Experiences in Peer Education and Intervention among High-risk Groups in Tianshui City, Gansu Province

I. Background

1) Tianshui City

Tianshui City is located in the southeast part of Gansu Province and consists of two districts and five counties: Qinzhou District, Maiji Second District, Gangu County, Wushan County, Qin'an County, Qingshui County and Zhangjiachuan Hui Autonomous County. Throughout the city there are a total of 217 health facilities, with 6,985 beds and 7,727 healthcare staff; 114 township health centers; 2,850 village clinics; and, eight disease control and prevention institutions.

2) High-risk groups

According to survey results, within the Qinzhou and Maiji Districts there are 303 entertainment establishments and approximately 2,500 female sex workers (FSWs). Men who have sex with men (MSM) have no fixed entertainment venues yet, using the Delphi method, this population group was estimated to include around 2,000 men. There are also approximately 600,000 migrants within urban areas of Tianshui City. A baseline survey for high-risk groups was conducted across the city in 2006; survey results indicated that high-risk groups generally had low rates of HIV/AIDS awareness, they commonly engaged in high-risk behavior and they had limited access to HIV/AIDS-related information. There is therefore an urgent need to strengthen the HIV/AIDS response in this area.

3) The HIV/AIDS epidemic

Since 1997 when the first case of HIV was reported in Tianshui City through December 31, 2007, a cumulative total of 104 HIV/AIDS cases were identified in the city, accounting for 22% of all HIV/AIDS cases found in Gansu Province. Within Tianshui City, people living with HIV/AIDS (PLHA) are mainly located in Gangu County, Qinzhou District, Maiji District and Qingshui County. Some 41 AIDS cases were identified in Tianshui City in 2007, indicating a rapid increase in the number of AIDS patients; HIV/AIDS is already spreading from high-risk groups to the general population.

The HIV/AIDS epidemic in Tianshui City has the following characteristics: 1) The number of reported HIV/AIDS cases has been increasing yearly: in 2006, 19 HIV/AIDS cases were reported, which is 171% higher than the number in 2005; and, in 2007, 41 HIV/AIDS cases were reported, which is 115% higher than the 2006 number. 2) Rural residents account for 60% of new HIV/AIDS cases, HIV is prevalent across a wide variety of areas, and the virus is spreading from high-risk groups to the general population. 3) HIV transmission through sexual contact and drug injection – especially among migrant injecting drug users (IDUs) – is markedly increasing. The first case in Tianshui City of HIV transmission through drug injecting was found in 2005, and the first case through sexual contact between men was found in 2006. Among all HIV/AIDS cases discovered in 2007, the proportion of infection through sexual contact and injecting drug use was, for the first time, higher than that of infection through blood, accounting for 58% of all newly discovered cases. 4) Some 8% of all HIV/AIDS cases occur among family members. In just 14 households, a total of 29 HIV/AIDS cases were reported, including 8 mother-to-child transmission (MTCT) cases. 5) The arrival of PLHA from other regions (primarily non-local women who married local men and migrant IDUs) is causing an increase in HIV cases. Among a recent survey testing 170 immigrant wives in Gangu County for HIV, five women were found to be HIV positive, and five of their family members tested positive, for a total of 10 cases. More HIV survey testing is currently underway concerning immigrant wives. Among the 23 HIV/AIDS cases found in Gangu County, 19 cases were female immigrants (mainly from Yunnan Province) married to local males; these women and their family members infected through sexual transmission and MTCT accounted for 82.6% of all cases in the county. 6) Among the HIV/AIDS cases found in 2007, the number of HIV infected people exceeded the number of people with AIDS for the first time, with HIV-infected people being four times higher than that of the number of people with AIDS. This indicates an increase in active HIV surveillance in Tianshui City.

