Communication for Hiv/Aids

CONTENT

I. INTRODUCTION

II. THE ROLE OF COMMUNICATION FOR HIV/AIDS

III. THE PROCESS OF BEHAVIOUR CHANGE: A FRAMEWORK FOR CFA DESIGN

IV. THE SPECIFIC GOALS OF THE CFA CAMPAIGN

V. GUIDING PRINCIPLES

VI. TB/AIDS PCU`s APPROACH

VII. CFA CYCLE

Statement of tactical goals

Involvement of stakeholders

Agreeing on the target populations

Conducting formative CFA assessments

Segmenting the target populations

Defining the behaviour change objectives

Design CFA implementation and Monitoring and Evaluation (M&E) Plan

Developing communication products

Pre-testing

Implementation and monitoring phase

Evaluation

Feedback and redesign

VIII. CHALLENGES

IX. MANAGEMENT OF CFA AND BUDGET

X. CAPACITY-BUILDING

XI. LINKAGES AND PARTNERSHIPS

XII. CONCLUSION

I. INTRODUCTION

Communication for HIV/AIDS (CFA) is an interactive process with communities (integrated with the overall AIDS Control Project) to develop tailored messages and approaches using a variety of communication channels to develop desirable behaviours; promote and sustain individual, community and societal behaviour change; and maintain appropriate behaviours.

In the context of the AIDS Control Project, CFA is an essential part of a comprehensive approach that includes both services (preventive, medical, social, and psychological) and commodities (e.g., drugs, tests, condoms, needles and syringes). Before individuals and communities can reduce their level of risk or change their behaviors, they must first understand basic facts about HIV and AIDS, adopt key attitudes, learn a set of skills and be given access to appropriate products and services. They must also perceive their environment as supporting behaviour change and the maintenance of safe behaviours, as well as supportive of seeking appropriate treatment for prevention, care and support.

In Moldova, HIV is increasingly a sexually transmitted infection (STI). Development of a supportive environment requires national and community-wide discussion of relationships, sex and sexuality, risk, risk settings, risk behaviours and cultural practices that may increase the likelihood of HIV transmission. A supportive environment is also one that deals, at the national and community levels, with stigma, fear and discrimination, as well as with policy and law. The same issues apply in respect to unsafe injection of illegal drugs, as the main source of new infections.

The AIDS epidemic forces the Moldovan society to confront cultural ideals and practices that can contribute to HIV transmission. Effective CFA is vital to setting the tone for compassionate and responsible interventions. It can also increase understanding of the broader socioeconomic impact of the epidemic and mobilize the political, social and economic response needed to build an effective program. The TB/AIDS PCU`s pragmatic CFA approach, based on sound practice and experience, will focus on building national capacity to develop integrated CFA that leads to positive action by stimulating society-wide discussions. CFA will become both an essential component of each of the AIDS Control Project activities and the glue between the various areas. The approach of the TB/AIDS PCU is realistic. Society-wide change is slow; changes achieved through CFA will not occur immediately.

This document outlines the strategy of TB/AIDS PCU for Communication for HIV/AIDS. It is open for use by donors, partners, actual- and potential collaborators.

II. THE ROLE OF COMMUNICATION FOR HIV/AIDS

CFA is an integral component of Moldova`s comprehensive HIV/AIDS prevention, care and support program. It has a number of different but interconnected roles. Effective CFA must:

• Increase knowledge. CFA must ensure that people are given the basic facts about HIV and AIDS in a language or visual medium (or any other medium that they can understand and relate to).

• Stimulate community dialogue. CFA must encourage community and national discussions on the basic facts of HIV/AIDS and the underlying factors that contribute to the epidemic, such as risk behaviours and risk settings, environments and cultural practices related to sex and sexuality, and marginalised practices (such as drug use and sex work) that create these conditions. It must also stimulate discussion of healthcare-seeking behaviours for prevention, care and support.

Promote essential attitude change. CFA must lead to appropriate attitudinal changes about, for example, perceived personal risk of HIV infection, belief in the right to and responsibility for safe practices and health supporting services, compassionate and non-judgmental provision of services, greater open-mindedness concerning gender roles and recognising the basic rights of those vulnerable to and affected by HIV and AIDS.

Reduce stigma and discrimination. Communication about HIV prevention and AIDS mitigation should address stigma and discrimination and attempt to influence social responses to them.

Stigma is a mark of shame or discredit on a person or group. Stigma can manifest itself in a variety of ways, from ignoring the needs of a person or group to psychologically or physically harming those who are stigmatized. In Moldova, stigma is often felt by PLHA, men who have sex with men (MSM), sex workers (SWs), IDUs, Roma and others. The importance of addressing stigma in the context of CFA campaigns has programmatic implications that are much larger than the questions of compassion and humane treatment. Failure to address stigma jeopardies the HIV/AIDS project in critical ways:

Prevention. A CFA campaign that fail to address stigma allow some people to ignore the messages of HIV prevention. Stigma can cause people to perceive individuals with or at risk for HIV as the other ("them"), reinforcing their false feeling that HIV "couldn't happen to me." Failure to address stigma can also repel individuals from seeking out VCT and proper medical care, including MTCT prevention services.

