Couples HIV Counseling and Testing

Module Eight: Outreach and Recruitment

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

Module Perspective

This module will focus on the importance of outreach and reviewing
outreach strategies such as door-to-door, media, radio drama and
theater, and other outreach that can take place to recruit couples.
Trainers will facilitate discussion on the strength and weakness of
different type of outreach strategies.

The module will conclude with wrapping up the entire course by
conducting the closing exercise. Trainers should address Parking Lot
issues as necessary. Before presenting completion certificates, trainers
will need to distribute the Post-Course Knowledge Assessments and remind
participants to place the same identifier from the first day of training
on the Post-Course Knowledge Assessment.

**Objectives for Module Eight:**

-   Identify outreach strategies to make more couples aware of CHCT
    services available in their communities.

-   Understand the strengths and weaknesses of different types of
    outreach strategies.

**Advance Preparation**

-   ***Prepare Overheads** 8-1 through 8-8*

> 8-1: Importance of Outreach
>
> 8-2: Importance of Outreach (Continued)
>
> 8-3: Community Outreach
>
> 8-4: Door-to-Door Outreach
>
> 8-5: Media Outreach
>
> 8-6: Outreach through Fictional Drama
>
> 8-7: Outreach through Antenatal Clinics
>
> 8-8: Outreach in the Workplace

######## **Prepare the following newsprints**

> How can we get couples to come in for CHCT? (Blank---see page 4)
>
> Outreach Strategies (see page 5)

-   ***Be prepared to address Parking Lot issues.***

-   *Make copies of the Handout*

> Post-Course Knowledge Assessment (H8-1)

-   *If possible, provide certificates of completion to give to each
    participant at the end of the training.*

**[Day Five]{.underline}**

**Module 8: Topics/Activities Schedule**

+-----------------------------------------------------------------------+
| ***Start time: 10:20am***                                             |
|                                                                       |
| **Activity Time**                                                     |
|                                                                       |
| Outreach 60 Minutes                                                   |
|                                                                       |
| Closing Exercise 30 Minutes                                           |
|                                                                       |
| Post-Course Knowledge Assessment 15 Minutes                           |
|                                                                       |
| Completion Certificates/Adjourn 25 Minutes                            |
|                                                                       |
| ***End time: 12:30pm***                                               |
+-----------------------------------------------------------------------+

***Welcome the group back from break.***

***Display Overhead 8-1.***

As we discussed previously, married couples that do not know each
other's status are one of the highest risk groups for HIV transmission.

> Please refer back to page \_\_ in your manuals to the graph that shows
> the percentages of couples who are concordant and discordant. As you
> can see, CHCT helps reduce HIV transmission significantly among
> discordant couples by helping them to adopt risk-reduction behaviors,
> increase condom use, and reduce mother-to-child transmission.
> Unfortunately, few people know that it is possible to receive HIV
> counseling and testing as a couple.

Why is outreach important?

-   In many communities, CHCT is a new option---many people do not know
    that it is possible to receive counseling and testing as a couple.

-   Oftentimes, people do not know where the counseling and testing
    sites are in their community.

For example, one study showed that up to 80% of the couples recruited
through outreach for HIV counseling and testing did not previously know
where to get CHCT services. *(Source: McKenna 1997)*

***Display Overhead 8-2.***

Let's take a look at a few other important aspects of outreach.

-   More people learn about counseling and testing services when the
    program actively recruits participants.

-   Outreach can help couples during their decision-making process to
    decide whether to receive CHCT.

Display newsprint: How can we get couples to come in for CHCT?

***Facilitate a short brainstorming session, and list the participants'
ideas on the newsprint.***

What ideas do you have for how we can get couples to come in for CHCT?

***Display newsprint: Outreach Strategies.***

We will go over several outreach strategies today, including several
that we identified during this brainstorming session.

The outreach strategies we are going to focus on today are:

-   Community outreach

-   Door-to-door outreach

-   Media outreach

-   Fictional drama and theater

-   Antenatal clinics

-   Workplace recruitment

Please keep in mind that this list is not exclusive. You may discover
other ways to reach couples in your communities to let them know about
CHCT.

***Display Overhead 8-3.***

**Community outreach** involves a range of activities at the
community-wide level that are intended to gain support, awareness, and
interest for CHCT programs. They are also intended to help couples make
the decision to come in for CHCT.