II. Primary Practices

The Tianshui Municipal CDC’s high-risk intervention team has led integrated intervention activities that bring together the forces of peer educators and NGOs. Activities include HIV/AIDS awareness education, behavioral intervention, condom promotion, and the promotion of voluntary counseling and testing (VCT) and healthy treatment-seeking behavior for STDs. In addition, in May of 2007 the Tianshui CDC set up the "Red Ribbon Home " in the Qinzhou District to provide services to high-risk groups, recruiting qualified volunteers to serve as HIV/AIDS counselors that provide information on HIV/AIDS-related prevention, treatment and care, and who promote awareness, VCT, and more.

1) Conscientiously strengthening organizational leadership, earnestly drafting work programs and plans, and meticulously coordinating prevention, treatment and care work between all offices and departments. In 1990 the Tianshui Municipal Party Committee and the Tianshui Municipal People's Government established the STD Leading Group. In 2007 they went on to establish the Municipal HIV/STD Control and Prevention Leading Group, which is chaired by the Municipal Party Committee with the Municipal Government as vice-chair and 32 departments and organizations as members. The group promotes leadership coordination, defines the responsibilities of various departments, develops strategic work programs and plans, looks into all prevention, treatment and care work being carried out, and establishes working principles.

2) In order to suppress the spread of HIV/AIDS in Tianshui City, work has been carried out according to the national principle that, among the general population, promoting awareness should be the main focus while, among high-risk populations, combining intervention measures and educational campaigns should be the main focus. With the combined efforts the high-risk intervention group with peer educators and NGOs, a variety of intervention activities were carried out to help high-risk populations.

1. Establishing a high-risk intervention working team to take behavioral intervention directed at high-risk groups to the next level

A high-risk intervention team was established in Tianshui City in 2005. To increase the skills of team members, the "Training Workshop for Members of the High-risk Intervention Team in Tianshui City" was conducted in 2006. Through a baseline survey, team members identified local high-risk groups as well as their sizes and geographical distribution. They also developed intervention work plans, implemented activities, and mobilized, supported and cooperated with relevant departments and NGOs in order to carry out intervention activities among high-risk groups.

An in-depth baseline survey was conducted to look at the number, geographical distribution and business hours of entertainment establishments; identify local high-risk groups, their sizes, and degree of mobility; and, find out their major high-risk behaviors. Various methods were used to do this, including reviewing literature provided by relevant departments, interviewing owners of entertainment establishments as well as key insiders, taxi drivers, and staff at STD clinics and stores were condoms are sold. The team created files for high-risk venues and high-risk populations, mapped the geographical locations of high-risk venues, developed intervention protocols targeting high-risk groups, and made arrangements for on-site interventions.

Team members selected several cooperative entertainment establishments where the management was willing to assist in arranging direct contact with FSWs. Then, based on the principles of respect, confidentiality, non-judgment and harmlessness, they met with FSWs. For entertainment establishments that were less accessible, team members collected information from key informants, industry insiders and FSWs and conducted secret interviews while pretending to be clients. They gave FSWs information about STDs, HIV and AIDS; emphasized the harm STDs and HIV/AIDS can have on individuals, children, families and society as a whole as well as epidemiologic trends; and, got FSWs to understand the importance of prevention and 100% condom use and showed them the correct way to use condoms. They also gave out informative, educational materials and small gifts, and provided outreach services. After carrying out such activities multiple times, the attitude of venue owners, management and FSWs changed from nonacceptance to active cooperation and participation. In order to expand the coverage of these behavioral interventions, team members called on bosses and FSWs to tell their peers of the importance and principles of behavioral interventions and to actively mobilize their peers and coordinate their work.

Then, team members fully implemented interventions among high-risk groups. Intensive training was provided for management and FSWs, and FSWs gathered to participate in get-togethers, competitions to challenge their intervention knowledge, etc. In particular, a variety of face-to-face educational activities were organized for FSWs in entertainment establishments such as training, informal discussions, interviews, face-to-face communication, multimedia teaching, interactive Q&A sessions, games, VCT services, and outings. Gynecologists, doctors that specialize in STDs, and beauticians all took part in a variety of interventions. These activities raised awareness on behavioral interventions among FSW, inspired enthusiastic participation and increased the women’s knowledge of disease prevention. At the same time, peer educators were recruited and trained to participate in the implementation of behavioral interventions.

