BEHAVIOUR CHANGE COMMUNICATION A PROPOSAL FOR A STRATEGY FOR HIV PREVENTION IN BARBADOS MARCH 2007

Transcription

1 BEHAVIOUR CHANGE COMMUNICATION FOR HIV PREVENTION IN BARBADOS A PROPOSAL FOR A STRATEGY MARCH 2007 BARBADOS HIV/AIDS PREVENTION AND CONTROL PROJECT / WORLD BANK LOAN 7066 BAR

2 EXECUTIVE SUMMARY The evidence is clear and cmpelling: While the Barbads HIV/AIDS prgramme has achieved high levels f awareness f HIV/AIDS, its transmissin, preventin and treatment acrss all age and sexual behavir grups has been less successful in inducing and sustaining change in behaviurs that wuld result in a cntrl f the epidemic. Like several f its Caribbean Cmmunity (CARICOM) partners, Barbads has a nw recgnizable KAP (Knwledge, Attitudes and Practices) gap almst everyne has heard and are infrmed abut HIV and the required preventin behaviurs. Thugh many peple are cnvinced that these behaviurs are wrthwhile, nt all f them make the decisin t adpt the sexual and ther behaviurs required t affect the cntrl f the HIV epidemic. Even amng thse wh decide t adpt ne r mre f the preventin behaviurs, there are thse wh are nt cntinuusly practicing these behaviurs. Reasns fr discntinuing preventive practices vary depending n relatinship status and fatigue, as examples. The result, in terms f cases per ppulatin, is that the HIV prevalence fr Barbads is increasing at a much higher rate as cmpared t the ther cuntries in the Organizatin f Eastern Caribbean States (OECS 1 ). These estimates are cnsidered cnservative and they represent nly ne fifth f the infected ppulatin. An epidemic that in the early years was almst exclusively fund in special grups with high risk behaviur is nw evident in the general ppulatin. At present, increasing numbers f wmen and particularly female yuth are becming infected. In 2004, the male t female rati f HIV cases was 1.49 t 1. By 2005, the rati descended t 1.13 t 1. Females accunted fr almst 47 percent f all HIV cases in 2005 as cmpared t just ver 40 percent in The Health Ministry reprts that despite a reductin in the verall number f HIV cases diagnsed frm 2004 t 2005, there is an increase in the percentage f yung peple diagnsed in the 15 t 29 age grup 2. This situatin is wrrisme. If nt addressed urgently, natinwide scial and ecnmic cnsequences culd be disastrus. The fllwing five year behaviur change cmmunicatin strategy prpses a plan t achieve a shift in behaviur adptin that is required if a change in the prgress f the epidemics is t be achieved. The plan prpses a deliberate and fcused apprach t behaviur change interventin planning and implementatin that: i) Acknwledges that behaviur change (like behaviur develpment) is a prcess and that the prcess needs t be given time and enabled/ supprted 1 Camara, DeGrulard, Byd-Scby A strategic framewrk fr the preventin and cntrl f AIDS epidemic in the OECS: Ministry f Health Statistical Update. December Press Release fr Wrld AIDS Day BCC Strategy HIV/AIDS Preventin and Cntrl Prject, Lan 7066 BAR 2

3 ii) iii) at every stage with apprpriate cmmunicatin elements (including the interpersnal) t prduce the necessary results; and Recgnizes that the behaviurs (in this case, sexual, health seeking, partner selectin, and thers) f each individual are influenced as much by the individual s age, educatinal level, value system and ther individual/ persnal factrs as by that individual s external envirnment his hme, schl, church, wrkplace, the natinal plicies and laws, scial nrms and values, etc. Ensures a cherent link between the cmpnents and cmmunicatin elements f each interventin whether advcacy, skill building, scial mbilisatin, prgramme cmmunicatin, service delivery r plicy change s that each reinfrces and is reinfrced by the ther. The prpsed apprach fcuses n the individual (t prvide skills, attitudes and knwledge) while enabling that individual t adpt and maintain the desired behaviur(s) by prviding supprtive scial (peer grup, hme, health system, church); plicy (health care, human rights, access t quality sexual educatin); legal (access t services, prtectin f human rights); and wrk envirnments. In additin, because f the level f difficulty experienced in getting adults t adpt new behaviurs, as well as the individual and scietal health and ther benefits f having yung persns adpt the HIV preventin behaviurs, a parallel fcus f the strategy is n getting children and yuth t adpt the desired behaviurs. The gals f the prpsed strategy are t: 1. Psitively affect the current epidemic by seeking t: a. Reduce HIV primary infectin rates amng persns wh are sexually active thrugh the use f HIV testing services, partner reductin, and the crrect and cnsistent use f cndms until mutual mngamy is established fr the cuple; b. Reduce re infectin rates amng PWHIV thrugh the crrect and cnsistent use f cndms and ther safer sexual behaviurs; and c. Increase survival rates fr PWHIV thrugh use f testing/diagnstic services, adherence t treatment regimes, healthy living, and the crrect and cnsistent use f cndms and ther safer sexual behaviurs. 2. Influence disease (HIV/STI) trends by changing scial nrms abut the timing f first sexual intercurse and gender nrms assciated with sexual partnering and cndm use tw basic requirements fr HIV/STI preventin. d. Increase the prprtin f persns wh chse t delay sexual debut r make a deliberate decisin t adpt secndary abstinence. T achieve these gals, the strategy will be rganized arund sexual activity status and HIV status. The identified pririties are as fllws: BCC Strategy HIV/AIDS Preventin and Cntrl Prject, Lan 7066 BAR 3

