Download ART Communication Strategy

ART Communication Strategy and Work Plan
“SMART Patient and SMART Provider” Approach”
FY 07 – FY09
National AIDS Resource Center (NARC)
Ethiopia
Anthoula Assimacopoulou
Antje Becker-Benton
July 2008
1
Table of Contents
INTRODUCTION.................................................................................................................... 3
1. BACKGROUND .............................................................................................................. 3
2. APPLICABLE FRAMEWORKS AND MODELS ..................................................... 11
3. COMMUNICATION STRATEGY .............................................................................. 17
4. MANAGEMENT AND IMPLEMENTATION PLAN............................................... 24
5. MONITORING AND EVALUATION PLAN ............................................................ 25
2
INTRODUCTION
This document is serving as the National AIDS Resource Center’s (NARC) ART
communication strategy and workplan for the fiscal years (FY) 2007 – 2009. It is based on
the Ethiopia National Antiretroviral Therapy (ART) Strategic Communication Framework1
from 2004 but updated in both the analysis as well as its relationship to the current situation.
The strategic direction of this document has been strongly influenced by three technical
consultants: In 2006, Sarah Gibson helped NARC to elaborate on the Ethiopia ART
Communication Strategy. In March, 2008, Dr. Young Mi Kim helped update the document
to incorporate the “SMART Client & SMART Provider” approach and later incorporated a
monitoring and evaluation plan. In June 2008 the ARC ART team pulled together the pieces,
updated and finalized the strategy and developed detailed activities for FY 08 and FY 09.
This document is integrating and summarizing all approaches into one workplan.
Part 1 contains a summary of formative research and basic frameworks used to develop
NARC’s communication strategies and action plans.
Part 2 elaborates on the communication strategy and how its specific intervention activities
for FY 07, FY 08 and FY 09 are interrelated, using the “SMART Client & SMART Provider”
approach.
Part 3 outlines the Management and Implementation Plan.
Part 4 shows the proposed monitoring and evaluation plan for FY 08 – FY 09.
1. BACKGROUND
1.1. Dynamics of the HIV/AIDS Epidemic in Ethiopia
The Beginning: HIV was first detected in Ethiopia in stored sera in 1984 and the first AIDS
cases were diagnosed in Addis Ababa, in 19862. Two years later, high rates of HIV
prevalence were found among long-distance truck drivers (13%) and commercial sex workers
(17 %) living along the country’s main trading roads3. In 1987 the MOH reacted with a
national HIV/AIDS task force, while surveillance activities started in 1989. Since then the
epidemic has expanded rapidly throughout the country.
1
This framework was developed in November 2004 with various stakeholders, facilitated by the HIV/AIDS
Prevention and Control Office (HAPCO) and the Ministry of Health (MOH) with technical assistance by NARC
and the Johns Hopkins Center for Communication Programs (CCP). NARC has been leading the efforts of ART
communication since then. See Ethiopia National ART Strategic Communication Framework, March 2005,
AIDS Resource Centre, JHUCCP
2
Lester FT, Ayehune S, Zewdie D. (1988): Acquired Immunodeficiency: Seven Cases in Addis Ababa Hospital.
Ethiop Med J 1988, 26:139-145.
3
Mehret M, Khodakevich L, Zewdie D. (1990): HIV Infection and Related Risk Factors Among Female Sex
Workers in the Urban Areas of Ethiopia. Ethiop J Health Dev.1990, 4 (2):163-170.
3
Generalized epidemic with marked regional differences: At this point, Ethiopia is
experiencing a low-level generalized HIV epidemic with an estimated adult HIV prevalence
rate of 2.2%. Urban and rural areas show mean prevalence rates of 7.7 % and 1%
respectively% (FMOH 2008). Although the overall rate is not as high as in other countries
with generalized epidemics, given the size of Ethiopia’s population of 78 Million, this
translates into the third largest number of people living with HIV/AIDS, next to South Africa
and India. An additional challenge is formed by the fact that 84% of these 78 Million are
living in rural areas.
People Living with HIV/AIDS and gender patterns: Over 1 million Ethiopians are
currently living with HIV/AIDS. The female prevalence is 2.6% compared to only 1.7%
among males, which means there are 1.5 infected women on one infected male. Infections
seem to occur among women at a younger age, namely in their early 30s, than among men
who are infected in their mid to late 30ies. Women and men age 35 – 49 were three times
more likely to be HIV-infected compared with women and men age 15 – 24.4 In 2006,
88,997 people died of AIDS while AIDS deaths for 2007 were estimated at 71,902.
Urban/rural and socio economic differences: Urban residents were associated with much
higher HIV infection rates whereas geographic regions and ethnicity showed large
differentials. In addition, higher education and higher household wealth – usually found in
urban areas - were also positively associated with HIV infection. Currently the majority of
PLHA lives in urban areas with an estimated 602,740, while 374,654 PLHA reside in rural
area. Meanwhile the prevalence has leveled off in urban settings and continues to rise in rural
areas. The current PEPFAR funded HIV prevention strategies solved these slightly
contradicting data trends by continuing to focus more on urban than rural areas with attention
to transport corridors, trade hubs and other areas frequented by rural dwellers. 5
PMTCT: In 2008, 79,183 pregnant women are estimated to live with HIV while 14,083 HIV
positive children are expected to be born (FMOH, 2007).6 PMTCT uptake is fairly low in
comparison with other African settings due to low ANC rates (28%) , low institutional
delivery rates (6%), a mostly rural population with little service access; delay in opt-out
testing policies, poor tracking and follow-up with mothers and low PMTCT resources during
ART scale-up phase in Ethiopia.7
Pediatric ART and orphans and vulnerable children: About 135,000 children are
estimated to live with HIV; 43,000 are in immediate need of ART and 21,000 die due to HIV
annually (2007). The estimates for orphans in 2008 are at almost 5.5 million, 16% (or
898,350) of which will be due to AIDS.
Behavioral prevention issues and literacy levels: The Ethiopian BSS II showed that the
target population’s knowledge of HIV/AIDS is reasonably high, however comprehensive
4
Hong, R., V. Mishra, P. Godvindasamy (2008): Factors Associated with Prevalent HIV infections among
Ethiopian Adults: Further Analysis of the 2005 Ethiopia Demographic and Health Survey. Calverton,
Maryland., USA: Macro International
5
PEPFAR Ethiopia FY 2008 Country Operational Plan, page 5.
6
Pediatric HIV/AIDS Overview (2008). Courtesy of: International Center for AIDS Care and Treatment
Programs. Columbia University. Mailman School of Public Health. Presenter: Dr Solomie Jebessa. Pediatrician
at ALERT ART Clinic
7
Meg Doherty et al: Outreach ANC and PMTCT as a Model to Increase Coverage in Ethiopia, Abstract 1794
PEPFAR Implementer’s Meeting 2008, Kampala, Uganda
4
knowledge is low, and so is self risk perception. Only 15.8% women and 28.7% men aged
15-49 years have comprehensive knowledge8. The knowledge score of women was generally
lower than men across all regions of the country, and the variation of knowledge between
urban and rural women—42.4% and 10%, was large. Misconceptions seem to exist with
regard to how HIV is NOT transmitted, about ART side effects and false cures. This may
have to do with the fact that about 66% of the adult population (15-49 years age) is illiterate9
and most educational materials seem to use a fairly high literacy level. There is a substantial
level of unprotected sex among adults, while premarital sex is quite common. This puts
specifically young and unmarried women at risk as well as HIV negative partners in
discordant couples.
Stigma: The 2005 BSS found that the level of AIDS-related stigma was considerably lower
than that reported in the 2002 survey. Nevertheless, other recent studies (including ARC’s
formative research) still indicated that stigma and discrimination are considered to form the
main reason for non-disclosure of one’s status and non-adherence to ART and to be all
pervasive particularly among rural communities.
HIV/AIDS-related stigma and discrimination is a “process of devaluation” of people either living
with or associated with HIV and AIDS, according to UNAIDS (www.unaids.org). This stigma often
stems from the pre-existing stigmatization of sex and intravenous drug use—two of the primary routes
of HIV infection. Discrimination follows stigma and is the unfair and unjust treatment of an
individual based on his or her real or perceived HIV status. Discrimination occurs when a distinction
is made about a person that results in him or her being treated unfairly and unjustly on the basis of
belonging, or being perceived to belong, to a particular group (UNAIDS 2003).
Frequent exposure to AIDS specific mass media and other information sources have shown to
reduce levels of stigma. A study from 2004 found that respondents who received AIDS
information through "TV" and "friends/relatives" were more likely to have fewer stigmatizing
beliefs than those who received such information in other mediums.10 The 2008 formative
research study countered this with the remark that mass media and other efforts have only
succeeded in putting pressures on people not to show their prejudices as openly. According to
them, stigma and discrimination is continuously perpetuated by family members, neighbors
and work mates. Stigma at facility level, e.g., isolating the services into one corner of the
building tends to form strong barriers for utilization.
The “Comprehensive Knowledge” indicator is constructed from responses to the following set of prompted
questions: 1) Can the risk of HIV transmission be reduced by having sex with only one faithful, uninfected
partner? 2) Can the risk of HIV transmission be reduced by using condoms? 3) Can a healthy-looking person
have HIV? 4) Can a person get HIV from mosquito bites? 5) Can a person get HIV by sharing a meal with
someone who is infected? (DHS, Measure Survey Database www.measuredhs.com/hivedata )
8
9
Only 36% of the population is literate (46% for males and 25% for females). Ethiopia Federal Ministry of
Health. Health Sector Strategic Plan 2005/6 – 2009/10.
10
Lucas R, Mulatu MS (2004): AIDS-related stigma in Ethiopia: The roles of socio-economic conditions, health
knowledge, and sources of AIDS information. International Conference on AIDS (15th : 2004 : Bangkok,
Thailand). Int Conf AIDS. 2004 Jul 11-16; 15: abstract no. WePeD6454.
5
Anecdotal information indicates that clients on ART often leave their workplaces due to selfstigma, while many workplace policies are not enforced. There are hardly any positive role
models in the public, with the result that families and parents do not allow PLHA to model
for posters and other mass media activities.
Newest trends: A most recent study11 synthesizing previously disconnected national data
uncovered a number of major findings:
 The epidemic seems less severe, less generalized and more heterogeneous than
previously believed, with marked regional variations;
 The diversity of the HIV epidemic seems to be related to sexual behavior patterns and
factors such as the presence or absence of male circumcision (e.g., Gambela region
unexpectedly exhibited the highest prevalence of any area);
 Small towns and market centers may be HIV hot-spots that have had marginal
attention in HIV prevention and care efforts to date;
 Traditional at-risk groups such as sex workers seem to be reducing some of their risky
behaviors; while overall sex work is on the rise.
 Young populations, especially never-married sexually active females have the greatest
risk of HIV infection in the country;
 Discordant couples are also of great concern, puzzling ART clients. This points to a
clear need for couple counseling services which are presently non-existent or
rudimentary. ARC formative research concluded that the situation for the female
partner often ends in divorce and sexual violence (if she is not yet positive).
 The lack of recent data and research, especially on at-risk groups, makes further
conclusions difficult, and highlights the clear need for more research.
Ethiopia’s national response to the epidemic has shown progress especially in the area of
treatment roll out. The government with support of US-Government (USG) is following a
regionalized ART strategy in all regions providing ART to hospitals and health centres in the
private and public sectors.
1.1.1. ART Service Delivery and Uptake
There are currently 138 hospitals and 635 health centers operational to cater to the entire
population.12 Currently, one provider takes care of approximately 40,000 people. In
comparison, WHO recommends a ratio of 1 physician for 10,000 clients and 1 nurse for 5000
clients.13
Launched in 2003, as of March 200814 there are 100,503 patients on ARVs of which 5,096
are children. They are cared for in only 337 treatment sites (93 public hospitals, 14 private
hospitals, 12 military hospitals, 215 health centers and 3 NGO clinics) in all of the country’s
9 regional states.15
Facility assessments show that health professionals are overstretched, overworked, under
compensated and this overstretched capability has serious consequences on quality care
11
HAPCO, GAMET, Worldbank (2008): HIV/AIDS in Ethiopia. An Epidemiological Synthesis.
MOH cited in PEPF Ethiopia FY 2008 Country Operational Report.
13
Add
14
Monthly HIV Care and ART update, MOH- FHAPCO, April 10 (2008)
15
See ARC/CCP (March 2005): Ethiopia National ART Strategic Communication Framework.
12
6
provision. Providers are further challenged16 with complicated and changing treatment policy
(single dose, first line and second line and fixed dose combination treatment availability) and
a lack of up to date reference materials and training in ART, VCT, pediatric HIV and
nutrition among practitioners on the lower end of the clinical hierarchy. In general, even
though this has not yet been part of systematic research, paternalistic models of health care,
such as social distance between patients and providers and other cultural norms seem to
discourage patients from playing an active role in health consultations (weak provider/client
relationship).
Formative research among ART clients17 found that they consider health services to be
improving in general, but still would require a strong increase in the number of providers and
improvement of available space. Although the quality of HIV related services is reported to
be much better than that of the general health services, shortages of staff, of space and of
non-ART drugs cause tremendous discomfort. Clients may not be using services due to these
shortages. Clients also do not trust providers fully to keep confidentiality and feel procedures
on how to keep test results confidential are not well enough explained to them.
Potentially related to that, 289,000 people with HIV/AIDS are still in need of ART, while
about 17,000 are lost to follow up.18
DHS and BSS (2006) reports showed some lack of knowledge among a variety of population
groups, including providers, about where, how and when PMTCT and ART programs are
carried out; but exposure to mass media messages seemed to have reached most of its target
audiences with information about the general availability of free ART and PMTCT services.
1.1.1.1. Adherence Challenges
Adherence is defined as the extent to which patient’s behaviors coincides with the prescribed
health care regimen as agreed upon through a shared decision-making process between
patients and the health care provider. This includes taking them at the right time and in the
right amount. (WHO)
While ART requires a 95% adherence rate, patients rarely achieve more than 80% adherence
rate during treatment of chronic illnesses. Nevertheless, a study done in Ethiopia found that
self reported adherence among the study population was high with 96.6%19. Travel time to
treatment sites averaged an hour, while travel cost was between 44 US cents and 2.1 US$
which is considerable. Medicine labeling tended to be a problem as patients threw away the
ART packaging to avoid stigma.
Adherence studies in Ethiopia found as facility based factors affecting patient adherence:
16
The obstacles collected here are a summary of the formative research results in PART 1 and a questionnaire
which was pretested at two Addis Ababa hospitals, Zewditu Hospital and St. Paulo’s Hospital, with both ART
service providers and clients and as such the information gathered through this exercise can be used to inform
ART communication development.
17
Addis Continental Institute of Public Health (May 2008): ART Communication Qualitative Study in Four
Regions of Ethiopia.
18
HAPCO presentation at ART Adherence Baseline Assessment Dissemination and Way Forward National
Workshop, June 19, 2008, Addis Ababa.
19
For this and all following adherence data in Ethiopia: DACA, MSH, INRUD Ethiopia (2008): Determinants
of adherence to antiretroviral treatment. An explorative study at health facilities in Ethiopia
7