2. Promoting peer education

Based on the 2006 baseline survey, team members initially identified the sizes and geographical distribution of high-risk groups. To make up for the shortage of staff, to address the difficulty in reaching hard-to-reach groups and to improve the sustainability, timeliness and effectiveness of interventions, team members selected peer educators from among FSWs, MSM, migrants and bosses. Eligibility criteria included a long stay in the city, strong sense of responsibility, high level of education, strong influence and authority among peers, good communication skills and willingness to cooperate. Peer educators were provided with training on intervention skills, signed agreements with the high-risk intervention team, and conducted peer education among different high-risk groups.

Several training workshops were conducted among selected FSWs in entertainment establishment in Tianshui City in order to recruit qualified peer educators. The scope of the training covered basic knowledge about HIV/AIDS, HIV/AIDS policies, and correct condom use. Trained FSWs served as volunteers to disseminate knowledge about HIV/AIDS and correct condom use among peers, including basic knowledge about sex – including female physiology - correct methods of condom use, signs, symptoms and dangers of STDs, and the importance of regular physical examinations and correct health-seeking behavior. As a result, FSWs were able to improve their knowledge about STDs, HIV and AIDS and to increase their rates of condom use. In 2007, a total of 16 peer educators were recruited among FSWs across the city, expanding the coverage of HIV/AIDS education in entertainment establishments.

In Tianshui City, there were no regular activity venues specific to MSM and as this group is more hidden than other high-risk groups. Therefore, peer education was the most effective way to conduct interventions among this group. A total of 12 peer educators were recruited among MSM in the city’s two districts and five counties, with at least one peer educator in each district/county. Team members developed a good rapport with these peer educators; interventions among MSM is now on the right path.

Peer educators for migrants were mainly managers of buildings, supermarkets, marketplaces, and labor department offices, as well as young students. A total of 15 peer educators were recruited to conduct interventions among migrants across the city.

Performance assessments were conducted for peer educators on a quarterly basis, covering the workload, quality of work, completeness of on-site records, data collection, and effectiveness of interventions. Problems that occurred during work were addressed in a timely fashion. Peer educators were paid based on the results of performance assessments. Several incentives were provided to inspire the enthusiasm of peer educators, such as name-brand condoms, gifts, and priority to participate in activities organized at higher levels.

3. Mobilizing NGO participation

NGOs play a critical role in complementing the comprehensive HIV/AIDS response and can easily access marginalized populations during the implementation of intervention among high-risk groups. Incentives were given to encourage active NGO participation in the HIV/AIDS response by building their capacity and guiding them to develop and grow. Key NGOs in Tianshui City include Longcheng Working Group (targeting mainly MSM), Lan’guifang Working Group (targeting mainly FSWs), and Tianshui Red Ribbon Youth Group (targeting mainly immigrants, college students and migrant workers). These NGOs conducted a series of educational activities and interventions with the support of the Tianshui CDC, providing a solid platform on which to scale up the HIV/AIDS response, establish a comprehensive HIV/AIDS response system, and leverage the role of NGOs in the fight against HIV/AIDS.

With the support of the Tianshui CDC, Longcheng Working Group conducted several training workshops for MSM in order to increase their knowledge about HIV/AIDS. Japanese experts and municipal/provincial experts were invited to give lectures at training workshops. Participants developed rules for training workshops. Competitions testing participants’ knowledge, games and other interactive methods were used to combine learning and fun. All activities were presided over by peer educators, encouraging the enthusiasm and active participation of participants, and improving the effectiveness of activities. In addition to intervention and face-to-face communication, use of the Internet was taken advantage of in order to reach the MSM population. The Longcheng homepage (www.tslong.org) was created in March of 2007 and put into operation by mid-April of the same year. Internet-based interventions include the creation of QQ groups, provision of online counseling, and information dissemination, all of which extends the reach of intervention to online MSM users, gradually expanding intervention coverage.