4 Individuals wh have never been sexually active. The BCC pririties fr this grup are t enable and encurage delay f sexual debut while prviding knwledge and skills abut prtective behaviurs; Individual wh are n lnger sexually active. Fr this grup, the fcus is t encurage and supprt HIV testing t clarify status and nce status is knwn either t adpt practices t maintain a negative status r t seek treatment and practice ther healthful behaviurs including gd nutritin, psych scial supprt, exercise/daily activity); Individuals wh are sexually active. The BCC pririties fr this grup are similar t thse f the grup nt currently sexually active Testing t knw yur status, adptin f behaviurs apprpriate t the respective HIV status grup. In additin, safe sexual behaviurs will be included in the menu f behaviurs prmted t PWHIV. The prpsed apprach pushes the natinal prgramme t recgnise the need t prvide the supprt(s) and material needed by individuals at every stage in the behaviur adptin prcess. Such a cmprehensive apprach has implicatins fr the type and cntent f specific behaviur change cmmunicatin elements that are prvided by the prgramme. This apprach can help create an envirnment that is likely t supprt individuals maintaining the desired healthy behaviur. The implementatin perid f the prpsed strategy is 2007 t The fcus f Year 1 will be n i) capacity building in BCC interventin planning at the NHAC as well as in partner agencies; ii) assessment f existing interventins using custmized tls and the scaling up f at least ne f the interventins that is successful r shws prmise; iii) installing a manageable mnitring and evaluatin framewrk t ensure accurate and timely data cllectin needed t mnitr and evaluate the strategy as well as specific interventins intrduced during the strategy perid; iv) identifying research gaps and cmmissining research studies; and v) develping a plan fr sharing BCC experiences, thrughut the life f the strategy, with clleagues in CARICOM partner cuntries thrugh study turs and presentatins in reginal meetings and cnferences. In Year 2, the strategy wuld expand effrts started in the first year, specifically the identificatin and scaling up f existing, effective interventins. Additinal capacity building may be needed in line ministries and the private sectr. In Years 3 and 4, the strategy s fcus wuld shift tward launching new interventins and evaluating the impact f nging effrts. The prpsed strategy includes a critical mnitring and evaluatin cmpnent. Mnitring activities wuld be sustained thrughut the implementatin perid. The NHAC wuld prvide technical guidance t partner agencies t develp M&E plans including the develpment f necessary data cllectin tls. Infrmatin flwing frm these effrts wuld be critical in guiding plicy decisins; specifically, decisins abut scaling up interventins (r interventin elements) that achieve their bjectives. BCC Strategy HIV/AIDS Preventin and Cntrl Prject, Lan 7066 BAR 4

5 The implementatin f the prpsed BCC strategy will require additinal resurces, Year 1 needing apprximately BD$ 1 millin. These resurces and requirements include the establishment f additinal psitins in the NHAC Secretariat as well as in partner agencies. The multi sectr BCC team needs t be strengthened t supprt the specific cmmunicatin and advcacy elements f the strategy. Ideally, the team wuld include in additin t the BCC specialist in the NHAC a Senir Behaviur Change Officer (Sn BCO), tw Junir Behaviur Change Officers (Jn BCO), ne with respnsibility fr advcacy and the ther fr edutainment, fur Cmmunity Outreach Officers (COO), and a full time crdinatr fr the yuth develpment prtfli. In the shrt term, the BCC team shuld be increased by five psitins (Sn. BCO, Jn. BCO (edutainment), 2 COO, and a crdinatr fr yuth develpment). BCC Strategy HIV/AIDS Preventin and Cntrl Prject, Lan 7066 BAR 5

6 TABLE OF CONTENTS Executive Summary. 2 List f Tables Table 1: Suggested Schedule f Activities Table 2: Estimated Cst Year 1 BCC Strategy. 38 List f Figures Figure 1: Suggested Targets and Expected Outcmes fr BCC Strategy 17 Figure 2: Cnceptual Framewrk fr Develping HIV BCC fr Yung Adlescents 27 I. Intrductin.. 9 II. HIV/AIDS Situatin in Barbads Wh is Vulnerable? 12 III. A Suggested Framewrk fr Clarifying BCC Pririties IV. Cntextual Factrs and Cnsideratins that: A. Influence Sexual Behaviurs 18 B. Influence Planning and Implementing BC/D Interventins 21 Summary.. 23 V. The Strategy A. Suggested Overall Strategic Fcus fr BCC B. Cnceptual Framewrk. 25 C. Guiding Principles f the Strategy.. 27 D. Applying the Cnceptual Framewrk. 29 VI. Implementing the BCC Strategy A. Implementatin Apprach 34 B. Critical Human Resurce Needs.. 34 C. Time Line. 35 D. Cst.. 38 References.. 39 BCC Strategy HIV/AIDS Preventin and Cntrl Prject, Lan 7066 BAR 6

7 Attachments 1. Individuals and Agencies Participating in BCC Cnsultatins Suggestins fr Strengthening the Prject ACISS Draft TOR Senir Behaviur Change Officer Draft TOR Junir Behaviur Change Officer (Advcacy) Draft TOR Junir Behaviur Change Officer (Drama/ Edutainment) BCC Strategy HIV/AIDS Preventin and Cntrl Prject, Lan 7066 BAR 7

8 ABBREVIATIONS AND ACRONYMS AIDS ART ACISS BCC BCO CARICOM COO HIV KAP MSM NAP NHAC NGOs OECS PWHIV SRH STI SW UWI UWI HARP Acquired Immune Deficiency Syndrme Anti Retrviral Treatment Awareness Clubs In Secndary Schls Behaviur Change Cmmunicatin Behaviur Change Officer Caribbean Cmmunity Cmmunity Outreach Officer Human Immundeficiency Virus Knwledge, Attitudes and Practices Men wh have sex with men Natinal AIDS Prgramme Natinal HIV/AIDS Cmmissin Nn Gvernmental Organisatins Organizatin f Eastern Caribbean States Persn (living) with HIV Sexual and Reprductive Health Sexually transmitted infectins Sex wrker University f the West Indies University f the West Indies HIV/AIDS Respnse Prgramme BCC Strategy HIV/AIDS Preventin and Cntrl Prject, Lan 7066 BAR 8