Let's review some key points for successful community outreach.

-   Obtain buy-in from local leaders.

The first step in any community is to get the local leaders invested in
the importance of CHCT and how it can help the community.

How do you think you could do this?

***Acknowledge responses.** **Facilitate a brief discussion on how to
obtain buy-in from local leaders.***

Another step in community outreach is to:

-   Display posters advertising CHCT at local community centers,
    churches, adult education centers, and public buildings.

When using posters to advertise CHCT, it's important to decide where you
will advertise and to obtain appropriate permission.

-   Make presentations to various groups, including churches and
    community centers, to encourage participation in CHCT and to
    encourage referrals.

-   Recruit and train influential, social people in the community such
    as barbers, bartenders, and taxi drivers to talk about CHCT and to
    invite couples to receive CHCT.

You will need to give these people a brief training to teach them the
basics of why CHCT is important and how to give referral information,
such as clinic locations and hours of operation.

What other types of people in the community can be recruited and trained
to invite couples for CHCT?

***Acknowledge responses.***

In one study, community outreach resulted in nearly 60% of the
participants hearing about HIV counseling and testing services through a
relative, friend, or neighbor. *(Source: Balmer 2003)*

Let's summarize---what are some strengths and weaknesses of community
outreach?

***Facilitate a brief discussion.***

> ***Listen for:***

##### *Strengths*

-   ***Can reach a large number of people***

-   ***Can raise awareness and acceptance of CHCT***

-   ***Can be highly effective***

##### *Weaknesses*

-   ***Can be labor-intensive***

-   ***Cannot address decision-making barriers that couples may have***

**Door-to-door outreach** is another type of outreach. Door-to-door
outreach is more focused than community outreach. It focuses on reaching
couples individually and personally inviting them to come in for CHCT.

Have any of you used door-to-door outreach before?

***Acknowledge responses.***

***Display Overhead 8-4.***

Let's look at some important aspects of door-to-door outreach.

-   CHCT or VCT clients can be recruited as outreach workers to go
    door-to-door in their communities to invite couples to come receive
    CHCT.

-   Outreach workers should conduct brief door-to-door visits during
    which they:

    -   Invite couples to come in for CHCT

    -   Explain briefly why CHCT is important

    -   Provide information about clinic locations and hours of
        operation

-   Outreach workers should receive guidance or messages about CHCT
    through a brief training or seminar with CHCT site staff.

-   Outreach workers may answer basic questions or provide testimonials
    about CHCT, but they are NOT counselors and should not attempt to
    counsel couples.

A study from Zambia shows the effectiveness of door-to-door outreach in
promoting voluntary testing. In a study of over 7,000 individuals and
couples who received counseling and testing, 70% heard about the site
where they received testing through outreach workers. Eighty percent
said they had not previously known where to get services. *(Source:
McKenna 1997)*

To summarize, what are some strengths and weaknesses of door-to-door
outreach?

***Acknowledge responses.***

> ***Listen for:***
>
> ***Strengths***

-   ***Highly effective***

-   ***Allows outreach worker to recruit couples as a unit***

-   ***Provides an opportunity to address decision-making barriers for
    individual couples***

> ***Weaknesses***

-   ***Labor intensive***

-   ***May be expensive***

***Display Overhead 8-5.***

The next outreach strategy is **media outreach.**

Media advertising, such as advertising on the radio, is one way to let
the community know about sites offering VCT and CHCT.

Do any of you have experience using media outreach?

***Acknowledge responses.***

Media outreach has been less successful at actually getting people to
come in for CHCT. However, it is still one option for letting the
community know about sites offering VCT and CHCT. Let's take a look at
another option---fictional drama---and what it entails.

***Display Overhead 8-6.***

**Fictional drama** that involves stories about CHCT and other
HIV-related issues can help increase the social acceptance of CHCT in
the community and encourage couples to make the decision to come in for
CHCT.

In Botswana and Zimbabwe, radio dramas have had storylines about couples
dealing with their results, PMTCT, and other HIV-related issues.

-   Fictional drama:

    -   Creates role models

    -   Starts discussions

    -   Increases awareness and acceptance of CHCT

    -   Reinforces key messages

    -   Motivates people to get tested and change their behaviors

In the resources section of your manuals you will find a sample
storyline from a radio drama in Zimbabwe. This is for you to review at
your leisure.

