Cross-fertilization: HIV/AIDS Prevention Strategies Cross Borders

AIDSCAP staff and their partners in developing countries share and adapt ideas, methods and materials that benefit HIV/AIDS prevention efforts throughout the world.

All of these examples illustrate a process of "cross-fertilization" taking place among the AIDS Control and Prevention (AIDSCAP) Project programs and its subprojects in 35 countries worldwide. The size and scope of AIDSCAP, which is funded by the U.S. Agency for International Development (USAID), provide unique opportunities for testing innovative approaches to HIV/AIDS prevention and adapting them for use in a number of countries.

These transfers of ideas, materials, strategies and policies are sometimes carefully planned and other times occur serendipitously. Often the exchange goes beyond AIDSCAP, as other groups working in HIV/AIDS prevention recognize approaches they think would solve local problems. And in some instances, ideas that don't work the first time around provide knowledge useful for more successful implementation later.

AIDSCAP Director Peter Lamptey explains that AIDSCAP's involvement in a number of countries allows for the sharing of innovative approaches, success stories, lessons learned and adaptations to different cultural settings. Cross-fertilization occurs during technical assistance visits for program design, monitoring and evaluation. It also happens through systematic dissemination efforts, such as distribution of AIDScaptions magazine, workshops, conferences and training.

"We try to facilitate communications between our staff in different countries and between staff and implementing partners to create an environment where cross-fertilization can occur," Dr. Lamptey said.

From Cartoon Character To Film Star

One of the best-known AIDSCAP personalities to emerge from the project's cross-fertilization activities isn't a real person, but a cartoon character named "Emma." She first appeared in a flip chart used in a flip chart used in peer education sessions with West African women under the AIDSTECH Project (AIDSCAP's predecessor, which was also funded by USAID and managed by Family Health International). In 1994 AIDSCAP adapted the "Emma Says" flip chart for a series of three comic books, adding information on using condoms properly and recognized sexually transmitted diseases (STDs). So far, AIDSCAP has distributed 46,000 comics in 18 countries.

The Emma comic books have been translated into French, Portuguese, Creole, Swahili and Kinyarwanda. Local groups in Tanzania, Ethiopia, Nigeria and Cameroon have created dramatic performances featuring Emma. AIDSCAP's condom social marketing partner, Population Services International (PSI), has even made her a "film star" in Rwanda and a 25-minute video and a companion photonovella, a photographic comic-style book, funded by UNICEF. AIDSCAP is now developing three more Emma comics, which will focus on care and support for people living with HIV/AIDS.

One reason the Emma materials have been so widely adapted is that they address issues transcending cultural boundaries, according to Hally Mahler, an associate program officer with AIDSCAP's Behavior Change Communication (BCC) Unit. In a survey of 94 communication professionals around the world, 83 percent said that Emma's messages about methods of prevention, modes of transmission and the absence of an HIV/AIDS cure are universal concerns appealing to women of many cultures.

Sharing Lessons

To help identify and encourage adaptation of creative HIV/AIDS prevention materials, AIDSCAP developed a computerized database system, which contains records on more than 700 materials the project has created or reproduced. Each entry includes such data as target audience, literacy level, message, medium and language. AIDSCAP uses the database to identify model materials for its communication officers in the field and to share materials with other HIV/AIDS organizations.

Another way AIDSCAP has disseminated experiences and lessons learned has been through various "how-to" handbooks and manuals. While often created just for AIDSCAP staff and people working in the AIDSCAP subprojects around the world, a number of the guidebooks have found wider audiences.

One example is the series of "evaluation tools modules" designed to strengthen the evaluation skills of project staff and implementing partners. The four modules produced so far cover AIDSCAP's evaluation strategy, the use of focus group discussions, incorporating evaluation into project design and applying AIDSCAP's behavioral surveillance survey methodology. They have been reprinted several times, and two of the original modules were translated into French in Senegal for distribution in other French-speaking countries.

A series of practical handbooks on behavior change communication for HIV/AIDS prevention has also generated an enthusiastic response beyond the AIDSCAP Project. The handbooks cover developing communication projects, assessment and monitoring of BCC interventions, using mass media for STD/HIV prevention, peer education and pretests of BCC messages and materials. In 1996 alone, AIDSCAP fulfilled requests for more than 4,500 copies of the handbooks.

Another manual AIDSCAP plans to publish next spring will deal with AIDS and gender issues. It will guide policy-makers and senior-level officials in modifying existing programs and changing their staff members' perceptions so as to better incorporate gender concerns into HIV/AIDS prevention activities.

The gender and AIDS manual grew out of an October 1995 workshop the project held for policymakers and USAID Mission staff members from Ethiopia, Kenya, Tanzania, South Africa and Zimbabwe. Following the five-day workshop, the participants developed action plans to incorporate gender concerns into their local activities. They reassembled for three days in May 1996 to report on the projects they had designed and to consider ways to build gender issues into national HIV/AIDS prevention programs.