9 I. INTRODUCTION The epidemilgical and scial science data prvide cmpelling evidence f the need fr the Barbads Natinal HIV/AIDS Cmmissin t place a higher pririty n behaviur change cmmunicatin fr HIV preventin, treatment and care and supprt. T that end, a cnsultancy was cnducted in Nvember 2006 t evaluate Barbads current prgress in preventin effrts, but mre specifically t: Identify vulnerable and mst at risk grups; Prpse the key bjectives and pririties f the BCC strategy; and Design a strategy fr the develpment and implementatin f the BCC strategy. The infrmatin fr the cnsultancy was btained frm tw main surces: 1) Dcumentatin prviding infrmatin n the spread f the epidemics, and the main activities carried ut and lessns learnt by the Cmmissin; 2) Tw sets f meetings and cnsultatins with partners and key stakehlders engaged with the Cmmissin in implementing the Natinal AIDS Prgramme (NAP). Individuals and agencies participating in the cnsultatins are listed in Attachment 1. The cnsultatins revealed the cntinued cmmitment and desire f the natinal prgramme (the Cmmissin and its partners in the multi sectral respnse t HIV and AIDS) t stem the spread f the epidemics. In the 22 years since the first case f AIDS was identified in Barbads, the natinal prgramme has carried ut a range f preventin activities. These have included: Mass media infrmatin campaigns targeting the general ppulatin; Targeted cmmunicatin campaigns (e.g. Yuth Against AIDS campaign); Targeted interventins implemented by partners (e.g. Ministry f Educatin, Yuth Affairs and Sprts); A preventin f mther t child transmissin (pmtct) prgramme; Prmtins f crrect and cnsistent cndm use (fr primary preventin); and mre recently; and Vluntary cunseling and testing (VCT) prgrammes. The evidence is that preventin prgrammes implemented prir t 2001, when the multisectral respnse t HIV and AIDS was implemented, were nt sufficiently brad based t address a range f scial, cultural and behaviural aspects f the epidemic. The fcus f current preventin prgrammes is different. They seek t: Maintain levels f awareness f HIV risk and prtective measures; Prmte safer sexual practices (especially amng wmen and yuth); Reduce high risk behaviurs; Prmte advcacy n human rights and nn discriminatin. BCC Strategy HIV/AIDS Preventin and Cntrl Prject, Lan 7066 BAR 9

10 There is n questin that the current cmmunicatin effrts, fcused as they are n primary preventin, have created high levels f awareness f HIV, its transmissin, treatment, and preventin acrss all age and sexual behavir grups. They have been less successful, hwever, in assuring and sustaining the changes in behaviur that wuld result in declines in the epidemics. What are sme f the reasns prffered by prgramme partners? 1. Mst f the cmmunicatin prgrammes intrduced t date have been very knwledgefcused. There is the realizatin amng partners in the multi sectral respnse that knwledge (access t infrmatin) abut HIV and related matters, althugh necessary, des nt necessarily translate int behaviur change resulting in the nw recgnizable KAP gap. There is als grwing acknwledgement that behaviur change (as is behaviur develpment) is a prcess and the prcess needs t be given time and supprted t prduce the necessary results. 2. Limited fcus n evaluatin: Interviews with key individuals and partners participating in the cnsultatins identified anther imprtant perceptin, namely, that there has nt been sufficient investment in evaluatin. Further, there is the ntin that where evaluatin has been cnducted, these have been premature that is, they were cnducted befre the interventin f interest had the pprtunity t effect any meaningful change in the attitudes and practices f the primary beneficiaries f the interventin. 3. Interventins nt evidence based: Anther reasn suggested fr the lack f effective behaviur change interventins is that they are nt sufficiently evidence based. There are thse wh als suggest that there is an absence f sufficient basic scial science research with which t identify needs, and the prximal determinants/ crrelates f HIV preventin behaviurs fr sub grups in the Barbads ppulatin. One result is that cmmunicatin and ther change interventins are nt always based n real evidence. The strategy framewrk utlined here will attempt t address several f these cncerns. The gal is t install a system that, as needed, will enable the develpment, implementatin and evaluatin f meaningful, apprpriate and effective targeted interventins, with the necessary plicy and ther envirnmental supprts that, in time, will bring abut the kind f behaviur develpment r change necessary t keep the HIV epidemics in check. The final strategy fr HIV behaviur change cmmunicatin shuld include the fllwing cmpnents: educatin and cmmunicatin fr sexual behaviur develpment and change that is, educatin that prvides pprtunities fr the develpment f skills (cmmunicatin, cndm use, negtiatin, decisin making) and cmpetencies as well as knwledge fr several vulnerable grups including the pre schl child and the pre adlescent; an increased reliance n interpersnal cmmunicatin appraches, especially fr adlescents and yuth, that build self efficacy, self cnfidence and emtinal intelligence; BCC Strategy HIV/AIDS Preventin and Cntrl Prject, Lan 7066 BAR 10

11 effective mass media elements and prgrammes; advcacy t effect changes in scial nrms related t gender, sex and sexuality; public educatin and advcacy t: supprt the prper enfrcement f laws that prtect the sexual health and wellbeing f children; assure mdificatin f schl based sexual health educatin prgrammes t enable healthy discussins abut sex and sexuality, sexual health and behaviurs in ways that address need fr changes in gender nrms; and creatin and/ r strengthening f supprt grups t enable: i) develpment f effective cuple cmmunicatin skills (as required by cmmitted/married partners t prtect each ther frm infectin), ii) PWHIV and yuth, especially, t access available health and scial supprt services, iii) PWHIV, their families and significant thers cpe with stigma and discriminatin; and iv) adlescents and yuth wh chse celibacy r t delay sexual initiatin t cpe with the assciated stigma. A rse, is a rse is a rse. Nt really!! As utlined abve, this prpsed BCC strategy may appear t be similar t what is currently being dne by the NHAC and partners. This raises tw questins: First, is there a difference between this prpsed BCC strategy fr HIV preventin and HIV preventin prgrammes f the past and secnd, what is the difference between what is being prpsed and past preventin effrts? The answer t the first questin is YES, there is a difference. There are at least three fundamental differences between prgramming in the past and the prpsed strategic fcus f future HIV preventin behaviur change cmmunicatin effrts. First, in the past, the prgramme relied almst entirely n ne ff interventins that depended almst exclusively n mass media cmmunicatin elements. This prpsed BCC apprach is grunded in behaviur thery and uses mass media strategically t supprt and reinfrce the effrts f ther mre interpersnal cmmunicatin elements. Secnd, the new strategy assumes that behaviur develpment and change is a prcess. It is therized that an individual ges thrugh five (r six, if there is relapse) main stages in the prcess f behaviur change 3, 4. These are: Step 1: Becmes aware 3 Prchasta, JD, DiClementi, CG and Nrcrss, JC In search f hw peple change: Applicatins t the addictive behaviurs. American Psychlgist. 47(9): Everld Hsein s behaviur adptin mdel, HIC//DARM, includes seven stages. First we HEAR abut the behaviur, then we becme INFORMED abut it and later CONVINCED it is wrthwhile. In time we make a DECISION t d smething abut ur cnvictin and later we take ACTION n the new behaviur. We await RE CONFIRMATION that ur actin was a gd ne. If all s well we MAINTAIN the behaviur. BCC Strategy HIV/AIDS Preventin and Cntrl Prject, Lan 7066 BAR 11

