Case Title. The Greatest Gift: Improving Couple HIV Testing Rates in South Africa

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Case Title The Greatest Gift: Improving Couple HIV Testing Rates in South Africa Name of Authors: Tessa Meyer and Jocelyn Marlborough Name of Organisation: Society for Family Health (SFH) Address: 8 Hillside
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Case Title The Greatest Gift: Improving Couple HIV Testing Rates in South Africa Name of Authors: Tessa Meyer and Jocelyn Marlborough Name of Organisation: Society for Family Health (SFH) Address: 8 Hillside Rd, Parktown, 2193 Johannesburg, South Africa The Greatest Gift: Improving Couple HIV Testing Rates in South Africa Aims and objectives South Africa s highest burden of disease is HIV, with a high prevalence of 12.2%. The National Strategic Plan on HIV, STIs and TB (NSP), emphasizes the use of targeted, evidence-based combination prevention interventions, including expanding HIV prevention efforts. Further, the National HIV Counselling and Testing (HCT) Strategy, launched in 2010, outlines the objectives and plans to expand the number of points where HCT is available (e.g., mobile settings), launch targeted campaigns to increase demand for HCT services and integrate HCT delivery into the health system. After the launch of the National Counselling and Testing Strategy, the National Department of Health (NDOH) embarked on a national HCT campaign, and 20 million tests have been conducted since the start of the campaign in The National Department of Health continues to implement a series of sector-specific HCT campaigns, and embarked on the revitalization of the HCT campaign in The aim of this campaign was to support the NDOH HCT objective to test 10 million people annually. Behavioural Objectives and Target Group The campaign objective was to increase the number of couples who got tested together for HIV from 7% in Jun 2013, to 10% in Sept The target audience for this campaign was sexually active couples aged who live in the 4 districts where SFH operates. These areas are Nkangala and EMalahleni in Mpumalanga province, and Mangaung and Lejweleputswa in Free State province. According to the 2012 Human Sciences Research Council latest data (HSRC, 2012) these districts each have higher than the national average prevalence of 12.2% i.e. 14.1% in Mpumalanga and 14% in Free State. Citizen/customer orientation In South Africa, 6.4 million people live with HIV while only 41% of people know their status, having tested in the last 12 months (HSRC, 2012). Couples HIV counselling and testing (CHTC) is known to be a highly effective testing method because it: encourages couples to make informed decisions about HIV prevention and reproductive health, including contraception and conception (WHO, 2012) and increases marital cohesion through enhancing partner / family communication. In addition, it encourages partners to support each other, discourages risky behaviour, is shown to reduce HIV transmission among serodiscordant couples 1 (Dunkle, 2008) and in positive couples, enhances adherence to treatment (WHO, 2012). The WHO also states that (w)hile CHTC appears to offer potentially substantial personal and public health benefits, to date it has received insufficient programmatic attention. This has been due in part to a focus on individuals getting tested. In South Africa for instance there are no HCT organisations that are specifically geared towards CHCT, although they do occasionally run short couples HCT campaigns. 1 Serodiscordancy refers to a situation where one partner is negative and the other is positive Page 1 Society for Family Health s (SFH s) marketing team conducted consumer immersions with couples who already tested and those who did not want to test. The semi-structured interview guide asked questions about reasons for testing or not-testing, as well as the pre and post testing process. The interviews were aimed at understanding barriers and gaining insight. The following barriers were highlighted: that there is a logistical issue of the couple often not being in the same place and time as the counsellors; that the pre-chct discussion was very difficult to bring up; that there was a fear of what the results might be; as well as barriers related to disclosure, stigma, being judged or potential negative reactions from the partner. Further information gathering was undertaken with programme staff and community members to gain deeper insight into the barriers. The Social Offering HIV counselling and testing to couples was the key product. Other services are also offered including: testing of CD4 counts, tuberculosis (TB) screening through sputum collection and testing, linkages and referrals for TB and ARV treatment, link to community support groups, provision of free condoms, and referrals to other social services, such as in cases of gender based violence (GBV). This is in line with combination prevention programmes which offer various services, as described above, to impact positively on the