High staff turn over, heavy work load and long waiting times;
Shortages of OI drugs, insufficient space and inadequate laboratory services
Poor record keeping/documentation and inability to track patients
Inadequate counseling
Sit-in observations showed that the average consultation time for new patients was 15 – 30
and for re-visits under 10 minutes; Secondary prevention information was generally not given
to re-visiting patients and information on importance about adherence was low for all
facilities.
Key patient/community related retention challenges to ART as identified by the study were:
 Hindrances due to faith/religious beliefs. This was confirmed by ARC’s formative
research study among ART clients and providers: ART is widely recognized as
effective therapy for AIDS. Nevertheless, alternative therapies are praised as a cure,
particularly “holy water” was mentioned in almost all places. “Together with stigma
and discrimination, the promotion of false cures for AIDS forms a major barrier to
adherence to treatment.” 20 Even though the Patriarch of the Ethiopian Orthodox
church has publicly declared that ART and “holy water” are compatible treatments
(and not cures), lower level clergy seem to continue to spread misconceptions.
 Lack of food to accompany the intake of drugs. This relates to the serious food
insecurity in Ethiopia, aggravated by the risen food prices and galloping inflation,
which has recently hit international press coverage21.
 Absence of good community support or social support services.
The table below gives a summary of interviews with patients, peer counselors and medical
staff:
Factors Affecting Adherence in Ethiopia
Service delivery
Distance of service
Community
Disinformation
Cost for transport
Long waiting time
Stigma and discrimination
Religious beliefs
Poor/lack of laboratory services
Lack of support from family and
community
Ideas and understanding of
health, illness and treatment
Lack of and/or cost for OI drugs
Individual
Economic
 Poverty, food, shelter
 OI drug cost
 Transport
 Time
ADRs22 and OIs
Denial of status and lack of
disclosure
Forgetfulness
Stressful and unsafe way of life
20
Although side-effects were reported in ARC formative research, they were not considered as a serious
problem. See: Addis Continental Institute of Public Health (May 2008): ART Communication Qualitative Study
in Four Regions of Ethiopia.
21
Ethiopia: Rising food prices hit HIV-positive people. Addis Ababa, 23 June 2008 (IRIN Plus News) “Poor
nutrition weakens the body’s defenses against the virus, hastens the development of HIV into AIDS, and makes
it difficult to take ARVs (… )As food prices continue to soar, Ethiopians with HIV are especially had hit; they
may be weak and unable to work, they often have less savings, and they may have been shunned by the
community.”
22
ADR: Adverse Drug Reactions
8
Service delivery
Heavy patient load/few staff
Community
Support – family, friends, fellow
patients, support groups, work,
community
Lack of counseling
Individual
Lack of knowledge on illness and
ART
Loss of hope
Apart from various facility based recommendations for improvement (reduce transport cost
and waiting times, increase drug supply, improve adherence counseling, laboratory services)
the study suggested not to overlook the issues of poverty and access; it was further
recommended to focus on reduction of stigma and denial, on strengthening of community
linkages and of self-esteem and empowerment of clients as well as motivation of clinical
staff.
1.1.1.2. Pediatric and Early Teen ART23
The first HIV exposed newborn was identified in 1986. Prior to 2002 pediatric HIV care was
limited to provision of Cotrimoxazole preventive therapy and other supportive care. Free
ARVs were made available between 2002- 2003. In few private institutions and government
hospitals selected pediatric AIDS cases were treated with crushed adult tablets. In 2005
pediatric ARV formulations were available for free.
Although there has been a dramatic increase in number of children who are on ART since
2005, it is estimated that 43,000 children in Ethiopia are still in need of ART (2007). Only
7.2 of the eligible children for ART are actually receiving treatment and care. The reasons for
this according to available sources include
 Technical barriers
 Diagnostic challenges
 Relative failure to implement effective PMTCT
 Infrastructure & system capacity limitations
 Human resource requirements
 Developmental challenges in pediatrics
 Children are not small adults
 Complexity of ART administration
Further literature research is urgently needed here to find out if caretakers may form barriers
to testing and ART uptake for the positive children in their care because they may be in
denial of being positive themselves.
We secondly, need to know how many HIV positive adolescents there are on and eligible for
ART, and how many of those do know about their status.
Below are the results from formative research in Uganda, which strongly show caretakers of
children in need of more information and support in order to increase uptake; it also suggests
to make early teens an audience in their own right to address their specific problem
combination directly.
23
Pediatric HIV/AIDS Overview (2008). Courtesy of: International Center for AIDS Care and Treatment
Programs. Columbia University. Mailman School of Public Health. Presenter: Dr Solomie Jebessa. Pediatrician
at ALERT ART Clinic.
9
(Note: Until we are able to do a desk review and some more formative research in Ethiopia,
the pediatric strategy part needs to be considered as draft. A separate brief strategy
addendum will hash out the details.)
Pediatric adherence in Uganda
Barriers to adherence for caretakers of children (age 0 – 9) include: drug fatigue; feeling it
is too difficult/not worth it/don’t care; stress of timing drugs all the time; being too busy; not
involving others – alternative caretakers and health workers; and, concerns about disclosure
and stigma.
For adolescents on ART (age 10 – 15) , these issues are compounded by wanting to fit in
and “be normal”, not wanting others to see them take their drugs (especially in boarding
schools), and forgetting them if/when they travel from one location to another. Factors that
have been shown to increase adherence include disclosing to the child or adolescent and
including them in maintaining the drug regimen; seeing the results of what happens when one
stops taking the drugs (falling sick); a good relationship between the caretaker and the child;
and, social support from other caretakers/family members, the health worker, and/or
treatment supporters.
1.2. Provider and Client IEC Needs /Formative Research
2007 ARC Provider Needs Assessment. In 2007, ARC conducted a facility based needs
assessment in Antiretroviral Therapy in sampled hospitals and health centers located in six
regional states24. Self-administered questionnaires were used to gather the required
information both at facility and service provider levels.
 Results showed that a considerable proportion of health facilities do not have access
to up-to-date information on HIV/AIDS care and treatment. Only materials like hard
copy textbooks and journals were named as common sources; while internet database
and in country consultations with colleagues via e-mail/telephone was only mentioned
by a few interviewees.
 Similarly, the majority of the health workers do not have access to up-to-date
HIV/AIDS care and treatment related information in their workplace.
 Moreover, almost half the interviewed health professionals working in health centers
and hospitals do not have access to communication facilities like e-mails and
telephone services at their workplace. Nearly half of those with access only have a
telephone.
 The great majority of the respondents expressed their desire to contact a toll free callin center to receive advice from HIV experts on up-to-date HIV treatment and care for
patient management.
24
I.e. Amhara, Benshangul Gumuz, Gambella, Oromiya, SNNPR, Tigray and the Dire Dawa Administrative
Council.
10
2007 Client and Provider Focus Group Discussion.25In 2007, ARC conducted a series of
FGDs with ART patients and providers. The main results showed that
 Available education and communication materials tend to be in very short supply and
do not really fulfill the needs of the clients and service providers. Significant
improvements need to be made on the scope, quality and quantity of materials.
Regular supply needs to be ensured.
 Both clients and providers prefer communication materials with attractive illustrations
and if possible real photos showing changes in body appearances. People with higher
level education prefer information compiled in booklet format, while providers
reported that some clients do not want to take education materials home due to
stigma. Providers emphasized the need to have videos shown in HIV service areas.
 Most urban areas accept communication materials prepared in Amharic; however
most people expressed concerns about the usability of these materials for rural
population. Print communication materials can only be useful in rural areas if
prepared in simple local languages. Although true low literacy materials would be
most preferred, almost all families have someone at home or in the immediate
neighborhood who can assist in reading the materials.
1.2.1. Problem Statement
In summary, one of the biggest challenges to ART roll out, service uptake and adherence in
Ethiopia seems to lie in the current structure of the service delivery sector: a serious shortage
of medical staff, lack of trained facilities in proximity to clients, drug stock outs, and missing
servicing of testing equipment. This creates all kinds of communication problems among
clients and providers. Additionally, it is difficult to create demand for more service uptake as
long as service availability cannot be guaranteed.
Provider information updates, so critical in ART service delivery, are a big challenge, as is
the adequate provision of IEC materials for clients to manage their status and their chronic
disease. Confidentiality and other issues affected by stigma continue to form behavioral
barriers to disclosure and service utilization. Other major factors include hindrances due to
faith/religious beliefs in e.g,’holy water’, and the lack of food security as well as other
poverty-related issues.
Dovetailing with the PEPFAR 2008 Operational Plan that promises strengthening of the
health service delivery and adherence, communication’s role in this scenario should be to
a) Continue provider support and client education, with a focus on self management and
monitoring of HIV/AIDS as a chronic disease;
b) Motivate the community level to provide more support for PLHA in the areas of
nutrition, stigma and religious barriers to treatment.
c) Create demand for quality service provision from the client side as well as from the
community as a whole.
2. APPLICABLE FRAMEWORKS AND MODELS
25
Addis Continental Institute of Public Health (May 2008): ART Communication Qualitative Study in Four
Regions of Ethiopia.
11
2.1. Summary of the National ART Communication Framework
Following a partners’ workshop in Addis Ababa in November 2004, the Ethiopia National
ART Strategic Communication Framework was developed in partnership with more than 40
governmental and non-governmental organizations (NGO), service providers (including
physicians, nurses, pharmacists, and counselors), PLHA associations and representatives of
implementing partners.
The strategy development relied on a conceptual communication model used worldwide and
applied it to the Ethiopian situation. This “Communication Pathways Model for ART”
(below) envisages three domains for communication interventions, namely: 1) the
Social/Political Environment domain; 2) the Service Delivery domain; and 3) the
Community/Individual domain. With reference to these domains, the National Strategy
developed recommendations for all three areas of influence.
This document intends to expand on these recommendations but develops an implementation
plan only for the community/individual and service delivery domain, while communication
needs within the Social/Political Environment area are considered the responsibility of other
stakeholders.
Conceptual Framework:
Ethiopia - Communication Pathways for ART
Underlyi
ng
Conditio
ns
Context
High Disease Burden
Highly Religious
Gender Inequities
Significant Poverty/
High Level of
Unemployment
Low Tech
Fragile Health Service
infrastructure
Domains for
Communication
Interventions
CommunicationSocial Political
Environment
Communication
for Service
Delivery
System
Resources
Widespread
Network of
Partners
Religious Groups
Engaged in
Health and
Development
Communication
for Community/
Individual
Initial Communication
Interventions
•Treatment policy
Behavioral Outcomes
Sustainable
Health
Outcomes
•Equitable Access
•Nat’l communication strategy for ART•Increased commitment
•Active engagement of civil society •Coordinated
•Monitoring and evaluation systems communication support
ART Goal by
•Scaling up of services
•Networks for collaboration/coordination
mid 2008
•Availability of ART
•Increased
adherence
Sustainable
services
•Information to client
•Client satisfaction
•Counseling skills
-Reduced
•Increased demand for
transmission of
services
•Service referral linkages
HIV
•Increased quality of services
•Quality assurance system
(beyond
•Increased access
-210,000 people
•Support
••PLWAs/Hospice
hospital)groups
receiving ART
Effective mgmt of side
••Social
norms
•Stigma reduction
Team approach
effects
•Community
•Psychosocial
-Better quality
action
support
•Knowledge of
ART
•Perceived social support/stigma
PLWHAs
•ofLeadership
mobilized
•Knowledge of ART
•Reduced misconception around
•Treatment
support
•Treatment
•adherence
Improved
adherence
•Condom use
•Increase in VCT
•ART uptake
•HIV prevention
ART
•Motivation of HIV+ people
of life for
PLHAs
A number of issues that are pertinent to the development of communication interventions
within the Service Delivery System domain and the Community/Individual domain are
presented in the Framework document from 2004 and are listed below to aid and guide the
development of the ARC ART Communication Strategy and Implementation Plan.
12
2.1.1. Service Delivery Domain
The communication interventions for service delivery domain which are recommended in the
Framework are to:
- Inform the public about availability of ART service (now mainly for rural areas)
- Enhance quality of ART technical and healthy living information to patients/ clients
(SMART provider)
- Enhance interpersonal/counseling (IPC/C) skills of service providers (SMART
provider)
- Strengthen referral linkage among services (Warmline)
- Reinforce quality assurance system (beyond hospital) and
- Improve service team approach to solve problems and help each other
2.1.2. Community Domain
Workshop discussion identified communities as a priority for communication interventions.
They are best reached by Health Extension Workers of MOH; faith-based organizations
providing care and support, PLHA groups and treatment supporters providing supportive
networks for patients, and community links to health facilities to enhance service delivery
efforts.
2.1.3. Individual Domain
For the communication recommendations, Framework workshop participants decided to
focus on People Living with HIV/AIDS (PLHA). They segmented this audience in people
who
 Are already taking ART and
 People who are eligible for ART.
2.2. The Continuum of Care Model
In order to explain the content of the ART service and how it is related to other HIV/AIDS
services in Ethiopia, the Continuum of Care Model26 has been adopted, as shown below.
26
The Continuum of Care Model is based on the Model contained in the MoH Guideline for
Implementation of ART in Ethiopia. See Guideline for Implementation of Antiretroviral Therapy in
Ethiopia, January 2005, Ministry of Health.
13
Continuum of Care Model
Awareness Raising
- HIV/AIDS
- ART
VCT
} VCT Communications
Diagnosis
PMTCT Comms {
HIV + Preg. Women
PLHA not required
to be on ART
HIV +
HIV -
1° Medical Referral Visit
- HIV not terminal
- Disclosure
- Role of ART
- Adherence
- WHO Staging
- Positive Living (nutrition/safer
sex/exercise/OI/ alcohol/ drugs)
- Social Support
OI Prophylaxis &
OI Treatment
- OI Symptoms & Identification
- OI Prophylaxis
- OI Treatment
- OI Treatment Side Effects
- Weight Monitoring
- WHO Staging Changes
- Positive Living
PLHA on ART
12 Week ART
Assessment Period
- Side Effects
- Adherence
- OI Symptoms & Treatment
- Weight Monitoring
- WHO Staging Changes
- Positive Living
- Future Treatment Access Issues
3 Month Follow Up Visits
- Adherence Issues
- Positive Living
- Issues/challenges faced
- OI symptoms
- WHO Staging Changes
The Model graphically represents the different stages of care that a person living with
HIV/AIDS may progress through in managing their disease and accessing ART services. The
identified stages are;
1. ‘Awareness Raising’
2. ‘VCT’
3. ‘Diagnosis’
4. ‘Initial Medical Referral’
5. ‘OI Prophylaxis & OI Treatment’ (HIV+ individuals not required to be on ART)
6. ‘12 Week ART Assessment’
7. ‘3 Monthly Follow Up’ (the latter two stages for PLHAs on ART.)
Depending on the stage of care and the target audience, the communication needs will vary,
but need to be accentuated with more of a patient perspective and associated needs like in the
following figure. Here audiences are segmented according to stages of treatment.
14
Essential Communication Steps to Increase Effectiveness
2.3. The “SMART Patient & SMART Community” Approach
Client-provider interactions typically occur in the privacy of an examination or consultation
room, but how both of them relate to each other is strongly influenced by social conventions
and expectations, prior knowledge and experience, and communication skills (Kim, Eva,
Storey, 2007).
Due to various circumstances however, in health care consultations, patients often receive
information from providers that is insufficient or not addressing their needs. In turn clients
tend to communicate little with providers about their needs or concerns. Nevertheless, the
characteristics and quality of the client-provider interaction are strong predictors of client
satisfaction, understanding, recall of and compliance with the treatment plan. Studies in both
developing and developed countries have shown common problems with the communication
patterns between clients and providers. These patterns have strong effects on how patients
managed their health conditions.
The SMART Patient& SMART Community (SP&SC) Approach was originally developed by
JHU/CCP researcher Young Mi Kim and team for the area of family planning. At its core it
has the tested assumption that an improvement in the relationship between clients and
providers can lead to improved health outcomes. This is also confirmed by the HIV/AIDS
treatment literature, which considers the client-provider relationship as key indicator for
adherence to treatment.27
27
Bear, M., J. Roberts (2002): Complex HIV treatment regimens and patient quality of life. In: Cananda
Psychology, May 2002
15
Through interviews, Kim and team found that in family planning, providers could clearly
improve on issues such as, developing rapport w/ clients; building partnerships; expressing
emotional support; acknowledging client skills; gathering information on their lifestyle &
medical history; tailoring information to their clients and improving on communicating
technical content. They also found that clients could improve on asking questions (e.g.
address rumors); clarifying points/issues; participating in personal or social exchanges;
stating opinions; expressing concerns and providing essential information to the provider.
Results showed that clients who come prepared to be active seekers of information and
quality services are more likely to get them, but this competency and motivation must be
formed before the client enters the clinic.
A Cochrane’ review published in 2007 analyzed 33 randomized controlled trials which used
written materials such as question prompt sheets, audio/video material and/or patient
coaching as interventions to improve patent assertiveness. Most of these interventions were
delivered in the waiting room immediately before the consultation, and some of the
interventions delivered materials to patient’s home before their appointments. The findings
show that such interventions helped patients ask more questions in consultations; they
seemed to significantly increased patient satisfaction and, to a smaller extent, reduce patient
anxiety. 28
Interventions aimed at improving communication in health care have targeted providers and
clients, including the environment in which providers work and in which patients live, but
rarely has this been done in an integrated fashion. A well evaluated intervention in Indonesia
indicated that individual coaching can give family planning patients the confidence and
communication skills to talk more openly and vigorously to providers; a combined
community education and mass media approach showed improvements in client
communication with providers and in the quality of family planning counseling.29
This is how the different strategies were used:
 Client coaching: coaching clients on asking questions, expressing concerns, and
seeking clarification
 Mass media: drawing public attention to the value of effective client-provider
interaction.
 Group education at the community level to create new norms and expectations about
service utilization among women.
Together, these approaches encouraged and reinforced effective use of services and create
public pressure on service delivery systems to meet growing demand for quality.
Three critical elements were needed for this success: 1) Informing clients of their right to
speak; 2) Coaching clients on basic communication skills; 3) Ensuring warm response by
providers to client participation.
28
Kinnersley P, et al 2007): Interventions before consultations for helping patients address their information
needs. Cochrane Database of Systematic Reviews 2007, Issue 3..pub2.
Kim Y.; E. Bazent, D. Storey (2007): SMART Patient, SMART Community. In: Int’l Quarterly of
Community Health Education, Vol. 26(3) 247 – 270.
29
16
Even though family planning does not usually take place under the same conditions as ART
consultations, there are ample similarities which allow tailoring a similar strategy for ART
clients and providers in Ethiopia.
The next chapter will outline the communication strategy based on the health analysis, and
review of frameworks above. The strategy will follow the Continuum of Care Model/Life
Stages Approach and apply the SMART Client – SMART Provider Approach.
3. COMMUNICATION STRATEGY
3.1. Intended Audiences
The ARC ART Communication Strategy will focus on three primary, three secondary, and
one tertiary audience.
Audiences
Primary audience:
Individual domain
Men and women of
reproductive age 30 –
5030 who are already
taking ART in urban
and rural areas
Secondary
audience: Service
Delivery Domain
Treatment providers
(physicians, nurses,
counselors, pharmacists
including pediatric
providers) in urban and
rural areas
Secondary
audience:
Community
Domain
Religious leaders
in urban and rural areas
Men and women of
reproductive age 30
– 50 who are
eligible for ART in
urban and rural
areas
Early adolescents
age 10 – 1531 who
are already taking
ART in urban and
rural areas
Treatment
supporters (PLHA
Associations and
family or friends) in
urban and rural
areas
Care takers of
children age 0 -9
and adolescents age
10 – 15 eligible for
ART in urban and
rural areas
3.1. Communication Goal and Objectives, Channels and Message Briefs
by Audiences
Goal
Demand is consolidated and enhanced for quality ART services (including pediatric) and
service uptake is increased.
Women and men age 35 – 49 were three times more likely to be HIV-infected compared with women and
men age 15 – 24
31
Children 0 – 9 will hardly be reached directly but rather through their care takers
30
17
Primary Audience
Men and women of reproductive age on ART
Desired Behaviors