Street and community theater and outreach drama can also portray
CHCT-related stories.

In summary, what are the strengths and weaknesses of the drama strategy?

***Acknowledge responses.***

Listen for:

> ***Strengths***

-   ***Creates role models the audience can relate to***

-   ***Increases awareness***

-   ***Provides motivation for people to get tested***

> ***Weaknesses***

-   ***Radio dramas require time and money***

-   ***Community theater takes time***

Another option for outreach is to target **antenatal clinics**.

Why might antenatal clinics (ANC) be a good place to recruit couples?

***Acknowledge responses.***

> ***Listen for:***

-   ***Women may be very interested in knowing their and their partner's
    status for the health of their baby.***

-   ***This strategy could reach a large number of interested people.***

One way to conduct outreach at antenatal clinics is to display posters
at the clinics where clinic patients will see them. The patients can
then talk to the clinic staff about the services being advertised.
Clinic staff can encourage their patients to seek CHCT with their
partners. In some communities, antenatal clinics may even be able to
offer CHCT as an HIV testing option at their site.

Is there a disadvantage to recruiting couples through antenatal clinics?

***Acknowledge responses.***

Listen for:

-   ***In many situations, men are the decision-makers in couple
    relationships. This strategy generally puts the burden of starting a
    dialogue about CHCT on the female partner.***

Several programs have addressed this issue by sending women home from
antenatal clinics with personalized letters from the clinic's program
director that asks the couple to come into the clinic for HIV testing.
This helps relieve the burden that is on the woman to open up a dialogue
with her partner about seeking HIV testing.

This method has been highly effective in getting men involved,
especially when their name was put on the letter and the letter was in
an official clinic envelope.

An example of a letter like this can be found in the resources section
of your manuals.

***Display Overhead 8-7.***

Outreach through ANC and PMTCT clinics offer the following benefits:

-   CHCT staff can target antenatal clinics in their community outreach
    efforts.

-   Many women at antenatal clinics are interested in HIV counseling and
    testing.

-   Antenatal clinic staff can encourage women to seek CHCT with their
    partners.

-   Antenatal clinics can double as CHCT sites, and women can be
    encouraged to bring their partners in with them.

In some cases, men do not like to go to antenatal clinics. However, one
program solved this problem by using an antenatal clinic as a CHCT site
on the weekends.

This was effective because although men were not comfortable visiting
the ANC during the week when antenatal services were being offered, most
felt comfortable coming in over the weekend when the clinic was closed.

Remember, even if a pregnant woman gets tested at the antenatal clinic
and knows her status, she can still come in with her partner to receive
CHCT services.

In summary, what are some strengths and weaknesses of outreach at
antenatal clinics?

***Acknowledge responses.***

> ***Listen for:***
>
> ***Strengths***

-   ***Women want to know their status for the health of their baby.***

-   ***The outreach can reach a large number of people.***

> ***Weaknesses***

-   ***Woman is responsible for bringing up CHCT with her partner.***

-   ***Men are not always comfortable with antenatal clinics.***

The next strategy to discuss is **workplace recruitment**. Studies have
shown that large numbers of couples can be recruited by targeting large
employers and the military. *(Sources: Lurie 2003, Ryder 2000)*

***Display Overhead 8-8.***

Community outreach workers can target both large and small employers
through their community outreach efforts.

-   Workplace recruitment is important because it can be used to target
    men. Because men have traditionally been the decision-making
    partners in couple relationships, outreach strategies directed
    towards men are needed.

Do any of you have experience recruiting men for HIV counseling and
testing?

***Acknowledge responses.***

-   Many larger companies have peer health educators who can give out
    information about CHCT programs.

CHCT staff can meet with workplace peer health educators as part of
their outreach activities and set up a referral and linkage system to
CHCT information and clinics.

To summarize, what are the strengths and weaknesses of workplace
outreach and recruitment?

***Acknowledge responses.***

> ***Listen for:***
>
> ***Strengths***

-   ***It targets men, who are frequently the decision-making
    partners.***

-   ***It can potentially reach large numbers of people.***

> ***Weaknesses***

-   ***Generally targets male individuals rather than couples as a
    unit.***

-   ***Confidentiality at workplaces could be limited.***

***Facilitate a brief discussion about which outreach strategies will
work best for the participants' CHCT sites.***

Now that we have discussed several types of outreach strategies, which
do you think will work best for you at your CHCT sites?