12 Step 2: Cntemplates change Step 3: Prepares t change/ Takes steps t change Step 4: Begins t make change Step 5: Maintains the new behaviur Step 6: Relapses (this may ccur at any stage in the develpment/change prcess). This new BCC apprach pushes the natinal prgramme t recgnise the need t prvide the supprt(s) and material needed by individuals at every stage in the behaviur develpment/ change prcess. Such a segmented apprach has implicatins fr the type and cntent f specific behaviur change cmmunicatin elements that are prvided by the prgramme. Such a directed apprach helps create an envirnment fr the individual that is likely t supprt that individual t maintain the desired healthy behaviur. Third, this new apprach t behaviur develpment and change will ensure that the cmpnents f every interventin whether advcacy, infrmatin, service delivery, plicy change, mass media cmmunicatin fr behaviur change are linked in a cherent manner s that each cmpnent reinfrces and is reinfrced by the ther. II. HIV/AIDS SITUATION IN BARBADOS WHO IS VULNERABLE? The first case f HIV was reprted in Barbads in At that time, like mst ther cuntries, HIV infectin was prevalent amng s called high risk behaviur grups namely men having sex with men (MSM) and sex wrkers (SW). During the last 20 years, the prfile f the epidemic has changed. The trend is nw fr the general ppulatin t be infected. The 2005 data frm the Ministry f Health surveillance system indicate that ne in every three cases f HIV reprted is a wman. This is up frm 4:1 reprted in Data prvided by the Ministry f Health indicate that in March 2005, abut 73 percent f all reprted cases f HIV were amng persns 15 t 49 years f age. At that time, ne in every three cases was a wman. One shuld nte that althugh the prprtin f persns 15 t 49 years f age with HIV declined between 2000 and 2005, the rati f females reprting HIV infectin in the same perid has increased. As f December 2006, the majr burden f HIV cntinued t be evident in the age grup, and despite the reductin in the number f new cases diagnsed between 2004 and 2005, there has been an increase in the percentage f yuth years diagnsed with HIV. As f December 1, 2006, an estimated 1827 persns were living with HIV (PWHIV) 5. 5 These data were abstracted frm Ministry f Health statistics released fr Wrld AIDS Day, BCC Strategy HIV/AIDS Preventin and Cntrl Prject, Lan 7066 BAR 12

13 With respect t HIV and AIDS in Barbads, the situatin in Barbads is nt unique. Similar trends are reprted fr the wider Caribbean. Hwever, in terms f cases per ppulatin, the rate fr Barbads is increasing at a much higher rate cmpared t the ther cuntries in the OECS 6. These estimates are cnsidered t be cnservative and t represent nly ne fifth f the infected ppulatin 7. HIV is spreading in the Caribbean at a rate that is secnd nly t that f sub Saharan Africa. Levels f HIV infectin in the regin are highest amng newly identified grups including wmen, adlescents and the pr. The vulnerabilities that give rise t these new trends in the HIV epidemic derive frm a dynamic cnflatin f prevailing scial, ecnmic and cultural factrs. Imprtant amng these are scial class differentials, a glbal culture f materialism that creates unrealistic ecnmic needs and wants, entrenched gender nrms assciated with sexual partnering that place wmen at ptentially high risk fr infectin by their cmmitted male partners, and pwer dynamics that influence sexual utcmes, especially fr adlescents and yuth, but als fr wmen. In the past five years, AIDS has becme the leading cause f death in the Caribbean amng adults 15 t 44 years f age and the epidemic is having the effect f reducing life expectancy at birth by as much as 9 years. 8 Yuth are especially vulnerable t early sexual initiatin and HIV/STI infectin due t their age, lack f pwer t negtiate in a sexual relatinship, their pr ecnmic status and the scially assigned tasks and respnsibilities f child minding and husehld headship many f them must assume. The cnsultatin revealed anecdtally that an increasing number f bys and girls are victims f incest and sexual abuse. Yuth in secndary schl that is, persns in the age grup 10 t 18 years f age are vulnerable t the influence f and recruitment int gangs and ther anti scial behaviurs (alchl and drug use) that help drive the epidemic amng yuth. It is estimated, fr example, that 49 percent f yuth in Barbads use alchl. Use f Marijuana, tbacc and inhalants each is reprted by 11 percent f yuth in the same survey 9. Other vulnerable grups identified during the cnsultatin include individuals wh are newly diagnsed with HIV. It appears that althugh the necessary care and supprt and treatment services are available, these individuals are ften very tardy in accessing them. Further explratin is required t islate reasns fr this negative help seeking behaviur. 6 Camara, B, DeGrulard, M and Byd-Scby, C A strategic framewrk fr the preventin and cntrl f AIDS epidemic in the OECS: Actin Plan fr a Cmprehensive Prgramme n the Management, Preventin and Cntrl f HIV/AIDS Ministry f Health, Barbads. Nvember AIDS Epidemic Update: December Minister Eastmnd s presentatin at launch f the Life Educatin Centre n Octber 26, BCC Strategy HIV/AIDS Preventin and Cntrl Prject, Lan 7066 BAR 13