Experience shows that in Moldova, a certain amount of stigma can be attached to carrying condoms.

Although currently, there is a reasonably tolerant environment around Harm Reduction activities in Moldova, stigma can work against prevention programs; for example, outreach or peer education programs for IDUs, CSWs and MSM, can be damaged by police "razie-s" and harassment of beneficiaries.

Policy. Failure to address stigma will help perpetuate discriminatory laws and practices and, in some cases, result in failure to enforce laws against them. The AIDS Control Project can miss opportunities to influence policy direction.

The CFA campaign that address stigma will work with and involve people from traditionally stigmatized groups, such as PLHA, CSWs and MSM, as advocates for policy change. Such individuals will also serve as dedicated caregivers, social workers, peer educators and role models for change.

Create a demand for information and services. CFA must determine individuals and communities to demand information on HIV/AIDS and appropriate services.

Advocate. CFA must lead policymakers and opinion leaders toward effective approaches to the epidemic.

Promote services for prevention, care and support. CFA must promote services for STIs, PLHA, intravenous drug users (IDUs), commercial sex-workers; clinical care for opportunistic infections; voluntary counseling and testing (VCT) for mother-to-child transmission (MTCT); CFA is also an integral component of these services.

Improve skills and sense of self-efficacy. CFA programs must focus on teaching or reinforcing new skills and behaviours, such as condom use, negotiating safer sex and safe injecting practices. It must contribute to development of a sense of confidence in making and acting on decisions.

III. THE PROCESS OF BEHAVIOUR CHANGE: A FRAMEWORK FOR CFA DESIGN

The TB/AIDS PCU`s CFA has its roots in behaviour change theories that have evolved over the past several decades. These theories are valuable foundations for developing comprehensive communication strategies and programs. TB/AIDS PCU's CFA will be based on various models and theories to design effective programs and activities. These include the Diffusion of Innovations model (Everett Rogers), the Stages of Change model (Prochaska, DiClemente and Norcross), the Self-Efficacy model (Bandura) and the Behaviour Change Continuum (World Bank). TB/AIDS PCU will use a combination of theories and practical steps that are based on field realities, rather than relying on any single theory or model. The following figure is based on the prevailing models and theories, and is one framework that guides TB/AIDS PCU's CFA design.

Figure 1. The framework of TB/AIDS PCU`s CFA design

IV. THE SPECIFIC GOALS OF THE CFA CAMPAIGN

The goals of the Communication for HIV/AIDS campaign are developed in the context of the overall program goals and specific behaviour change goals.

The overall goal is to contribute to improving Moldova’s health status and assisting the country to achieve its health-related Millennium Development Goals (MDG) through reducing mortality, morbidity and transmission of HIV/AIDS, and other sexually transmitted infections (STIs).

The CFA will assist the country to:

i) scale up HIV/AIDS/STIs prevention programs targeted at vulnerable and highly vulnerable groups (young people, IDUs, CSWs, MSM, etc);

ii) strengthen treatment, care and support for persons living with HIV/AIDS (PLWHA);

iii) strengthening Moldova’s institutional capacity to better respond to HIV/AIDS, STIs in a multi-sectoral approach.

The key project indicators and behaviour change goals are:

1. Reduction of HIV incidence among young adults (15-24 age group);

To achieve this the CFA will have to achieve the following behaviour change and CFA goals:

• Promote acceptance among communities of youth sexuality and the value of reproductive health services for youth
• Increase the individual perception of vulnerability
• Increase in the knowledge of ways of preventing the sexual transmission of HIV and number of those who reject the major misconceptions about HIV transmission
• Change attitudes toward use of condoms. Increase condom use
• Improve the sexual repertoire by adoption of lower risk practices
• Delay sexual debut
• Reduce number of partners
• Interest policymakers in investing in existing youth-friendly VCT services

2. Achieve a 25% reduction in the growth rate of HIV prevalence among identified intravenous drug users (IDU); Behaviour change and CFA goals:

• Create demand for clean injection equipment
• Decrease needle sharing
• Decrease intravenous drug use by joining substitution or abstinence programs
• Achieve a better societal acceptance of Needle Exchange and Methadone programs.

3. Achieve a 25% percent reduction in syphilis sero-prevalence rate; Behaviour change and CFA goals:

• Raise the STI awareness and promote services
• Increase the knowledge of squeals of STI`s
• Increase appropriate STI care-seeking behaviour
• Increase condom use
• Delay sexual debut
• Reduce number of partners

4. Achieving a 90% reduction in mother-to-child HIV transmission (relative to the baseline transmission rate per cohort of seropositive pregnant women).

• Increase awareness about availability of PMTCT services
• Increase the demand for VCT services
• Achieve compliance with ARV prophylactic schemes and formula feeding in HIV infected mothers.

V. GUIDING PRINCIPLES

• CFA is integrated with program goals. CFA is an essential element of HIV prevention, care and support programs, providing critical linkages to other program components, including policy initiatives.