Since the follow-up seminar, Tanzanian nongovernmental organizations (NGOs) have begun expanding their gender-specific work from just one region of the country to eight others. In West Africa, AIDSCAP is collaborating with USAID and other agencies to replicate its gender and AIDS training activities as part of a major new health project in that region.

100 Percent Condom Policy

Adapting AIDSCAP materials that have broad appeal, such as the "Emma Says" flip chart, for use with different audiences and even in different countries has been relatively easy. Other AIDSCAP cross-fertilizations, however, have required much more extensive customizing.

One example is the potential adaptation of Thailand's 100 percent condom policy in the Dominican Republic. In Thailand this government policy has made condom use in commercial sex a nationwide practice, contributing to reductions in STD rates and decreased HIV incidence among military conscripts (see p. 35). The national strategy was modeled after a pilot project the Thai government began in Ratchaburi Province and expanded to eight provinces with support from Family Health International's AIDSTECH Project.

Tony Schwarzwalder, AIDSCAP's deputy project director, mentioned Thailand's experience during a meeting with officials from the Centro de Orientación e Investigación Integral (COIN), an AIDSCAP partner in the Dominican Republic that has a successful track record working with commercial sex workers (CSWs).

"Based on what Tony told them," said Maura McCarthy, a field officer for AIDSCAP in the Dominican Republic, "COIN took off with the idea." Many businesses that COIN staff members contacted agreed to a 100 percent condom policy, but the NGO lacked the enforcement authority and national government backing that Thai officials have.

"Although COIN has an excellent relationship with the bar and brothel owners, they have not been extremely successful in implementing the 100 percent condom policy," said McCarthy. "The owners are open to the idea and willing to cooperate, but do not yet enforce the program in their establishments."

COIN asked AIDSCAP's Dominican Republic country office for technical assistance, including more detailed information on the Thai experience. In the summer of 1996, an AIDSCAP consultant spent several months interviewing CSWs, their clients, brothel owners and government officials. With this new data, COIN and AIDSCAP hope to develop a more structured project with a greater chance of success.

"Based on this study," said McCarthy, "we'll work more on the implementation phase -- not just getting the brothel owners to put a sign in the window, but making condoms available and getting all the brothel owners to implement the 100 percent policy."

Tracking Sexual Behavior

Another successful approach from Thailand is an evaluation methodology called the behavioral surveillance survey (BSS). Developed by AIDSCAP in Bangkok, the BSS monitors high-risk sexual behaviors through periodic surveys among key target groups.

Unlike other evaluation instruments that look at an intervention only before it begins and after it is completed, the BSS is a dynamic tool that can help direct program interventions. It provides an understanding of the behavioral trends that drive HIV epidemics and helps policymakers set priorities, modify existing interventions and plan new prevention strategies.

Impressed with AIDSCAP's results in Bangkok, Thai Ministry of Health officials launched similar surveys in most of the country's provinces. AIDSCAP is helping health officials in a number of other countries establish behavioral surveillance, including Indonesia, India, Senegal and Cambodia.

Social Marketing

Another AIDSCAP activity where much cross-fertilization has occurred is condom social marketing (CSM). Borrowing many techniques from for-profit businesses, social marketers use commercial distribution channels and marketing methods to promote condom use for HIV/AIDS prevention.

In Haiti, AIDSCAP's CSM partner PSI added another marketing innovation: a sales force of outreach workers from NGOs. Some 175 workers from 14 collaborating groups sell PSI's Pantè brand condoms directly to individuals and wholesale to boutiques, bars and other small businesses, expanding access for many customers who are not reached by the for-profit outlets and vendors who also sell Pantè. To encourage NGOs involved in HIV/AIDS prevention to incorporate condom sales into their work, PSI offers outreach workers a percentage of sales revenue.

"To my knowledge, PSI had never done this elsewhere, nor had anyone else," commented Robert Clark, AIDSCAP's private sector officer for the Africa region, who helped launch the innovative Haiti sales strategy. "After Haiti, I was assigned to AIDSCAP's Africa Regional Office, and I began pushing my PSI counterparts in the region to consider using community-based agents from NGOs or even free-lancers to sell condoms."

In Tanzania Clark gave a seminar on Haiti's experience for USAID and NGOs under contract with AIDSCAP to implement USAID's Tanzania AIDS Project (TAP). That stimulated Tim Manchester of TAP's Social Marketing Unit to start training community-based agents.

"Manchester," said Clark, "will train anyone. He presents the opportunity as 'micro-business' development, which it is for those agents. They see the income-producing possibilities and like to hustle. So far his training team of two persons has trained over 1,600 agents!"

Clark also suggested the NGO sales agent approach to his PSI counterpart in Rwanda, who has trained NGO sales agents. Clark is now working with an AIDSCAP-funded subproject in South Africa to launch this condom sales strategy.

STD Treatment Kits

AIDSCAP applied a creative promotional approach in Cameroon with another product, prepackaged drug therapy for men to treat the symptoms of urethritis. Intended to be offered both by prescription and over the counter, these M-STOP brand STD treatment kits included antibiotics, condoms, informational brochures, and cards for referring sexual partners for treatment.