***Acknowledge comments.***

Are there any questions about any of these strategies or how they can be
used?

Given the value of CHCT, it is important for us not only to begin
offering CHCT in our communities, but also to raise community awareness
and make sure that couples have access to CHCT.

***Be sure to address any final questions and remaining Parking Lot
issues.***

Before we conclude the content portion of our training, I would like to
take some time to answer any final questions and clarify any of the
information we have covered. Are there any questions?

In your manual you will find a CHCT reference list as a resource to help
you when you return to your sites.

During the final exercise, be sure that the participants can see and
hear each other. You may want to ask participants to rearrange their
chairs to form a circle.

> ***The impact of this exercise is greatest when everyone who played a
> role in the training participates, including participants, trainers,
> and observers.***
>
> ***Ask participants to turn to their manuals. Give them time to think
> about the statements listed. Ask them to use these sentences to come
> up with a comment or thought that they would like to share. When
> everyone is ready, ask a volunteer to begin. Request that the group
> model respectful and quiet acceptance of what is said and that no one
> respond to the comments as they are being shared.***

After everyone has shared, thank the participants for their hard work
and energy. Congratulate them on the important work that they have done
and will continue to do as they become couple HIV counselors.

It is now time for the closing exercise of the training. Please turn to
your manuals. Take some time to think about these statements, and
complete any of the sentences that you choose.

***Give participants time to look over the statements and write down a
thought or comment that they would like to share.***

Please choose one of the statements you wrote down that you would like
to share. We would like to hear from everyone, so let's go around the
room. Please share one thought or comment about this training. As people
share, please listen, consider what is being said, and model respectful
acceptance. Please do not respond to a person's comments.

Is there a volunteer who would like to begin our closing exercise by
sharing a thought or comment?

***Go around the circle until everyone has shared.***

Thank you all for sharing.

As we discussed throughout the course, counseling couples together can
help them plan for a healthy lifestyle, prepare them to protect each
other's health, and prepare them for the future welfare of their
families.

Couple HIV counseling and testing can and will be more effective with
trained, skilled, and knowledgeable counselors, such as yourselves!
Thank you for your hard work over the past few days.

Distribute Post-Course Knowledge Assessments. Allow participants 15
minutes to fill them out.

Before we completely wrap up the training, we would like for you to fill
out a Post-Course Knowledge Assessment, which I am handing out now.
These will help us evaluate and improve this training course. Please
place the same code you placed on your Pre-Course Knowledge Assessment
on your Post-Course Knowledge Assessments.

Please take 15 minutes to fill these out. When you have finished, please
return them to me.

> ***After everyone has completed the Post-Course Knowledge Assessment,
> have a closing ceremony. If certificates are available, present one to
> each of the participants. Distribute the certificates in a culturally
> appropriate way. Warmly congratulate each person, and thank the group
> for the work that they do. Finish with any housekeeping details that
> need to be taken care of, such as rearranging the room, and adjourn
> the training.***
>
> **References**
>
> Balmer D, Grinstead OA, Kihuho F, Gregorich SE, Sweat MD, Kamenga MC,
> et al. Characteristics of individuals and couples seeking HIV-1
> prevention services in Nairobi, Kenya: The Voluntary HIV-1 Counseling
> and Testing Efficacy Study. AIDS and Behavior 2000; 4(1):15-23.
>
> McKenna SL, Muyinda GK, Roth D, Mwali M, Ng'andu N, Myrick A, et. al.
> Rapid HIV testing and counseling for voluntary testing centers in
> Africa. AIDS 1997; 11(Suppl 1):S103-S110.
>
> Lurie MN, Williams BG, Zuma K, Mkaya-Mwamburi D, Garnett GP, Sweat MD,
> et. al. Who infects whom? HIV-1 concordance and discordance among
> migrant and non-migrant couples in South Africa. AIDS 2003;
> 17(15):2245-2252.
>
> Ryder RW, Kamenga C, Jingu M, Mbuyi N, Mbu L, Behets F. Pregnancy and
> HIV-1 incidence in 178 married couples with discordant HIV-1
> serostatus: additional experience at an HIV-1 counseling centre in the
> Democratic Republic of the Congo. Trop Med Int Health 2000;
> 5(7):482-487.