Reasons why they are
currently not doing
this:
Key Constraint to
adopt behavior:
Communication
Objective:
Benefit: 32
Support Points33
Communication
Channels and
Approaches
Know how to manage their ART treatment (adherence, side effect
management, regular doctors visit, positive living including positive
prevention and disclosure to sexual partners, friends and family)
 Feel confident and come prepared to ask providers for services and
information they need
 Practice positive living and adherence to their ARVs and treatment
for opportunistic infections because it will improve their health
Lack of relevant and trusted information, stigma to be openly HIV
positive, poverty-related hurdles such as food insecurity, and facilitybased issues, including service providers not having enough time for
intense counseling and not being used to assertive clients; lack of social
support services.
Services overloaded and not being used to assertive clients (especially
women)
By the end of the project there will be an increase in the proportion of
men and women of reproductive age on ART who manage their life and
their ART actively – become a SMART client
If you become a SMART client you will be more in control of your life
with ART and AIDS.
Because everyone has the right to ask questions
Because you are in charge of your health and well-being.
Because SMARTer Clients get better treatment
 Targeted print support materials (positive living, adherence, self
monitoring/ SMART Client) distributed in provider settings and
through PLHA network for clients already on ART
 Video modeling SMART Client and Provider interaction for waiting
rooms
 Hotline answers encouraging SMART Client behaviors
 Betegna radio diaries modeling SMART Client
 Radio spots demonstrating effective client provider interaction
 Community outreach (roadshows)
Primary Audience
Men and women eligible for ART
Desired behaviors


