Case Study: Preventing HIV/AIDS on Road Projects in Yunnan

This 14-page paper shares the processes, experiences, and lessons learned from the Baolong Healthy & Safe Action (BHSA) Project, which was designed by Asian Development Bank (ADB) as a model highway construction HIV prevention project and implemented as an operational research initiative in Yunnan Province of the Peoples Republic of China (PRC) on the border of Myanmar. Recognising the HIV risk that the Baolong Highway construction project potentially posed to local communities and construction workers, the ADB (with funding from the United Kingdom Department of International Development, or DFID) supported a partnership between the Office of Yunnan Provincial Working Committee for HIV/AIDS Control, the Provincial Communication Bureau, Marie Stopes International Australia/China, the Baoshan Bureau of Health, local government and health authorities, and construction companies to create a holistic approach to HIV prevention in future infrastructure projects in PRC (and beyond). This approach integrates a package of interventions covering health sector interventions, behaviour communication change (BCC), condom social marketing, advocacy, community mobilisation, and policy and structural change in an effort to advance the knowledge base for HIV prevention in infrastructure projects through its quasi-experimental design (intervention-control baseline research and a follow-up study).

The opening sections of the evaluation document provide context for, and an outline of, BHSA. In short, this project sought to reach over 20,000 construction workers, villages and townships along the highway - with a focus on preventing HIV/AIDS along the highway during the construction phase and the goal of testing a model communication strategy that could be shared and adapted to other highway construction projects in PRC and elsewhere in the region. As author Che Katz explains here, key to the initiative has been the development of a health service referral network which has involved expanding a number of previously existing private and public health services into model sexually transmitted infection (STI) and voluntary counselling and testing (VCT) health services and pharmacies.

Katz stresses that partnership building with a range of government stakeholders has been an important strategy in facilitating local-level advocacy, training, coordination, implementing, social marketing, project monitoring and evaluation, and so on. For example, the Bureau of Culture has supported film nights in construction sites and local communities. Other types of collaborations have also proved central; for instance, the mass media has communicated HIV and project-related messages through radio, television (TV), and newspapers. Also, communication companies have worked to develop new strategies such as sending short messaging services (SMS) to highway construction workers. In addition, partnerships formed with local villages and community-based organisations (CBOs) have proven fruitful in terms of recruitment, training, and support of a voluntary field workforce which includes both peer educators in entertainment sites and social mobilisers in villages along the highway.

Katz explains that this partnership-centred approach reflects the BHSA philosophy, which involves responding to the vulnerability associated with interconnectedness of construction worksite and local communities and the associated socio-economic and environmental factors that contribute to HIV risk and vulnerability. This approach, Katz claims, represents a strategic shift from other models which have "targeted" construction workers or narrowly defined "risk groups". BHSA's organisers have hoped, through their more "holistic" approach, to reduce the potential for generalisation, stereotyping, and stigma and discrimination, and to capitalise on networks between and within settings. Tools that have shaped this process include advocacy, behaviour change communication (BCC) materials, access to and promotion of health services and products, and monitoring and evaluation. The aim is to support individual change as well as to create an enabling environment by addressing organisational, community, and social change.

This framework has informed BHSA activities to reduce HIV risk, which are described in this document, and which - broadly - include making "settings" (e.g., the construction workplace, entertainment centres, transport corridors) "safe" through such communication channels as film nights, photo exhibitions, VCT, condom social marketing, the training of peer educators, and the creation of mirror hangers (for truck drivers) that reinforce HIV and road safety messages and a road safety-kit including a condom. Other strategies detailed here include participatory learning and action (PLA) that is designed to facilitate community plans that promote the benefits and ameliorate the risks of highway construction. This process involves a team of volunteer social mobilisers working with mobile and out-of-school youth to foster life skills related to HIV prevention and to provide information about safe migration.

To explore the reach and impact of BHSA, organisers enlisted the assistance of an independent consultancy under the direction of Kunming Medical College. Katz indicates that the findings of the process indicators to date "have been encouraging. In the first year of implementation the project has reached over 2,000 persons for the first time, 900 persons in one-to-one peer education, and over 20,000 persons in group and community events. In addition, the Project trained over 300 persons to be peer leaders and educators and sold or distributed for free over 80,000 condoms. The findings of the follow-up survey which was conducted in August 2006 to evaluate impact after the first year of implementation also exceeded expectations." However, as outlined here, the project had limited impact on changing the behaviours of drivers. Also, although a very small number of unskilled workers reported to have had commercial sex partners at baseline, this population was (the only one) found, at follow-up, to have increased their risk behaviours (as evidenced by reduced reporting of condom use).

Among the lessons learned shared in this document are the following:

• Providing information is not enough: "The BHSA project found that those who are at most risk of HIV are middle managers, evaluators, subcontractors, and drivers; all of whom have more disposable income, are more mobile, and are more likely to need to socialize and impress their work colleagues. With the exception of drivers, these populations also have more education and knowledge about HIV/AIDS issues but nevertheless reported higher risk behaviors. This emphasizes the need for HIV prevention messages to go beyond knowledge and address attitudinal and behavioral change through compelling motivational messages, address issues of peer pressure, and develop skills that support behavior change."
• "Construction workers who build relationships with local communities over time, trust and respect the community and so are more open to their communication. Empowering local communities with the resources and skills to not only plan for their own resilience but also to share this knowledge and skills with local worksites can be a very powerful communication channel for behavior change."
• "Construction and entertainment workers move frequently, and local communities also move regularly tempted by increased economic opportunity and greater road access. This rapid change challenges HIV prevention in two ways. Firstly messages need to be at an intensity and frequency to ensure new populations continue to be exposed. Secondly communication strategies need to accommodate regular turn-over of the field team by constantly replacing and re-training peer-educators, social mobilisers, and project advocates."
• "Only a handful of workers are interested in becoming peer-educators....Integrating HIV messages into general health and work-safety messages was the most successful way to get managers on board to understand that improving the workforce health can also improve productivity by making workers feel more valued."
• "There is a brief window of economic opportunity during a highway construction for all sorts of people with all types of skills and experience....Motivating and sustaining a field team of volunteers to do HIV prevention instead of taking the once in a life-time financial opportunities that construction brings is extremely challenging. To address this issue BHSA made efforts to motivate volunteers with incentive and reward systems..."
• Issues of timing and geography can be challenging - for example, on Baolong Highway, the workers preferred to have HIV prevention information during the wet season when they didn't have much work; however this was the most difficult and dangerous time for field teams to access worksites. Similarly, while construction workers may prefer to receive information at night, this can be hazardous for HIV prevention field workers. Since evaluators found that the field team was crucial to ensuring the frequency and intensity of messages, these factors can pose challenges.
• Gender issues should not be neglected, since women in construction sites and surrounding communities are equally vulnerable and have an important role to play in HIV prevention efforts. Organisers sought to address this dimension through strategies like supporting equal access to training and peer education, integrating HIV prevention with reproductive health services, and promoting female condoms.

The paper concludes with a discussion about - and a diagram illustrating - possible strategies for duplicating the BHSA's approach to preventing HIV on highways in PRC, through multisectoral collaboration/coordination and a complex mix of technical support.

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