Reducing the knowing-doing gap amongst HIV high-risk groups

A report by UNAIDS released at the 22nd International AIDS Conference in July 2018 highlighted that there was a “dangerous complacency” over treatment and prevention of HIV globally that could lead to a resurgence of the deadly disease. Even in India, public health workers and activists attribute the deceleration in the control of new HIV cases to waning interest in the program, and shrinking funds.

The need of the hour was to use newer methods in behavioural design and create effective interventions to move closer towards UN AIDS’ 90-90-90 target, i.e. By 2020, 90% of all people living with HIV will know their HIV status; 90% of all people with diagnosed HIV infection will receive sustained ART; 90% of all people receiving anti-retroviral therapy will have viral suppression.

FHI 360, on request from the National AIDS Control Organization (NACO), commissioned a Communication Needs Assessment (CNA) at the national level through a qualitative assessment as well as review of existing communication packages. The purpose of this CNA was to provide recommendations to support development of a new package of BCC materials for NACO; and to highlight the training needs in BCC and counselling of HRGs and Bridge Populations, to address gaps along the HIV prevention to care and treatment continuum to meet the UNIAIDs 90:90:90 goal for India. But while printed communication material (in the form of posters, flip books and so on) has played a major role in interventions over the past years, we needed

‍to redefine the problem in the context of today’s smart-phone-generation, and go beyond just top-down communication funnel methods that assume knowledge/awareness will lead to behaviour.‍

The outcomes of our effort in this project were:

•Synthesis all of this research information - bringing forth an

understanding of the deeper belief systems that drove current behaviour withrespect to HIV awareness, access and adherence - encompassing the barriers and facilitators for the desired behaviour amongst high risk groups‍

Visualizing this synthesis in a format that was easy to grasp,

not just by experts from the field (NACO, SACS and other social organisation teams) but also for creative communication agencies who were complete newbies to the subject at hand

A 4-day workshop - with all relevant stakeholders and creative teams, where we generated a number of ideas and prototypes that would influence behaviours and help reduce the knowing-doing gap and help take us closer to the 90-90-90 target

As we analysed the CNA findings, we also managed to have a few one-on-one interactions with 3 high-risk groups-Female Sex Workers (FSW), Men who have Sex with Men (MSM) and Hijras and Transgenders (HTG). These interactions lent a face to all the data we had at hand. We then mapped out their ecosystem interactions and studied their behaviours across Prevention-Testing-Treatment.

Our interactions entirely changed the tone of the project for us. A startling realization for us was that most of these high-risk groups knew exactly what the ‘right’ behaviours were. They just couldn’t get down to executing those behaviours in the moment. A classic case of Hot-cold empathy gap.This questioned the problem this entire ordeal of redesigning BCC collaterals was actually trying to solve. We now knew that the initially defined problem of motivating and educating the high-risk groups would’ve been only an aesthetic improvement, with presumably no change in behaviour.

In the ART Treatment phase, this was one of the macro problems that had to be discarded and deep-dived into as we moved along:

One of our candid conversations revealed that while the FSW knew what all the ‘right’ behaviours were forART adherence, there were a few glaring, yet unnoticed, occurrences in her journey to the ART centre.

Everyday, at a fixed time, the ART health-caretaker lady would call out her name as she eagerly knocked on the door. This, in a room the FSW shared with 6 others. Within a few days, this FSW was ostracized by her roommates - separate eating, separate washing, and also led her to getting a reduced number of clients.

Another loophole was the green book that was given to all who were on ART treatment. Anyone seen witha green book in their hands became an instant record of them being on ART. And, again, led too stratification that sabotaged the FSW’s business.

This led us to our micro problem - 1 in about a 100 that we identified through this process.

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