Reasons why they are
currently not doing
this:
Key Constraint to
Know about ART provision (when, where and how to access it)
Feel confident and come prepared to ask providers for services and
information they need
Post-test counseling not sufficient and people come too late for treatment
and harbor misconceptions about ART.
Insufficient post-test counseling
32
The Benefit or Key Promise selects one single, subjective promise/benefit that the audience will experience
upon hearing, seeing, or reading the objectives you’ve set
33
The Support Points or Statement should include the reasons the key promise/benefit outweighs the obstacles
and the reasons what we are promising or promoting is beneficial. These often become the key messages.
18
Primary Audience
adopt behavior:
Communication
Objective:
Benefit:
Support Points
Communication
Channels and
Approaches
Men and women eligible for ART
By the end of the project there will be an increase in the proportion of
men and women of reproductive age eligible for ART (or whose children
maybe eligible) who know that accessing ART at the right time will
give their (or their children’s) lives a second chance (meaning
treatment will work better and prolong their lives).
If you know the right time to access ART you will have a second chance
in life.
Because you can live to see the results of your treatment
Because there is a right time for everything
Because coming late may be too late.
Mass media messages for eligible clients and print materials (e.g., posters
in health facilities)
Primary Audience
Adolescents 10 – 15 on ART34
Desired behaviors