• Formative CFA assessments will be conducted regularly to adjust understanding of the needs of target populations, as well as of the barriers to and supports for behaviour change that their members face (along with other populations, such as stakeholders, service providers and community).

• Having a variety of linked communication channels will be regarded as more effective than relying on one specific one.

• Thorough Pre-testing is essential for developing effective CFA materials.

• Planning for monitoring and evaluation will be part of the design of the CFA campaign

• The CFA strategies will be positive and action-oriented.

VI. TB/AIDS PCU'S APPROACH

CFA is an essential component of the HIV/AIDS Control Project, managed by the TB/AIDS PCU. The PCU runs the CFA campaign, by sub-contracting a Communication Firm (World Bank`s Quality and Cost Based Selection), in the context of a prevention, care and support program. A sound CFA campaign effectively influences community discussions and social norms and plays an important role in services and individual and community behaviour. TB/AIDS PCU works to contribute to national program goals and collaborate with other national and international partners to achieve greater impact. Linkages with other CFA activities in-country (ex UNAIDS, UNICEF, NGO`s) will ensure the effectiveness of TB/AIDS PCU's CFA activities.

VII. CFA CAMPAIGN PLANNING

To put this approach into action, TB/AIDS PCU will promote a practical, step-by-step methodology for developing and implementing the CFA campaign by the winning Communication Firm.

Figure 2. Steps in developing a communication for HIV/AIDS strategy

Statement of tactical goals

The goals of the AIDS Control Project, managed by the TB/AIDS PCU are designed in coordination with national HIV and AIDS strategies. The Communication firm will identify the specific tactic goals after reviewing existing data, epidemiological information and in-depth program situation assessments.

Involvement of stakeholders

Key stakeholders will be involved by the Communication firm early on in every step of the process of implementation of HIV/AIDS programs and their CFA components. Stakeholders include policymakers – Ministry of Health, Ministry of Education, National AIDS Centre, the STI Services, the SOROS Foundation, UN agencies; opinion leaders, community leaders (ex. Representatives of local authorities), religious leaders (ex. orthodox church) and members of target populations (IDU`s, CSW, LGBT, PLWA,). Their active participation at appropriate stages of CFA implementation will be essential. Stakeholders' meeting will be held to obtain commitments to the process and to develop coordination mechanisms.

Agreeing on the target populations

TB/AIDS PCU defines target populations as primary and secondary. Primary populations are the main groups whose HIV/AIDS-related behaviour the communication campaign is intended to influence. Secondary populations are those groups that influence the ability of the primary population to adopt or maintain appropriate behaviours.

Target populations include:

• Individuals at high risk or vulnerability - sex workers, their clients, youth, Roma, IDUs, uniformed services personnel

• People providing services, such as health workers, private practitioners, pharmacists, counselors and social service workers

• Policymakers, such as politicians

• Leaders and authorities, formal and informal, including law-enforcement, social and religious leaders

• Local communities and families

Conducting formative CFA assessments

The Communication Firm will start its formative CFA assessments by seeking out all available studies, including data from Moldova`s integrated M&E system - the rapid behavioural assessments performed by the SOROS Foundation, future behavioural surveillance surveys performed as part of the surveillance system, and other related studies. After synthesizing this information, the Communication Firm will develop the protocols for its own formative CFA assessments. The formative CFA assessment will collect information on:

• Risk situations, showing in detail how decisions are made in different situations, including what influences the decisions and settings for risk
• Why individuals and groups practice the behaviours they do, and why they might be motivated to change (or unable to change) to the desired behaviours
• Perceptions of risk and risk behaviours
• Influences on behaviour, such as barriers or benefits
• Insights of opinion leaders
• Health care-seeking behaviours. Patterns of service use and opinions about these services.
• Perceptions of stigma and discrimination
• Future hopes, fears and goals in the target groups
• Media and entertainment habits
• Positive deviants, or those most willing to model change
• Media resources

Formative CFA assessments will make use of objective qualitative methods, such as focus group discussions, key informant interviews, direct observation, participatory learning methods, rapid ethnographic assessments, mapping and in-depth interviews.

Segmenting target populations

Based on the formative CFA assessment, target populations will be segmented. For example, sex workers can be grouped more specifically according to work location (street, home, brothel), income level, ethnicity, or language.

Population segments are defined by psychosocial and demographic characteristics. Psychosocial characteristics include the knowledge, attitudes and practices typically demonstrated by a given group or audience; or by their role in society, their formal and informal responsibilities and their level of authority.

Demographic characteristics include age, place of residence (or work), place of birth, religion and ethnicity. In addition, structural factors and settings (e.g., in the workplace, risk settings, border settings) will also be considered. For example, if sex workers and truck drivers are the target population, border crossings and truck stops constitute risk settings.

Defining the behaviour change objectives

The Communication Firm will build on the HIV/AIDS program behaviour change objectives, that can be inferred from project goals:

• Increased safer sexual practices (more frequent condom use, fewer partners)

• Increased incidence of healthcare-seeking behaviour for STIs, and VCT (for example, calls or visits to facilities)

• Increased use of universal precautions to improve blood safety