14 Finally, the epidemilgy data indicate that wmen, including married wmen, are als amng the mre vulnerable grups fr HIV infectin. The March 2005 data frm the Ministry f Health indicate that men mre s than wmen in all age grups except the 15 t 19 and 20 t 24 age grups are at higher risk f HIV. The infectin rates fr females 15 t 25 years are higher than fr males in the same age grup. The trend cntinues as the data frm December 2006 shws that in 2005, females accunted fr almst 47 percent f cases cmpared t just ver 40 percent in III. A SUGGESTED FRAMEWORK FOR CLARIFYING BCC PRIORITIES Given the situatin regarding HIV and AIDS and NHAC s ultimate gal f reducing the incidence f HIV in Barbads, hw shuld the NHAC classify its BCC pririties? Transmissin f HIV in Barbads is primarily thrugh unprtected sexual cntact. One means f classifying the BCC pririties f the NHAC, therefre, is n the basis f sexual activity status. Three grups f individuals are identified when that classificatin is applied. They are: i) thse wh never have had sexual intercurse; ii) thse wh have had sexual intercurse but have chsen secndary abstinence; and iii) thse wh currently are sexually invlved. If HIV status is superimpsed n this classificatin, seven sub grups emerge. A schematic f selected target behaviurs and expected impacts fr the pririty grups is presented in Figure 1. i) Individuals wh have never been sexually active. The prgramme fcus fr this grup shuld be t encurage delay f sexual activity by prviding skills and a supprtive envirnment (peer and parent supprt) t enable delay. In mdern Barbads where the psitive value frmerly placed n virginity, especially fr females, appears t be waning, the prgramme culd fcus n helping t remve the stigma assciated with nt being sexually invlved by highlighting ne s right t chse as well as the psitive health benefits f delaying sexual invlvement, especially fr yung adlescents. Public educatin and advcacy is required t remve the stigma assciated with nt being sexually active. Additinally, age and gender apprpriate and specific educatin (infrmatin and skills) n safe behaviurs (intimacy BCC Strategy HIV/AIDS Preventin and Cntrl Prject, Lan 7066 BAR 14

15 alternatives 10, cndm negtiatin and use, and mngamy) shuld be part f the fcus. 11. ii) Individuals wh are nt currently sexually active. This grup includes individuals wh have chsen temprary celibacy 12 (yuth and adults). This grup can be divided int three sub grups i) thse wh knw their HIV status (nt living with HIV), ii) thse wh d nt knw their status, and iii) thse wh knw their HIV status (living with HIV). Nt currently sexually active and nt living with HIV: Fr this grup, ne fcus shuld be n HIV testing in rder t knw ne s status and the necessary skills and scial supprts t enable individuals t maintain that status. Nt currently sexually active and unaware f HIV status: The fcus fr this grup shuld be t prmte use f HIV testing services and educatin/mtivatin t either apprpriate help and health seeking (cunseling, treatment, care and supprt r educatin fr practice f prtected sexual behaviurs and intimacy alternatives as and when the individual chses t becme sexually active again). Nt currently sexually active and living with HIV. The fcus fr this grup shuld t encurage and enable health and help seeking that includes access t and use f treatment services, educatin fr healthy living, and use f scial supprt mechanisms. iii) Individuals wh are sexually active. This grup includes three subgrups i) Persns wh are nt PWHIV, ii) persns wh are unaware f their status, and iii) persns wh are PWHIV. Sexually active and nt PWHIV The prgramme fcus fr this grup f individuals shuld be n prmting HIV testing as a means f knwing yur status and the using safe sexual practices 10 Term was suggested by a participant in ne f the cnsultatins. It cnntes alternative activities in which a cuple may engage that will enable intimacy but will nt expse either partner t risk f infectin. Sme f these alternatives may include practices that have been defined in the literature as Outercurse. 11 The scial science literature indicates that apprpriate sexuality educatin des nt hasten sexual debut but appears t enable the practice f safe behaviurs (use f prtectin, etc.) when the yung persn chses t initiate sexual activity. 12 The term is used here t mean pstpning sexual relatins whether fr religius reasns, because f dislike f the cndm r fear f becming infected with STI/ HIV. There is anecdtal evidence that a grwing number f persns wh were sexually active are chsing t pstpne sexual relatins fr these reasns. BCC Strategy HIV/AIDS Preventin and Cntrl Prject, Lan 7066 BAR 15

16 (fidelity, crrect and cnsistent cndm use, and safe intimacy alternatives) t safeguard ne s health status; Sexually active and unaware f HIV status: The fcus fr this grup shuld be n prmting use f HIV testing services and n educatin/mtivatin t either apprpriate help r health seeking (cunseling, treatment, care and supprt r educatin fr practice f prtected sexual behaviurs and intimacy alternatives as and when the individual chses t becme sexually active again). Sexually active and living with HIV: The prgramme fcus fr this grup shuld be t prmte healthy living (diet and exercise, scial interactin, and psych scial supprt), ARV adherence, apprpriate testing and practice f safer sexual behaviurs including the adptin f safe intimacy alternatives. Achievement f the expected utcmes prpsed in Figure 1 fr each pririty grup is dependent n the individual man, wman, r yung persn adpting a required set f behaviurs. Hwever, because f the dynamic relatinship (sme may argue reciprcity 13 ) between the individual and his/her envirnment, the adptin and subsequent maintenance f the desired behaviur(s) by that individual is dependent n a number f cnditins being in place. It is clear that cnditins required fr successful behaviural utcmes will vary fr each grup f interest. Hwever, the set f cnditins shuld include: access t safe, affrdable, client friendly, cnfidential and age apprpriate educatin, cunseling and clinical services; access t accurate age apprpriate sexuality educatin; access t accurate infrmatin abut HIV and AIDS, HIV testing, and treatment and care; access t stigma free and cnfidential psych scial supprt services; a scial envirnment (health facility, hme, schl, wrkplace) that is free frm scial stigma whether directed t PWHIV, r persns wh chse t delay/ pstpne sexual debut, r t be mngamus, r t be in a same sex relatinship; and a legislative and ethical framewrk at natinal and institutinal levels that supprts the prvisin f the cnditins nted abve and safeguards the rights f each individual. In the name f equality, it shuld nt be difficult fr the NHAC t apply these cnditins. These are delineated in several internatinal cnventins t which Barbads is a signatry. Ntable amng these cnventins is the United Natins Cnventin n the Rights f the Child 14 and the Internatinal Cnference n Ppulatin and Develpment (ICPD) Prgramme 13 Bandura, A Scial Fundatins f Thught and Actin: A Scial Cgnitive Thery. Englewd Cliffs, NJ: Prentice Hall BCC Strategy HIV/AIDS Preventin and Cntrl Prject, Lan 7066 BAR 16