Reasons why they are
currently not doing
this:
Key Constraint to
adopt behavior:
Communication
Objective:
Know that adherence to their ART drugs is important and that they
can infect others through unprotected sex
 Feel confident to talk to their providers and care takers about
problems they are encountering
 Adhere to their medication and abstain from unprotected sex
Many of them don’t know their status; don’t want anyone to know they
are positive, wanting to be “normal”; drug fatigue or feeling better and
not seeing the need
Wanting to be normal
Benefit:
By the end of the project there will be an increase in the proportion of
children 10 – 15 who
 feel that they can live a good normal life, but only with ART
 Feel responsible for safer sex
If you adhere to your treatment you will be able to achieve your dreams
Support Points
Because you have a right to be here and make your dreams come true
Communication
Channels and
Approaches
Targeted and attractive print materials for adolescents, radio spots
scheduled during youth programming
Secondary
audience
ART providers (physicians, nurses, counselors and pharmacists)
Desired behaviors


34
Know how to counsel their clients with regard to effective drug
utilization, adherence and management of side effects.
Value effective client-provider interaction(including IPC/C and
confidentiality)
Pending more formative research
19
Secondary
audience
ART providers (physicians, nurses, counselors and pharmacists)
Reasons why they are
currently not doing
this:
Key Constraint to
adopt behavior:
Communication
Objective:

Benefit:
Support Points
Communication
Channels and
Approaches
Lack of time, not aware of the needs and value for SMART clientprovider interaction
By the end of the project there will be an increase in the proportion of
providers who value client self management as something that makes
their job easier and better
If you value effective the SMART client and provider approach it will
make your work easier.
Because your clients will know that you care




Secondary
Audience
Desired behaviors
Reasons why they are
currently not doing
this:
Key Constraint to
adopt behavior:
Communication
Objective:
Benefit:
Support Points
Communication
Channels and
Approaches
Overstretched, lack of time, not used to assertive clients
IPC/C training guideline; SMART Provider module and peer
supervision
Warmline promotion (trained in SMART Clients/SMART
Communicator/provider approach)
Public acknowledgements for SMART Provider behaviors
Job aids (treatment, OI treatment, adherence, positive living, etc.)
Treatment supporters (PLHA Associations and family/friends)
Encourage members to become SMART clients (know their rights to ask
questions and come prepared to provider visits)
Did not know that assertive clients get better services; Services
overloaded and providers not being used to assertive clients (especially
women)
Did not know that being assertive can make a difference
By the end of the project there will be an increase in the proportion of
PLHA group leaders and family and friends religious leaders who
actively encourage their members to become SMART Clients
If you support effective client provider communication you will make a
change in your community.
Because SMART Clients get better services
Because people living with HIV/AIDS need your help
 Targeted print material (on SMART client)
 SMART Client/SMART Communicator advocacy ppts for leaders
and PLHA networks
 Hotline answers encouraging SMART Client behaviors
 Betegna radio diaries modeling SMART Client
Secondary audience Caretakers of children (0 – 9) and adolescents (10 – 15) eligible for
ART35
35
Pending more formative research
20
Secondary audience Caretakers of children (0 – 9) and adolescents (10 – 15) eligible for
ART35
Desired behaviors
 Make sure children and adolescents in their care have been tested and
are getting ART services
 Encourage adherence and abstinence
 Feel comfortable to ask questions about treatment and adherence to
their children’s providers
Reasons why they are  Unsure/denial about their own status, ignorance about existing
currently not doing
services for children, lack of assertiveness with regard to the health
this:
system
Key Constraint to
 Ignorance about available services and lack of assertiveness
adopt behavior:
Communication
Objective:
Benefit:
Support Points
Communication
Channels and
Approaches
By the end of the project there will be an increase in the proportion of
caretakers of children and adolescents who know about HIV testing,
care and treatment services for children and adolescents and where
they can be accessed.
If you make sure children and adolescents in your care are getting the
services they need, you feel relieved from your worries
Because knowing is better than fearing;
Because your worry does not help them, only action does.
 Targeted print material
 Radio spots
 Betegna diaries
 Hotline
Secondary
Audience
Religious leaders
Desired behaviors

Reasons why they are
currently not doing
this:
Key Constraint to
adopt behavior:
Communication
Objective:
Benefit:
Support Points
Communication
Actively discourage stigma, and misconceptions about ART and
PLHA in their communities Know about the benefits of ART for
their community
 Actively support ART service utilization and food security,
 Use their influence to encourage church members to become SMART
clients and providers
Religious leaders: Church doctrine is interpreted to consider PLHA
guilty of their status; lower church personnel contribute to
misconceptions about holy water as cure; Islam denies having HIV as a
problem among their followers
Not enough open and strong discouragement of stigma and faith-based
misconceptions by the church and Islamic leadership;
By the end of the project there will be an increase in the proportion of
religious leaders who see themselves as agents of change with regard
to HIV/AIDS treatment and care
If you actively support ART service utilization and discourage
misconceptions and stigma you are making a real change in people’s
lives.
Because that’s what JesusChrist /Mohammed would want you to do
Because you will be good shepherd’s by saving people’s lives.
 Existing TV shows (with panel discussions)
21
Secondary
Audience
Religious leaders
Channels and
Approaches



TV spots by faith leaders correcting misconceptions
Radio spots
Revise AIDS ART related curriculum/guidelines of main faiths
3.2. Positioning and Long Term Identity (Brand or Umbrella Campaign)
ARC has developed a logo for all ART related
materials for clients with a slogan: ‘Beye Kenu
Le Hiwot’ or Everyday for Life!
Branding guidelines on the use of this logo, its
size and position on the material, font types and
sizes as well as use of color on all materials will
help to make the series of materials and activities
recognizable as a campaign.
3.3. Strategic Approach and Media
channels
A combination of targeted print materials, mass media triggers and interpersonal
counseling, using also the ARC Hotline and Warmline services will be able to address not
only individual issues but community norms (see details above).





Radio reaches the majority of the target audiences in urban and rural areas,
TV reaches mostly urban audiences, providers and some of the community leadership
Print materials find good distribution in health facilities but need to be more adapted
to semi-urban and rural reading levels as well as regional languages
Preferred print formats need to be explored by audience
Provider training will be piggy-backed onto exiting training.
3.4. Key Content 36
Primary Audience
 SMART client: right to ask questions
 How to manage ART treatment (adherence, side effect management, regular doctors
visit, positive living including nutrition, positive prevention and disclosure to sexual
partners, friends and family)
 New drug regimens and the differences between them
 Side Effects, including PLHA Role in Improving ART Adherence
 When and where to access ART
 Misconceptions
 Need to add pediatric content for adolescents
Secondary Audiences
36
Each materials will have its own creative brief outlining the required content in detail.
22