Lan’guifang Working Group took advantage of being an NGO to seek the support of the Red Ribbon Home and conduct interventions among many types of FSWs. Different intervention strategies were developed for different types of FSWs as their levels of awareness of HIV/AIDS and rates of condom use were different. Interventions adhered to the strategy of “stabilizing the situation among FSW that work in settings that are economically better off, keeping an eye on those that work in mid-level economic settings, and actively going after FSW that work in economically poor settings”. In regards to FSWs that work in better-off settings, priority was given to interventions directed toward venue owners; for those in med-level settings, a combination of intervention among owners, peer education and face-to-face communication was used; concerning FSWs that work in economically poor settings, priority was given to peer education and face-to-face communication.

The Red Ribbon Youth Group developed the school-family-society model to expand education from students to groups outside schools by making use of volunteers, the Red Ribbon Group, and communities. Students of Tianshui Normal College were organized to conduct the large-scale performance art show "The Fluttering Red Ribbon" on campus and at Longcheng Square on World AIDS Day in 2007; the performance art programs catered to the tastes of the public and saw great results.

4. Using a variety of methods to promote condom use among high-risk groups

All interventions were aimed at changing the unhealthy behaviors of high-risk groups. In order to increase the effect of education, the high-risk intervention team posted special HIV/AIDS-related information on bulletin boards in entertainment establishments to spread knowledge on correct condom use and the role of condoms in disease prevention, and they distributed free condoms and lubricants to high-risk groups. According to a survey in 2007, the rate of condom use among high-risk groups showed evident increase from that of 2006. The level of HIV/AIDS awareness also rose significantly. This indicated an initial success in interventions directed toward high-risk groups after one year of effort.

III. Experiences

1) Government leadership and multi-sectoral cooperation in the comprehensive HIV/AIDS response are the guarantees for effective interventions among high-risk groups.

2) Staff training, performance assessment and the dissemination of proper messages are the foundation of effective interventions.

The training and performance assessment of both team members and peer educators are absolutely necessary. Until they master the correct methods and skills, team members and peer educators cannot transfer proper messages to high-risk groups, learn from others' strong points to offset their weakness, improve working methods, or develop regionally appropriate measures.

3) Respect, understanding and care are preconditions for effective communication with high-risk groups.

High-risk groups generally have feelings of inferiority and cynicism, and they distrust intervention staff. Any discriminatory words may injure their self-esteem, lead to poor communication and affect the effectiveness of interventions. On the other hand, one caring greeting or handshake can eliminate estrangement and misunderstanding, and enable them to feel that staff do indeed care for their health. Therefore, intervention staff must follow the principles of "respect, confidentiality, trust, harmlessness, fairness, mutual help, and benefit".

4) Targeted strategies for different types and levels of high-risk groups are key to improving the effectiveness of interventions.

5) Flexible teaching methods are mainstays for attracting the participation of target groups.

Participatory, recreational and interactive methods should be used to promote health education. Excellent pictures and descriptions can be combined to incite the enthusiasm of target groups and improve the effectiveness of interventions.

6) In addition to the high-risk intervention team, owners of entertainment establishments, peer educators and doctors that specialize in STDs can be mobilized to provide outreach services so as to expand intervention coverage and improve effectiveness.

7) NGOs can play a complementary role in conducting interventions.

The HIV/AIDS response is a comprehensive social program requiring the participation of the whole society. NGOs play a key role in providing health counseling and safe sex education, and in conducting STD, HIV and AIDS interventions among high-risk groups.

(Tianshui CDC, Gansu Province)