17 Figure 1: Suggested Target Behaviurs and Expected Impacts fr BCC Strategy Natinal HIV/AIDS Cmmissin, Barbads Pririty Grup 1 Pririty Grup 2 Pririty Grup 3 Never sexually active Nt currently sexually Sexually active active Yuth and adults wh Yuth and adults in chse t delay/ Yuth and adults wh high/lw risk abstain chse 2 ndary abstinence behaviur grups Delay first sexual intercurse Safe intimacy alternatives Apprpriate help/ health seeking Cndm use at first and subsequent sexual intercurse Nt Knwn Apprpriate HIV/STI testing Other health seeking HIV HIV Status Knwn HIV HIV+ Safe sexual activity Cnsistent/ crrect cndm use Intimacy alternatives Mngamy Apprpriate health/ help seeking Apprpriate HIV/STI testing Expected Impacts Lwered rates f STD infectin Lwered rates f HIV infectin Lwered rates f HIV re infectin Imprved survival rates HIV+ Safe sexual activity Cnsistent/ crrect cndm use Intimacy alternatives Partner reductin Early access f treatment Apprpriate cd4 testing and ther required health seeking Cnsistent use f psychscial supprt(s). BCC Strategy HIV/AIDS Preventin and Cntrl Prject, Lan 7066 BAR 17

18 f Actin 15,16. These cnventins may indicate plitical will. Mving the rest f the ppulatin t accept them will require effective nging advcacy at several levels f sciety. IV. CONTEXTUAL FACTORS AND CONSIDERATIONS THAT: A: Influence Sexual Behaviurs Sexual and ther health behaviurs that determine the spread, r nt, f HIV are themselves derived frm and supprted by a series f sci cultural and ecnmic factrs. One f these is gender and mre specifically, the perceived and real sexual rles and relatins between men and wmen in sciety. Gender Issues Despite effrts in the past tw decades t address gender and gender scialisatin issues in Barbads and the rest f the regin, gender nrms that negatively influence the HIV transmissin remain intact. It has been bserved, fr example, that men in the Caribbean are ften rewarded within cultural cntexts fr the very risks that might increase expsure t and pprtunity fr HIV infectin r transmissin f HIV t thers 17 These risks cntribute t what is nw cnsidered the feminisatin f the HIV/AIDS epidemic in Barbads and the rest f the regin. In 2004, the Caribbean had ne f the highest rates f new AIDS cases amng wmen in the Americas with wmen 15 t 24 years f age being especially vulnerable. The sexual duble standard that persists allws men t have multiple sexual partners and families. Therefre, wmen wh are married r in mngamus relatinships are nt guaranteed prtectin against HIV r ther STI. Irnically, frm the man s perspective, the characteristics that are cnsidered masculine (being strng, having an intense sexual desire that demands immediate satisfactin and being audacius) are the nes that increase men s vulnerability fr HIV infectin. The challenge is t re rient men s thinking t diminish vulnerability by being respnsible, and a gd financial, sexual and affective partner 18. The NHAC must seek t get men t re think masculinity and wmen t be s empwered as t nt nly have the cndm cnversatin but t insist n its use, and t recmmend that bth partners be tested fr HIV. Even as we bserve the persistent duble standard, there is anecdtal evidence frm multiple surces that gender nrms assciated with sexual partnering are changing. Increasing numbers f yung wmen see themselves as equal t men and, as such, entitled t engage in the same sexual partnering practices as men. While serial mngamy is generally the practice fr yung 15 ICPD Prgramme f Actin (1994) Strengthening the Caribbean Reginal Respnse t the HIV Epidemic. Reprt f the Caribbean Technical Expert grup Meeting n HIV Preventin and Gender. Octber 28 29, Jamaica. 18 Guerrier, ICZ. Gender and vulnerability t the HIV: hw the cncepts abut masculinity influence hetersexual men s vulnerability. Glbal Frum fr Health Research. Frum 8. Mexic City, Nvember BCC Strategy HIV/AIDS Preventin and Cntrl Prject, Lan 7066 BAR 18

19 wmen, increasingly multiple cncurrent sexual partnering is being bserved. These behaviurs have imprtant implicatins fr the preventin prgramming cntent and apprach that is adpted by the NAP. Ecnmic Cnsideratins Barbads perfrmance in the ecnmic sphere has been described as impressive 19. Between 1993 and 2000, the ecnmy recrded eight cnsecutive years f grwth that resumed in 2002 and cntinued thrugh Unemplyment rates have declined steadily frm 24.3 percent in 1993 t 9.8 percent in In additin, pverty levels are lw and the well develped scial security safety net is available t thse wh need assistance. This healthy natinal ecnmic situatin belies the pressure, real r perceived, n adults and yuth t acquire r wn the latest brand r in item and lk. The items may include the ubiquitus mbile telephne, a particular mtr vehicle, designer clthes, sunshades and ther accessries, r a huse. This culture f materialism, diffused as it appears t be thrugh the media (televisin and music vides) and travel, presents enrmus challenges fr scial and behaviural change prgrammes as it has effectively changed traditinal values and cultural nrms. One effect f this trend is that it places already vulnerable individuals at even higher risk f physical and psychlgical abuse and mre as they attempt t achieve the in item r lk. In this cntext, prgrammes like the NAP are challenged in at least tw ways. First, they need t make individuals cnscius f ptential risks assciated with this culture f materialism. Secnd, they must attempt t create pprtunities fr the ecnmic empwerment f individuals, including PWHIV. While it is nt the rle f a natinal HIV/AIDS prgramme t prvide jb skills training r t create jbs r emplyment pprtunities, the NAP can be strategic in assisting individuals and grups t link t rganizatins and prgrammes that d. Further, the NAP can supprt, facilitate and encurage the placement f HIV preventin cmpnents in existing jb skills training r emplyment prgrammes. Legal and Regulatry Issues The legal and regulatry framewrk and whether it cntributes t sexual behaviurs als shuld be cnsidered in understanding the cntext in which sex and sexual practices and behaviurs take place in Barbads. The state s prtectin f the yung persn frm sexual abuse is enshrined in law and in the Cnstitutin. Barbads als is a signatry f the Cnventin in the Rights f the Child which prtects children frm sexual harm and guarantees them access t accurate sexual and reprductive health infrmatin and services. Under the law, a yung man r wman in Barbads can legally cnsent t participate in sexual relatins if he r she is 16 years r lder. Ntwithstanding this legal requirement, several females yunger than 16 years deliver babies at the Queen Elizabeth Hspital (QEH). The median age at first sexual intercurse reprted frm the recent Secndary Schl Behaviur Surveillance Survey (SSBSS) 19 The Natinal Strategic Plan f Barbads June 2005, Draft. Research and Planning Unit, Ecnmic Affairs Divisin. Ministry f Finance and Ecnmic Affairs. Pp 11, 12. BCC Strategy HIV/AIDS Preventin and Cntrl Prject, Lan 7066 BAR 19