SMART client
Stigma and misconceptions (holy water, fasting and ART)
Where to find food support and other positive living support
Adherence
Community Participation in ART roll out
Need to add pediatric content here for caretakers of children and adolescents
Tertiary Audience
 Counseling & IPC Skills for service providers, including patient confidentiality
 SMART Provider duties and client rights
 Various content for specific job aids (e.g. Fixed Dose Combinations etc.)
3.5. Tone
(What feeling or personality should your communication have?)
The SMART Client and Provider promotions should have a modern/innovative style, but
warm and caring; the undertone should be non-confrontational and rather collaborative.
3.6. Openings
(What opportunities, e.g., times and places exist for reaching the audiences?)
Primary Audience
Most print materials developed for the primary audience (individuals on ART and not on
ART) will be distributed by service providers at health services based on their stages of care.
Our print as well as audio and visual communication media will also take advantage of
clients waiting for their turn in waiting rooms. The SMART client approach will be promoted
by national radios across the country including broadcasts in collaboration with the Betegna
radio programs; special efforts will be made to include the SMART patient approach in their
already existing structure and programs.
Secondary Audience
Religious leaders will be put into a training of trainers (TOT) loop by their institutions where
they will make use of the TOT manual developed. Practical spin-off material developed from
the training manual will be used by advocating leaders at religious gatherings at their
respective institutions.
PLHA associations and health centers will be recipients of materials where clients can access
them.
In collaboration with Partners, ARC will design a distribution plan. This will include
orientation trainings (guidance on how the materials should be used) that ARC will provide to
University Partners, PLHA Associations, Religious institutions and others.
Tertiary Audience
Service providers will receive materials developed for their purposes (job aids and
educational manuals) through all respective partners working in the different regions. Private
hospitals and clinics/health centers will be exposed to materials through the ARC
23
clearinghouse. The distribution of materials will go hand-in-hand with material briefings
during provider meetings and trainings.
Materials developed for the primary audience and planned to be distributed by service
providers will be channeled to hospitals and health centers by respective partners and the
ARC clearinghouse.
Provider training on the SMARTER approach will be facilitated with a special, but short and
pragmatic SMARTER Provider module, which we hope to be able to integrate into regular
ART provider trainings held by university partners. This module with address IPC/C skills.
The ARC Warmline will play an important role in service provider campaigns designed to
promote SMART clients and SMART providers. Warmline counselors will provide SMART
motivating messages at the end of calls received and/or calls made by the Warmline.
3.7. Creative Considerations
The type of illustrations preferred from the formative research seems to be images showing
the effect of treatment (before and after), as well as a preference for “real” people and
photography.
All materials need to be adapted to the regions and translated into at least 3 local languages
(Orominya, Tigrinya and Somalinya).
4. MANAGEMENT AND IMPLEMENTATION PLAN
4.1. Communication Activities during FY 07 – FY 09 (see Activity Sheets
in the Appendix)
4.2. Working with partners for dissemination of materials
The dissemination of ART communication materials was discussed as one of the agenda
items in a meeting held with USAID and CDC PEPFAR partners late August 2008. The
following agreements were found:
1) Avoid materials development duplication
- The idea to use ARC in three ways, as hard copy library, on the website and making
space for partners to announce their new materials was welcomed.
- Instead of putting partner materials on ARC website, participants suggested to rather
make linkages to their website and materials posted
o ARC was referred to the MSH Electronic toolkit; to gather ideas about how to
develop ARC online resources as well as include the MSH link in our website
24
-
ARC should call bi-annual meetings with partners to review and coordinate materials
development needs and plans
2) Effective materials distribution
- We need to send our order list and focal person list to all participants electronically
- USAID will also forward the lists to the prevention technical working groups
- Dissemination should be facilitated by all partners
3) Materials briefings
- Orientation meetings will take place along with the ABY team. Partners have agreed
to let us know of opportunities such as provider meetings and trainings where we
could display and orient participants on our materials
4) Materials monitoring
- After discussion about integrating communication indicators into existing quality
assurance systems (as done already by JHPIEGO), this was considered to
cumbersome in the current situation.
- ART Materials Monitoring sheet from us should be filled out quarterly at the various
site levels and discussed with us
- It was decided to have a materials review meeting with partners twice yearly.
Monitoring will also be discussed in this meeting.
It is proposed that the following partner organizations37 are contacted with regard to
developing an ART materials dissemination plan.
- HIV/AIDS Prevention & Control Office (HAPCO)
- Ministry of Health (MoH), including Drug Administration & Control Authority
(DACA) and RHBs
- Ministry of Education
- ETAEP: PEPFAR in Ethiopia with the main actors: State Dept. USG, Dept of
Defense, USAID, CDC
- UN Agencies: WHO, UNICEF, UNAIDS
- National Alliance of State & Territorial AIDS Directors (NASTAD)
- NGOs, FBOs, CBOs, including but not limited to: Ethiopian Interfaith Forum for
Development Dialogue and Action (EIFDDA), Family Health International, I-TECH.
JHU Tsehai Project
5. MONITORING AND EVALUATION PLAN
Regular monitoring of materials distribution will be facilitated by university partners and
others with the help of monitoring tools at site level. A survey will be conducted with a
number of representative sites (especially among the so called “busy” sites with more client
traffic) twice to record improvements in distribution cycles and effective monitoring.
A behavior change impact evaluation is not possible under the current funding structure.
37
This list is not proposed to be comprehensive and other partner organizations may be identified and included
in these discussions, as necessary.
25
APPENDIX 0
Workplan Activity Sheets
ARC ACTIVITY SHEET - Area of Intervention: ART Service Delivery
Promotion
Geographical coverage
Activity name: Updates of ARC user driven
(Districts:) National
update on ART
Program Objective: No 5
Focal person: ABB
Start Date: July 14th 08
End Date: March 31st 09
Budget US$: Staff time
Activity Objectives

Increase the number of ARC user driven services which are regularly updated on
relevant ART information
Background (e.g., if continuation from last year, or other justification for activity)
In the ever changing world of ART research and communication needs, it is of clear that all
ARC user driven services, which include the resource center, the web site, hotline, and
Warmline, are regularly updated on ART information; it is equally important that information
is presented so as to reinforce the strategic direction of the ART communication strategy. The
ART team will make a special effort in FY08 to make the necessary linkages and be
proactive in their collaboration with other program parts.
Activity Description (2 - 4 sentences specifying to whom it is directed, where and how it
will take place)




Brief other departments on communication strategy
Update of hotline FAQ and guidelines
Update of website on ART information and communication products
Link in materials research and production with resource center and Warmline for
input
Key Outputs




All relevant departments aware of ART communication objectives
Hotline FAQ and guidelines reviewed and commented on
Website updated
Ongoing collaboration with resource center and warmline
Indicators and Targets (PEPFAR, or # of people reached, # of materials distributed etc.)



3 meetings on communication strategy
3 documents reviewed and commented on for other services
200 of website hits by the end of March
26
Linkages and Partners Involved (e.g, Warmline, university partners, Betegna, etc.)
Hotline, Warmline, resource center, website team and Betegna
ARC ACTIVITY SHEET - Area of Intervention: ART Service
Promotion Initiative
Activity name
Consolidation & Scale up of Public Awareness
Program Objective: No 5
Focal person: Hailu Nurga
Start Date: April 1st , 08
Geographical coverage
National
End Date: November
30th 08
Budget US$: 99,000
Activity Objectives
By the end of the project there will be an increase in the proportion of men and women of
reproductive age eligible for ART in urban and rural areas who
Know about ART provision (when, where and how to access it); and among men and
women of reproductive age on ART in urban and rural areas who
 Know how to manage their ART treatment (adherence, side effect management, regular
doctors visit, positive living including positive prevention and disclosure to sexual
partners, friends and family)
 Practice positive living and adherence to their ARVs and treatment for opportunistic
infections
Background
ARC’s formative research with regard to ARC showed that available education and
communication materials tend to be in very short supply and do not really fulfill the needs of
the clients and service providers. Significant improvements need to be made on the scope,
quality and quantity of materials. Translations and lower literacy materials are needed and
regular supply needs to be ensured. Based on these findings the team will in FY 08 step up
the production, re-printing and adaptation/translation of existing materials for the regions and
semi-urban areas.
Activity Description




Finalize, produce and distribute 12 ART drug use guides for clients
Adapt & translate all ARC ART communication materials in to Oromigna, Tigrigna
& Somaligna
Produce low literacy ART materials (including smart patient messages)
Finalize M & E plan and baseline
Key Outputs




12 ART drug use guides produced and distributed to 11 regions
25 materials adapted and translated in 3 languages
2 low literacy materials developed
M &E plan developed and applied
27
Indicators and Targets


25 materials distributed
60,000 target audience received materials (excluding university partners’ audiences)
Linkages and Partners Involved
University partners; Betegna, Warmline, HAPCO
ARC ACTIVITY SHEET
Area of Intervention: ART Service Promotion Initiative
Geographical coverage
Activity name:
(Districts:) National
Smart Patient/Provider Campaign
Program Objective: No. 5
Focal person:
Anthoula Assimacopoulou
Start Date: June 16, 08
End Date: –January 31, 09
Budget US$: 62,000
Activity Objectives
To increase the proportion of
 People on ART or eligible for it as well as care takers of positive adolescents and
children who feel confident and come prepared to ask providers for services and
information they need

Adolescents on ART who feel confident to talk to their providers and care takers
about problems they are encountering

Associations and relatives and friends of PLHA who encourage positive living, health

seeking behaviors and good client-provider interaction in their community
Providers who value effective client-provider interaction(including IPC/C and
confidentiality)
Background
The activities under the Smart Client and Provider campaign are part of the overall Art
communication strategy. Its aim is to create demand for quality ART service delivery by
strengthening provider support and client education, with a focus on self management and
monitoring of HIV/AIDS as a chronic disease. This includes strengthening the relationship
and communication between clients and health service providers; encouraging clients to
have a more proactive role in their health care by visiting health facilities with questions and
concerns they have about their health. This is based on data showing that clients who are
active seekers of information are more likely to get quality services.
Activity Description (2 - 4 sentences specifying to whom it is directed, where and how it
will take place)

Smart Clients
o Develop smart client print communication materials (diary, posters)
28
o


Create several episodes addressing smart client daily experiences with
providers and radio spots in collaboration with Betegna
Smart Providers
o Develop a slide video on a model conversation between a smart provider and
a smart client.
o Organize a 2 week Smart Provider promotion from the Warmline to
providers nationally
o Develop a Smart Provider interpersonal communication and counseling
module to be used for provider trainings
o Develop Smart Provider job aids (ring bound pocket references)
Smart Caretakters/PLHA Association/Community
o Develop one print material for relatives and friends of PLHA (suggested title:
how you can support your friends and relatives to be smart ART clients)
Key Outputs









1 patient adherence diary
2 waiting room posters
2 episodes on smart client issues on Betegna
3 radio spots
1 slide video
2 week Smart Provider promotion on Fitun Warmline
1 IPC/C module
3 job aids
1 caretaker brochure
Indicators and Targets (PEPFAR, or # of people reached, # of materials distributed etc.)


