girls from sexual assault and HIV/AIDS. Another environmental change -- construction of a community sports complex with a soccer field and basketball court -- helped combat the boredom that often led to high-risk behavior. It also provided a venue for creative HIV/AIDS prevention activities (Box 10.2).

Recommendations

HIV/AIDS prevention activities should not only target individuals passing through border towns and port cities, but should also address the factors that make cross-border sites such high-risk environments.

Examples of such interventions include policies requiring consistent condom use in brothels, presumptive STD treatment of key groups, provision of free condoms in hotels and brothels, and mass media messages warning of the heightened risk of contracting HIV in border towns and port cities.

Linkages need to be established between organizations implementing HIV prevention activities on both sides of an international border.

By agreeing on common goals, strategies and evaluation indicators, these groups can address cultural differences and language barriers to provide consistent, complementary and effective HIV prevention messages and programs to the populations they serve.

The lack of bilateral treaties or memoranda of understanding between governments should not deter projects from establishing the cross-border linkages needed for effective HIV/AIDS prevention among mobile populations. Project directors and managers can create successful linkages on their own while seeking wider support from national and regional governments.
Refugee programs should incorporate HIV prevention activities into reproductive health services as early as possible and should address environmental issues as refugee settlements emerge, such as the placement of latrines and creation of sports fields. They should also consider organizing income-generation activities to give women alternatives to trading in sex.

Challenges for the Future

Building Trust

Inspiring trust in target populations is one of the keys to convincing them to change behaviors. But establishing such relationships takes time and repeated contacts, which are very difficult to achieve with mobile populations. Programs need to use a variety of methods to convey consistent messages to mobile populations at different destinations and to design structural interventions that make the environments mobile populations encounter in their travels less hospitable for high-risk sex.

Increasing Support

Many international donors and national and regional governments do not seem to have the flexibility to fund projects that cross borders. The interest generated by the growing body of knowledge about HIV/AIDS among mobile populations needs to be converted into greater financial support for cross-border interventions. These interventions could also be integrated into more established cross-border initiatives in other sectors, such as transnational environmental projects.

Reaching Women

Women whose husbands or boyfriends have mobile lifestyles are at significantly greater risk of HIV and other STDs than the average spouse because their partners are more likely to acquire HIV than a husband who returns home every night. Reaching these women is difficult because they do not necessarily live or congregate in one place, and their homes are usually far from the sites of interventions for mobile populations. Empowering them to protect themselves from infection is even more difficult because of cultural expectations that wives submit unquestioningly to their husbands and because of their economic dependence on their male partners. More aggressive efforts are needed to help these women protect themselves without antagonizing their partners. HIV/AIDS prevention programs need to develop more realistic prevention options for these women as well as better ways to reach them.

Testing Alternative Strategies

Because many border areas lack the infrastructure needed to support traditional prevention efforts, including health facilities for STD treatment and a staff of outreach workers to educate and counsel members of the target audience, there is an urgent need to explore alternative strategies such as prevention marketing and periodic presumptive STD treatment of key groups. Pilot studies are needed to test prevention marketing approaches to HIV/AIDS among mobile populations, using existing commercial outlets to sell subsidized condoms and prepackaged STD therapy and employing the mass media available to target populations to promote healthy sexual behavior.

References

Jenkins C (1994). Final Report: Behavioral Risk Assessment for HIV/AIDS Among Workers in the Transport Industry, Papua New Guinea. AIDSCAP/Family Health International, Bangkok, Thailand.
Pramualratan A, Somrongthong R, Jindasak K, Saetiow S (1995). Assessment of the Potential for Spread and Control of HIV Among Cross-border Populations Along the Thai-Cambodian Border. AIDSCAP/Family Health International, Bangkok, Thailand.
Rao A, Sundararaman R, Shrestha BK (1995). Report of the Study Team for the Assessment of HIV/AIDS Situation on the Trucking Routes between Nepal, India and Bangladesh. AIDSCAP/Family Health International, Bangkok, Thailand.
Simbulan NP, Gomez DC, Tayag JG, Imperial RH (1996). Formative Research on the Seafaring Population: Philippines Final Report. AIDSCAP/ Family Health International, Bangkok, Thailand.
CARE International/Laos (1995). Three Provinces Focus Group Project. AIDSCAP/Family Health International, Bangkok, Thailand.
Program for Appropriate Technology in Health (1995). Rapid Ethnographic Assessment: Strategic Planning for AIDS Prevention in Five Indonesian Cities. AIDSCAP/Family Health International, Bangkok, Thailand.
Benjamin JA, Engel D, DeBuysscher R (1996). AIDS prevention amid chaos: the case of Rwandan refugees in Tanzania. XI International Conference on HIV/AIDS, abstract Tu.D.241. Vancouver, Canada, July 7-12.
Mbuya C (1995). STD services for women in truck stops in Tanzania: an evaluation of acceptable approaches. Abstract presented at the Third USAID HIV/AIDS Prevention Conference, Washington, DC, August 7-9.
Nyamuryekung'e K, Laukamm-Josten U, Buylsteke B, et al. (in press). STD services for women in truck stops in Tanzania: an evaluation of acceptable approaches. East African Medical Journal.

Making Prevention WorkGlobal Lessons Learned from the AIDS Control and Prevention (AIDSCAP) Project 1991-1997

10. Crossing Borders: Reaching Mobile Populations at Risk

Making Prevention Work
Global Lessons Learned from the AIDS Control and Prevention (AIDSCAP) Project 1991-1997