20 is 13 years 20. These tw items f data prvide evidence that the laws that prtect the rights f children are nt being enfrced. The questins are whether yuth and adults are aware f the law and its penalties and, if they are, t what extent are they cmpelled, r nt, t recgnize it. The prgramme is challenged t understand the scial and cultural underpinnings, patterns and reasns fr child sexual abuse and its rle in cntrlling, r nt, the incidence f HIV infectin. Under law, the yung persn at 16 years can legally cnsent t sexual activity but cannt access the services needed t prevent STI including HIV (testing, cndms), pregnancy r ther health cnditins withut parental cnsent unless she has been emancipated. Giving birth t a child is ne f the cnditins that may emancipate the female minr. The anmalies in the age f cnsent t sexual relatins and the age f majrity (marriage, vting, medical prcedures) need t be ratinalized and addressed if the NAP is t prvide r create an envirnment that enables and supprts help and health seeking, amng ther psitive preventative behaviurs, amng yuth in particular. 21 Parenting Parenting practices and daily rutines are knwn t be imprtant factrs in a child s scial, physical and cgnitive develpment 22. There is als evidence f the value that having familiar patterns and rituals prvide children, especially yung children, with the security f knwing what t expect, and help build their sense f identity and respnsibility 23. In fact, there is cmpelling evidence that parents can psitively influence the sexual and ther health behaviural utcmes fr adlescents and yuth 24. It has been bserved, hwever, that: Parents ften assume the task f parenting withut fully understanding and appreciating the significance f the rle they must play in their children s lives. A number f parents have had t assume this rle befre they are emtinally r psychlgically ready, and many wh believe they are ready are affected in the perfrmance f their rle by the many envirnmental factrs which make the cmplex task f nurturing and caring extremely difficult 25 Given the imprtance f parents and effective parenting fr values and attitudes frmatin, children s healthy develpment and healthy sexual and ther health utcmes, the NAP shuld 20 Reprt n the Barbads Secndary Schl Behaviural Surveillance Survey, 2003/ The recent experience f Jamaica in apprving guidelines fr the prvisin f services, including cntraceptives, t minrs is wrth nting and may prvide imprtant lessns. 22 Yung,KT, et al Listening t parents. Archives f Pediatric Adlescent Medicine 152: Parenting practices that shape the lives f yung children. May L.A.Health. Cunty f Ls Angeles, Department f Health Services Blum, Rbert. Presentatin t WHO Technical Cnsultatin t Review Interventins t Supprt the Parents f Adlescents. Chevannes de Bgis, Geneva. Octber Elsa Le Rhynie. June Frewrd. Parenting Pathways: A Caribbean Apprach. Parenting Partners Caribbean. BCC Strategy HIV/AIDS Preventin and Cntrl Prject, Lan 7066 BAR 20

21 cntinue t place emphasis n parenting. The prgramme fr parents shuld be designed t encurage and enable effective parenting by prviding skills, knwledge and scial supprts. Parents, rle mdels and mentrs might als be cnsidered as a sub cmpnent f a child/yuth develpment interventin. Examples f effective parenting prgrammes in the regin are available and shuld be studied carefully. Music The cultural and scial nrms in relatin t sexuality and sexual expressin, and interpersnal relatinships f Barbadians, like many thers glbally, are cnstantly being influenced and reshaped by the media, in particular televisin, music vide and vide games. Add the music DJ t the list f persns wh influence yuth culture in Barbads. The glbal electrnic media is available and easily accessible t Barbadians. Althugh n specific data were available during the cnsultatin n yuth expsure t media, yuth are reprted t spend several hurs each day watching cable televisin, surfing the internet and watching music vides f lcal, reginal and internatinal singers and entertainers. Besides this expsure, yuth wh attend ppular night clubs and ther entertainment venues are expsed t the influences f the music DJs. The pwer f media influence has a number f immediate implicatins fr the BCC effrts f the NHAC. First, the cmmunicatin appraches and materials used by the NHAC in its BCC effrts must be as attractive and appealing t the designed audiences as thse n the public media if the NHAC is t cmpete successfully with them. Secnd, the placement f the materials fr maximum reach and penetratin, given cst must be carefully thught ut. Third, the pwer f the DJs as values influencers must be cnsidered. The imprtance and value f high quality media research data is undeniable. Such data are currently cllected by at least tw private sectr research cnsulting agencies in Barbads. The NHAC shuld avail itself f these reprts and explre the pssibility f using these surveys as mnibus pprtunities, as well. It is essential t understanding the rle f media as well as infrming decisins abut use f media and placement f cmmunicatin material. B: Influence Planning and Implementing Behaviur Change/ Develpment Interventins 1. Changing fertility nrms Lessns frm the past: Barbads has a rich histry f successful scial transfrmatin in the area f sexual and reprductive health. In the perid Barbads was able t achieve replacement fertility levels thugh a brad based pregnancy preventin prgramme that was mdeled by several ther cuntries. Thrugh strng cmmunity utreach, educatin, increased access t services and gvernment cmmitment t the benefits fr the natin f fertility decline, the prgramme was able t mve fertility rates frm an average f 6 children per cuple (in the 1940s) t 2 per cuple (in the 1980s). The success f the natinal family planning prgramme during that perid can be attributed t a number f natinal, cmmunity, family and individual factrs. First, Barbads is a small island state that, given its tpgraphy, allwed easy access t residents acrss the cuntry. BCC Strategy HIV/AIDS Preventin and Cntrl Prject, Lan 7066 BAR 21