7 print materials produced and disseminated
1 video produced and disseminated



2 episodes and 3 spots broadcast on 5 radio stations
2000 providers reached with Warmline smart provider promotion
5 university partner trainings implemented using smart provider module
Linkages and Partners Involved (e.g, Warmline, university partners, Betegna, etc.)
Warmline; Betengna; University partners; other key stakeholders
ARC ACTIVITY SHEET
Area of Intervention: ART Service Promotion Initiative
Geographical coverage
Activity name:
(Districts:) National
Pediatric ART
Program Objective: No. 5
29
Focal person:
Anthoula Assimacopoulou
Start Date: October 1st 08
End Date: February 30th 09
Budget US$: 9,000
Activity Objectives



To have a clear understanding of the communication gaps that influence the quality
of pediatric ART service delivery and uptake from the client side
To develop a specific pediatric ART communication strategy
To create effective and relevant pediatric communication materials
Background
Pediatric ART communication is very new to Ethiopia and very challenging as service
delivery is developing and new research results come in everyday. In order to develop
effective materials and activities we need to get a better understanding on the quality of
service provided as well the communication gaps. In FY08 we are therefore planning an indepth analysis of existing literature and some additional focus group discussions with target
audiences and relevant stakeholders. The information obtained will serve as a stepping
stone for the development of a communication strategy for pediatric ART and materials
development.
Activity Description (2 - 4 sentences specifying to whom it is directed, where and how it
will take place)



Undertake a literature desk review and analysis of focus group discussions to
determine communication gaps that influence the uptake of pediatric ART services
Develop a strategy for pediatric ART communication exploring pediatric ART
services and communication gaps and potentially integrating them into the Smart
Client Smart Provider strategy
Prepare creative briefs for a series of effective and relevant materials
Key Outputs




Consultant identified
Literature review and focus group discussion report
Pediatric ART communication strategy
3 creative briefs for relevant materials and activities
Indicators and Targets (PEPFAR, or # of people reached, # of materials distributed etc.)



20 studies summarized in the literature review
4 Focus groups held
5 partners who gave comments on the communication strategy
Linkages and Partners Involved (e.g, Warmline, university partners, Betegna, etc.)
University partners; PLHA groups, Warmline
30
ARC ACTIVITY SHEET - Area of Intervention: ART
Geographical coverage
Activity name: Community Conversation
(Districts:) National
Program Objective: No 5
Focal person: Hailu Nurga
Start Date: April 1, 08
End Date: –March 31, 09
Budget US$:81,000
Activity Objectives
After the completion of the activity, there will be an increase in the number of religious
leaders and treatment supporters (PLHA networks and families and friends) who



Know about the benefits of ART for their community
Encourage their members to manage ART well (use ART services, adhere to treatment
and practice positive living behaviors).
Actively support ART service utilization and food security, anti-stigma, and religious
activities correcting misconceptions about ART and PLHA in their communities
Background
Numerous studies as well as our own formative assessments indicate that, in Ethiopia, there
are a number of thoughts and practices that contribute to challenges for adherence to ART;
these include stigmatizing attitudes and discrimination, misconceptions with regard to
religious practices and ART, false “cures” and issues of food security and nutrition. ARC has
been striving to address these issues through different approaches; e.g. our ART
communication materials have been launched recently and a review of a curriculum that the
Ethiopian Orthodox Church is using to teach about HIV/AIDS has been started. These
efforts need to be further strengthened through community outreach approaches using mass
media various approaches and methodologies. The ARC-ART team will focus on these
approaches for the next eight months.
Activity Description




Develop 2 3-minute video testimonials about relevant ART issues such as “holy water”
and food security developed together with the E-TVs “Forum Cinema’ Crew; these will
be followed by panel discussions with community and religious leaders and broadcast
on the their weekly TV show. Videos of the shows will be used during road shows.
Develop and broadcast 1 TV and 1 radio spots by religious leaders with statements on
issue of holy water, fasting and ART adherence
Link to Betegna diaries with positive faith-based leader
Revises and finalize EOC’s HIV/AIDS guideline/curriculum in collaboration with EOC
and ANERELA using an innovative and practical format including one spin- off pocket
size material for everyday use. Material drafts will be presented at a validation
workshop with church scholars and clergies. A similar activity for the Islamic faith is
planned for FY09.
31


Develop creative briefs and make contacts with organizations offering road –shows for
semi-urban populations in the regions, using short skits, fames and play ART-related
video materials during night shows; we hope that these will be ready to take off in FY09
Develop indicators and monitor broadcast and feedback of these activities as part of the
overall ART monitoring plan
Key Outputs







Two 3- minute testimonial videos
Two transmissions of TV panel discussions (an hour long in total)
VCD/DVD records of the panel discussion and video testimonials ready to distribute
to health facilities
1 Radio and TV spots produced and transmitted on daily basis for three months
Updated and approved version of Ethiopian Orthodox Tewahido Church
curriculum for HIV/AIDS and 1 spin off material
2 creative briefs for road-shows discussed at meetings with relevant organizations
3 Indicators developed and integrated into overall ART Communication monitoring
plan
Indicators and Targets



10,000 people exposed to TV panel discussions
20,000 people exposed to radio and TV spots transmitted
5000 religious leaders using updated HIV/AIDS curriculum for Ethiopian Orthodox
Tewahido Church
Linkages and Partners Involved (e.g, Warmline, university partners, Betegna, etc.)
o
o
o
o
o
University partners
Ethiopian Orthodox Church
Ethiopia TV and Radio Enterprise
HAPCO
All ARC Sections
ARC ACTIVITY SHEET - Area of Intervention: ART Service Delivery
Promotion
Activity name: Network of University Partners Geographical coverage
(Districts:) National
Program Objective: No 5
Focal person: ABB
Start Date: April 7th 08
End Date: March 31st 09
Budget US$: 3000
Activity Objectives
1. Collaborate closely with university partners and PLHA associations to achieve needed
synergy in creating demand for quality service delivery
2. Create effective materials distribution and monitoring
32
Background (e.g., if continuation from last year, or other justification for activity)
The ART service delivery promotion team has in the past years already been very responsive
to partners needs, including HAPCO and the CDC university partners. In order to ensure
wide and effective distribution and use of materials developed as well as in the development
of new materials, the team will increase its collaboration in various ways for FY 08. This
includes development of materials on demand from the partners.
Activity Description (2 - 4 sentences specifying to whom it is directed, where and how it
will take place)




Coordinate distribution plan with partners
Coordinate material distribution monitoring with partners
Develop material training for partners and integrate into existing trainings
Develop new materials for clients and providers on demand with support from
partners
Key Outputs




Distribution plans
Monitoring plans integrated into site quality control
Materials training for partners during regular provider trainings
Materials development currently for JHU Tsehai:
o Instruction leaflets for clients on emergency nutrition; supplemental feeding;
why and how to take multivitamins
o Material on body mass index and middle upper arm circumference chart and
criteria for intervention for various providers
o TB guidance on DOTS and IPT adherence for adults and children
o Wallchart on IPT algorithms for providers
o Wallchart or table reference on TB treatment algorithms from WHO and
national program
o Multi-drug resistant (MDR)-TB guidelines (including infection prevention) for
clients
o Materials on new PMTCT replacement breastfeeding guidance for mothers
and family members
o New ART wallchart (new first line and second line regimens) for providers
o Wall or table chart on clinical staging (starting and changing criteria) for
providers
Indicators and Targets (PEPFAR, or # of people reached, # of materials distributed etc.)
10,000 materials distributed and used
10 trainings sessions on materials held during partner trainings
15 new materials developed on demand from partners
Linkages and Partners Involved (e.g, Warmline, university partners, Betegna, etc.)
All university partners; HAPCO, NGO and CBO
33
APPENDIX 1
Identified Existing Communication Materials
Prior to proposing the development of ART communication materials, a review of
existing materials has been undertaken. Although every effort has been made to identify all
ART communication materials currently available in Ethiopia, the following list cannot
claim to be exhaustive. Identified existing materials have been categorized by target
audience. It is intended that this information will assist in identifying critical communication
gaps and prevent duplication of effort where a suitable communication material already
exists.
Existing Communication Materials – for Service Providers
6.1