In Cameroon, as in many other countries, men often try treating their own STDs with drugs purchased in pharmacies or markets rather than paying a high fee to a doctor or spending hours waiting to be seen at a public clinic. AIDSCAP hoped the new kits -- when combined with training health care providers and pharmacists to manage urethritis using the "syndromic" method recommended by the World Health Organization and to provide prevention counseling and condoms -- would expand access to more effective treatment.

The M-STOP kit developers conducted careful research before launching the product. Nevertheless, the treatment approach ran into a number of difficulties. Initial government support for the concept diminished, and many health care providers were uneasy about selling the kits without a prescription. Some physicians thought the kits would hamper efforts to regulate new and powerful antibiotics and interfere with their authority to diagnose and treat STDs. With kit sales far below what had been hoped, AIDSCAP ended the experiment.

In spite of those problems, the M-STOP trial generated interest in other countries -- most notably Uganda. AIDSCAP has provided technical assistance to The Futures Group's SOMARC Project there, which already markets condoms and female contraceptives.

Based on the Cameroon experience, AIDSCAP consultants to SOMARC have suggested a more gradual introduction of the treatment kits in Uganda. Initially, they would be available by prescription only and over the counter in a few selected areas. Extensive evaluation studies would assess whether the kits improved access to effective, affordable STD treatment and whether the approach encouraged men to seek care first through more qualified providers such as pharmacies, clinics and doctors rather than friends, traditional healers and market sellers. That research could provide clear evidence of the benefits prepackaged therapy. It might also help convince physicians and pharmacists to accept more widespread sale of treatment kits without prescription.

National Policy

Cross-fertilization between AIDSCAP programs has most often happened with specific materials, strategies or ideas once a country has already determined its policies for HIV/AIDS prevention. One exception to this pattern is the series of study tours of Thailand that AIDSCAP organized for Indonesian officials during 1993 and 1994.

Twenty-five policymakers from 17 Indonesian government ministries and agencies each spent five days in Thailand learning lessons their country could apply in national HIV/AIDS prevention programs. The Indonesian officials looked at a range of issues, including STD control, condom promotion, cultural and religious traditions and HIV/AIDS programs, AIDS and the military, women's special needs, and HIV testing and counseling.

Once back in Indonesia, some of the tour participants formed the "Bangkok Group" and continued meeting with each other. They and other tour participants have played key roles in developing a national HIV/AIDS program and policies for Indonesia.

"Officials adopted what they learned on the tours to plan or implement AIDS intervention programs at various levels," said Chalintorn Burian, a training officer in AIDSCAP's Asia Regional Office in Bangkok. Two of the most significant results, she noted, are a multisectoral approach to HIV/STD prevention and multisectoral involvement in HIV/STD interventions that links the government, NGOs, academicians and the private sector.

U.S.-International Linkages

AIDSCAP's overseas experiences have also benefited HIV/AIDS prevention groups in the United States. Last year, the project undertook an experiment that brought together NGOs in Haiti and the Dominican Republic and community-based organizations (CBOs) in the United States that serve immigrants from those countries.

Program participants attended the third USAID HIV/AIDS Prevention Conference in Washington, D.C., as well as a special preconference round-table session. Representatives from the U.S. groups visited their counterpart organizations in the Caribbean, and the Haitians and the Dominicans visited their partners in the United States.

"It was a great experience, a great exchange of ideas," said Eduardo Aguilu, the deputy chief executive officer of the Latino Health Institute (LHI). That Boston-based group operates statewide programs in Massachusetts focusing on HIV/AIDS prevention and other health concerns of Hispanics.

One technique the LHI adapted from a Dominican organization is "provocative street theater." In the Dominican Republic, actors portraying sex workers, their managers, doctors and others put on presentations in bars and in the street. Initially unaware that these are staged performances, bystanders are pulled into explicit discussions of STDs, HIV/AIDS and negotiating condom use. The LHI has revised the approach and uses it in areas where youth get together, such as schools and playgrounds.

A New York City social service agency that also participated in an exchange with the Dominican NGOs is the Alianza Dominicana. "It was an opportunity to get firsthand information as to public attitudes, government response and living conditions," said Julio Dicent-Taillepierre, the group's director of AIDS services. "It deepened our understanding of the nature of AIDS for Dominicans."

From an NGO in the Dominican Republic, Dicent-Taillepierre said, Alianza developed a deeper appreciation for the need to gather ethnographic and epidemiological information on Dominicans in New York. His agency helped the Dominican NGO better understand services for HIV-infected persons who are still relatively healthy, including comprehensive education, mental health services and case management.

The way Dicent-Taillepierre described the Alianza's experience working with its Caribbean counterpart could summarize much of AIDSCAP's cross-fertilization experience. "The issues and patterns overlap," he said. "They need to be examined together if an understanding of the reality of HIV/AIDS is to be fully addressed."

-- Bill Black