22 Cmmunity utreach by cmmitted educatrs and advcates thrived in this envirnment. The scpe fr inter persnal cmmunicatin and interactin was therefre enrmus. Secnd, Barbads had a very literate ppulatin fr whm the rewards f fertility reductin were judged t be attractive. This was especially s fr thse wman wh, by way f fewer children, culd themselves transitin frm wrking class t middle class. Secndary educatin ffered them, and their children, the real pssibilities f lessening dependence n men fr their ecnmic and scial survival. Third, the effective cntraceptive methds available (ntably the pill) culd be discretely used by wmen withut their partners knwledge. 2. Prximate determinants Delayed age f marriage (delayed sexual initiatin): The prximate determinants mdel f fertility reductin includes five factrs 26 that, taken tgether, will help cuntries achieve their desired fertility gals. Each f the five factrs has a differential cntributin t the mdel. One f the mst significant factrs, hwever, is age f marriage r in the Caribbean cntext where sex and marriage are mutually exclusive age at sexual initiatin. The health and scial advantages fr the individual and the cmmunity/ cuntry respectively f delaying first sexual intercurse (marriage) are enrmus. The internatinal literature prvides clear evidence f the link between late age f sexual initiatin (marriage) and reduced fertility, use f mdern cntraceptin at sexual initiatin, and fewer lifetime sexual partners. By extensin, there shuld be reduced rates f HPV and cervical cancer a majr advantage fr the Caribbean regin where cervical cancer rates are high and, in part, attributed t early sexual initiatin and the related cnsequence n the number f sexual partners ver a wmen s lifetime. 3. Principles f disease transmissin and preventin: In basic public health practice, the standard apprach t reducing disease transmissin is t eliminate the vectr. In the case f HIV transmissin in cmmunities where transmissin is via sexual activity, it is nly individuals wh have the virus wh have the ptential t transmit it. On this basis, effective ways t eliminate HIV infectin wuld be t a) eliminate the infected persn (an ptin that is neither ethically nr mrally acceptable); b) restrict the infected persns sexual cntacts and ensure that he r she always uses prphylaxis during sexual intercurse (this ptin is likely t be seen as infringement n the rights f the individual), r c) t ensure that thers d nt cme int intimate cntact with the infected persn (an ptin which wuld fuel the already high levels f stigmatisatin f PWHIV. Given the difficulty in implementing any f these ptins, the mst effective apprach t HIV preventin may be t attempt t delay sexual debut fr yung peple and prmte mngamy and fidelity. The advantages f such an apprach are dcumented. The internatinal scial science literature indicates that delayed sexual initiatin has psitive health and scial benefits fr the individual and the sciety. Yung persns wh delay their sexual debut are mre likely 26 Bngaarts, J and Ptter R Fertility, bilgy and behaviur: An analysis f the prximate determinants. Academic Press. BCC Strategy HIV/AIDS Preventin and Cntrl Prject, Lan 7066 BAR 22

23 than thse wh d nt t use prtectin at first intercurse, t have fewer lifetime sexual partners, and have reduced risk f sexually transmitted infectins. Fr reasns assciated with sex and sexuality and the related scial, cultural, mral and religius values that gvern them, managing the spread f HIV where it is sexually transmitted is nt nly different t general public health practice, it is difficult. Sexual delay until marriage r the attainment f the age f majrity is nt always achievable. The ptin f cnsistent cndm use, especially in relatinships in which partners are nt exclusive r are discrdant, is required t cntrl the spread f the virus. Mutual mngamy shuld als be actively prmted. 4. Prmting Healthy Living Barbads dcumented experiences with the healthy living and lifestyle initiatives in the private and public sectrs 27 are relatively recent. Nnetheless, they prvide imprtant insights int the value Barbadians place n gd health and lngevity. These insights can be applied t HIV preventin effrts. If nthing else, they indicate the desire f a crss sectin f the sciety t invest in healthy living paying attentin t healthy eating, exercise and the adptin f preventive practices. Summary A number f key lessns n hw t apprach BCC fr HIV preventin can be learned frm several cntexts bth lcal and internatinal such as the prximate determinants literature, basic public health principles f disease transmissin, Barbads recent experiences with healthy living initiatives and her histric success with scial transfrmatin f the ppulatin structure in the 20 th century. The lessns include: The intrinsic psitive value f interpersnal cmmunicatin and utreach at the cmmunity level in effecting and sustaining behaviur change/develpment. The rle f well trained, cmmitted and credible cmmunity utreach wrkers, peer cunselrs and ther behaviur change cmmunicatrs culd be significant in the HIV behaviur change effrt. The imprtant, even central, rles f wmen t effect shifts in the epidemics. These revlve arund: wmen as mthers prtecting children frm sexual abuse and advcating fr enfrcement f child prtectin laws; mthers as partners wh, uncmprmisingly and cllectively, demand mngamy r cndm use; and wmen as mthers acting as psitive rle mdels and mentrs fr their children male and female. Prmting the physical and psychlgical health benefits (fr the individual) f adpting desireable new behaviurs. These measures are imprtant, whether they are 27 These include the Health Lifestyle prgramme f the Natin [Keep Fit, Be Fit] which builds n their annual fun run and walkathns ; Barbads Natinal Bank s Wellness prgramme launched in September 2006; the Gvernment f Barbads Life Educatin Centre initiative launched in 2006; and the new thrust f the Ministry f Educatin t eliminate the sale f junk fd t primary schl children. BCC Strategy HIV/AIDS Preventin and Cntrl Prject, Lan 7066 BAR 23