Guideline for Use of Antiretroviral Drugs in Ethiopia, January 2005 (MoH)
ART Pocket Guide for Ethiopian Nurses (I-TECH)
ART Quick Guide for Ethiopian Nurses (I-TECH)
Positive Living - Desk-top interactive for counseling – Amharic (Linkages)
BMI chart & ARTs – English and Amharic (Linkages)
Existing Communication Materials – for Clients
6.2





ART Information Sheets – A4 information sheets in Amharic (I-TECH)
Positive Living – A4 booklet in Amharic (NARC)
Staying strong with HIV/AIDS – A5 leaflet – English and Amharic (Linkages)
Positive Living – Nutrition – Posters – English and Amharic (Linkages)
Pocket sized booklets – Amharic (information on ARTs, side-effects, adherence, OIs)
(MoH, The Federal Democratic Republic of Ethiopia Drug Administration and
Control Authority of Ethiopia, Office of the United States Global AIDS Coordinator)
Existing Communication Materials – Audience Unknown
6.3

ART Information Kit  General background - English (ARC)
APPENDIX 2
2004 Panel Discussion
During the 2004 ART Communication Framework workshop, ART providers and clients38
participated in a panel discussion to share key insights regarding the future development of
ART communication materials and interventions. Topics discussed are listed below;
 Counselling - There is a need for ongoing counselling to provide psychosocial
support, help manage side effects, and adherence.
 Adherence - Providers and patients need to identify potential barriers to adherence
and develop appropriate strategies.
In this specific context, the term ‘client’ refers to a person living with HIV/AIDS who is receiving ART. It
should be noted that throughout this document the term ‘client’ is used as an umbrella term to distinguish the
communication needs of community members and individuals from those of service providers. In turn, the term
‘community members’ includes; Community Leaders, PLHA Associations, and Treatment Supporters.
38
34





Patient Confidentiality - Providers need to learn of their responsibility to maintain
patient confidentiality.
Disclosure to care givers - Disclosure to at least one person in their family is one of
the eligibility criteria for receiving ART. People who disclose their status are more
likely to adhere and have a reliable support system.
Disclosure to partners- Whether or not to disclose one’s status to their partner is a
challenge for PLHAs. Providers should discuss this, emphasizing concerns around
partner protection and re-infection.
Nutrition - Good nutrition needs to be discussed as essential for successful ART.
Stigma - Stigma and discrimination need to be continuously addressed at various
levels in order for treatment to succeed. This includes presenting HIV/AIDS as a
chronic disease as well as issues of disclosure, sexual violence and patient
confidentiality.
APPENDIX 3
Wegen AIDS Talkline Data
NARC operates the Wegen AIDS Talkline that provides a free, national talkline
service. Service statistics are collected for this service, including information pertaining to
most frequently asked questions. The information below reflects the most common questions
regarding ART posed to talkline staff by callers and as such can be used to guide future
communications development.
Understanding of CD4 Counts
 What factors related to life-styles help to sustain a high CD4 count?
 What factors related to life-styles can decrease CD4 counts? (stress, malnutrition,
poor hygiene, OI etc.)
 Why CD4 counts drop when on ART? Do we mean drop? ART increases CD4
counts.
These questions speak to the need for accurate information regarding ART effect on
disease progression and the factors that can enhance this effect (ART, Positive Living.)
Attitudes, Beliefs and Behavior
 Unwillingness to try second line drugs as first line drugs do not cause side-effects
 General religious beliefs versus medical approaches
- Belief that holy-water is more curative than ART – individuals decide to
discontinue treatment
- Impact of religious fasting on ART adherence – significant reason why people do
not take their medication as required
 Disbelief in ART and belief that HIV/AIDS and death are destiny
 Most people who have experienced the advantages of ART (including care givers)
have a positive attitude towards it
These points reflect the continued need to address misconceptions regarding HIV,
AIDS and ART, as well as the need to capitalize on existing religious and cultural practices
in a way that supports ART use and adherence (misconceptions, CBO and FBO role in ART
roll out.) The last point speaks to the appropriateness of using established ART users (and
associated care givers) as advocates for ART.
35
APPENDIX 4
National regional literacy levels
Region
University % of
population
Oromiya
Columbia 35.37
SNNPR
Tsehai
19.85
Amhara
I-TECH
25.4
Tigray
I-TECH
5.78
Somali
Columbia 5.77
Afar
I-TECH
1.85
Gambella
Tsehai
0.33
Benishangul-Gumuz Tsehai
0.84
Harari
Columbia 0.26
Addis Ababa
Tsehai
3.96
Dire Dawa
Columbia 0.53
Language
Literacy
Orominya
Amarinya
Amarinya
Tigrinya
Somalinya
Afarinya
Amh/English
Amh/Oromiffa
Amh/Oromiffa
Amarinya
Amarinya
Medium
Medium
Medium
Medium
Low
Low
Low
Low
Low
Medium
Medium
36
APPENDIX 5
ARC: ART- Materials Distribution Monitoring List
Name of Site:
Region:
Name of University
Partner:
Data Collector's Name and Title:
Date:
Code
Material
Type
Language
brochure
Amharic
#
received
Date
received
500
July 10th
2008
# of
copies
still
available
Location of
material at site
Used by
(client or
provider)
Example:
Positive living
A
A1
A2
A3
*A4
*A5
*A6
*A7
*A8
B
B1
B2
B3
B4
B5
B6
B7
B8
B9
200
waiting room
table
Audience: Health Service Providers
Interpersonal
Manual
Communications and
Counseling Skills (የየየየየየ የየየየየ የየየየ የየ
የየየየ የየየየየየ የየየየ)
Adult Fixed Dose
Laminated
Combination Quick
sheet
Reference
Pediatric Fixed Dose
Laminated
Combination Quick
sheet
Reference
SMART Client SMART
Provider Interpersonal
communication and
counseling slide video
UNDER DEVELOPMENT
SMART Provider
interpersonal communication
module development
UNDER DEVELOPMENT
SMART Provider Warmline
campaign
UNDER DEVELOPMENT
SMART Clients’ Road Map
UNDER DEVELOPMENT
SMART Provider job aids
(requests by partners)
UNDER DEVELOPMENT
Audience: People Living with HIV/AIDS
ART
Booklet
(የየየ-የየየየየ የየየየየ
የየየየየ የየ የየየየየ የየየ
የየየየ የየየየየ)
Positive Living
Booklet
(የየየ የየየየ የየየ
የየየየየ)
Opportunistic Infections (OI)
Booklet
(የየየየየ የየየየየ የየ የየ
የየየ የየየየየ)
Stages of HIV
Leaflet
(የየየ የየየየየየ የየየየየ)
CD4 Counts
Leaflet
(የየ4 የየየ የየየየ የየ?)
Risky Behaviors (addictions)
Brochure
(5የ የየየየየየ)
Drug Information (12 drugs)
Booklet
Fixed Dose Combination
Sensitization(የየየ የየየየየየየ የየየየየየ)
ART
(የየየየየ የየየየ የየየየ)
Pocket
Size
booklets
Poster
37
client
B10
B11
*B12
*B13
*B14
*B15
C
C1
C2
*C3
*C4
*C5
*C6
*C7
*C8
*C9
*C10
D
*D1
*D2
*D3
*D3
Healthy Eating
Poster
(የየየ የየየየ የየየየየ
የየየየ የየ)
Active Living + Productivity
Poster
(1)
(የየየየየየየየ
የየየየየየየየ የየየ
የየየየየየ!)
ART SMART Client Diary
UNDER DEVELOPMENT
Active Living + Productivity
(2)
UNDER DEVELOPMENT
SMART Clients’ Questions
UNDER DEVELOPMENT
SMART Clients’ Radio Spots
Campaign
UNDER DEVELOPMENT
Audience: Community and family members
Caregivers’ Booklet
Booklet
(የየ የየየየየ የየየየየ
የየየየየ)
Time of Death
Leaflet
(የየየየየየየ የየየ የየየየ)
Ethiopian Orthodox Church
Religious Leaders Training
of Trainees and Advocacy
Manual
UNDER DEVELOPMENT
Community and Ethiopian
Orthodox Church Religious
Leaders’ Video Testimonial
and Panel Discussions on
ART and faith based
misconceptions
UNDER DEVELOPMENT
Community Leaders’ Video
Testimonials and Panel
Discussion on ART and food
security
UNDER DEVELOPMENT
Ethiopian Orthodox Church
Religious Leaders’
Messages on TV and Radio
Spots
UNDER DEVELOPMENT
Betegna SMART Patient
Diary
UNDER DEVELOPMENT
Care Taker Brochure
UNDER DEVELOPMENT
Community SMART Client
support
UNDER DEVELOPMENT
ART misconception group
discussion guide
UNDER DEVELOPMENT
Pediatric materials
Lierature review
UNDER DEVELOPMENT
Materials for care takers of
children
UNDER DEVELOPMENT
Materials for adolescents on
ART
UNDER DEVELOPMENT
Materials for SMART
pediatric providers
(on request by partners)
UNDER DEVELOPMENT
38