**Handouts**

**Module 8: Outreach and Recruitment**

Couples HIV Counseling and Testing

Post-Course Knowledge Assessment

+-------------------------------------+-------+---+-----+---+-------+
| **Questions**                       | **    |   | **A |   | **    |
|                                     | Stron |   | gre |   | Stron |
|                                     | gly** |   | e** |   | gly** |
|                                     |       |   |     |   |       |
|                                     | **Ag  |   |     |   | **    |
|                                     | ree** |   |     |   | Disag |
|                                     |       |   |     |   | ree** |
+-------------------------------------+-------+---+-----+---+-------+
| 1.  A husband and wife can have     | 1     | 2 | 3   | 4 | 5     |
|     different test results---one    |       |   |     |   |       |
|     positive, one negative.         |       |   |     |   |       |
+-------------------------------------+-------+---+-----+---+-------+
| 1.  Most people understand that HIV | 1     | 2 | 3   | 4 | 5     |
|     is a sexually transmitted       |       |   |     |   |       |
|     disease.                        |       |   |     |   |       |
+-------------------------------------+-------+---+-----+---+-------+
| 2.  In the case of a concordant     | 1     | 2 | 3   | 4 | 5     |
|     positive or a discordant        |       |   |     |   |       |
|     result, it is important to      |       |   |     |   |       |
|     identify when and by whom one   |       |   |     |   |       |
|     or both of the partners became  |       |   |     |   |       |
|     infected by HIV.                |       |   |     |   |       |
+-------------------------------------+-------+---+-----+---+-------+
| 3.  When working with couples it is | 1     | 2 | 3   | 4 | 5     |
|     effective to separate them to   |       |   |     |   |       |
|     conduct individual risk         |       |   |     |   |       |
|     assessments.                    |       |   |     |   |       |
+-------------------------------------+-------+---+-----+---+-------+
| 4.  It is much more common in a     | 1     | 2 | 3   | 4 | 5     |
|     couple for both partners to be  |       |   |     |   |       |
|     negative than for the couple to |       |   |     |   |       |
|     have different test results,    |       |   |     |   |       |
|     one positive and one negative.  |       |   |     |   |       |
+-------------------------------------+-------+---+-----+---+-------+
| 5.  Window period explains why      | 1     | 2 | 3   | 4 | 5     |
|     couples have different HIV test |       |   |     |   |       |
|     results.                        |       |   |     |   |       |
+-------------------------------------+-------+---+-----+---+-------+
| 6.  After couple counseling,        | 1     | 2 | 3   | 4 | 5     |
|     couples frequently reduce their |       |   |     |   |       |
|     risk behavior.                  |       |   |     |   |       |
+-------------------------------------+-------+---+-----+---+-------+
| 7.  Women who are infected with HIV | 1     | 2 | 3   | 4 | 5     |
|     during pregnancy or while       |       |   |     |   |       |
|     breastfeeding are more likely   |       |   |     |   |       |
|     to transmit HIV to their        |       |   |     |   |       |
|     infant.                         |       |   |     |   |       |
+-------------------------------------+-------+---+-----+---+-------+
| 8.  A person taking ARVs cannot     | 1     | 2 | 3   | 4 | 5     |
|     transmit the HIV virus to       |       |   |     |   |       |
|     others.                         |       |   |     |   |       |
+-------------------------------------+-------+---+-----+---+-------+
| 9.  Divorce or abandonment occurs   | 1     | 2 | 3   | 4 | 5     |
|     frequently after married        |       |   |     |   |       |
|     couples receive different test  |       |   |     |   |       |
|     results.                        |       |   |     |   |       |
+-------------------------------------+-------+---+-----+---+-------+
| 10. How would you explain to a      |       |   |     |   |       |
|     disbelieving couple how it is   |       |   |     |   |       |
|     possible for them to have\      |       |   |     |   |       |
|     different HIV test results, one |       |   |     |   |       |
|     is positive and one is negative |       |   |     |   |       |
|     (write response below):         |       |   |     |   |       |
+-------------------------------------+-------+---+-----+---+-------+
|                                     |       |   |     |   |       |
+-------------------------------------+-------+---+-----+---+-------+
|                                     |       |   |     |   |       |
+-------------------------------------+-------+---+-----+---+-------+
|                                     |       |   |     |   |       |
+-------------------------------------+-------+---+-----+---+-------+

**Handout 8-1**

**Overheads**

**Module Eight: Outreach and Recruitment**

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