lives of the clients. The overarching reason to test as a couple is to allow them to demonstrate their love and affection for each other by testing together. It allows them to support each other, therefore increasing social support for each other. Engagement and Exchange SFH runs the social franchising brand New Start, which provides free HIV Prevention services to various districts in South Africa. There are four New Start HIV Counselling and Testing sites: two of which are run internally and two are run by franchise partners. New Start is a well-known service provider in the areas that we work. The teams who provide HIV Counselling and Testing work closely with the community, fully engaging with the local and regional stakeholders. Since the campaign was run in main areas within the districts that we work in, the teams engaged with the local government authorities or municipalities to get their permission to run the campaign. The HCT sites are considered very important stakeholders with whom the marketing team spent a considerable amount of time engaging with, and getting their opinions and buy-in on the project. This was felt to be critical so they could provide the technical assistance with quality services. During the process of the campaign, the teams engaged on a daily basis with the people in the communities that we serve. This was done through Interpersonal Communication (IPC) agents, what SFH refers to as Community Mobilisers. Each site had 6 mobilisers, talking to people one-on-one and as a group. The teams spoke to people as a result of their community engagement. The response from the communities was phenomenal - reports back from the field agents consistently noted that the communities were very excited by the campaigns. Competition analysis Page 2 The competition is not testing. HSRC data shows that 41.5% of the South African population have an awareness of their status, through testing in the last 12 months. This indicates that over 50% of the population do not know their status. Partners who work in the same districts include the government clinics and other NGO s. They do not concentrate their resources on couples, but rather on individuals. With our distinct brand presence and targeting of couples, we captured an untapped section of the market. Segmentation and Insight In the HCT arena, people can test as individuals, as couples or as a family. For this campaign, we specifically targeted the couples, because of the benefits associated with couples counselling and testing. The campaign title was Give your partner the greatest gift. The insight for this campaign centered around the universal idea that couples love to give each other gifts. These gifts, whether large or small, make the other partner feel special. The word gift was played upon to refer to the gift of having an HIV test together, which means that the couple has taken the next step in their relationship. It could result in numerous benefits such as feeling closer, deeper communication and feeling supported. The creative agency also tapped into the insight that campaigns need not be linked to public health messages, which are often soaked in fear messages. Therefore they created a campaign which looked nothing like a Public Health campaign, but was inspired by Vegas style bright and bold artwork. This broke through the clutter and attracted our target audience s attention. Integrated Intervention Mix Within our organisation, we use the 4P s model, as part of bigger marketing strategy. The 4 Ps for this campaign was: Product P: The product was the high quality HCT service to couples and adjunct support and clinical interventions. Consumers like our product because of the convenience - they do not find it convenient to access services through government clinics. We operate out of tents, which means our services are mobile therefore we go to where clients are. The clients also site preference of our services due to confidentiality concerns with government clinics 2. Price P: The CHCT services were free, in terms of monetary costs. However, the campaign did take into account emotional costs which were mitigated through the experienced counsellors who are trained to communicate and deal with emotional costs during their sessions so that the couple feel comfortable to discuss these in a safe and controlled environment. Promo P: The promotion mix involved Above-the-line (ATL) and Below-the-line (BTL) elements. The pre-campaign had a timeline of one month before the actual campaign, consisted of street pole ads and community radio. During the two week couples counselling 2 Routine programme data Page 3 campaign, in addition to the street pole ads and radio, the BTL elements were initiated. These included using Interpersonal Communication (IPC) through community mobilisers, mobile billboards, loud hailing, playing popular music that attracted the target audience, distributing Information, Education and Communication (IEC) material as well as the distribution of promotional items, such as branded water bottles, key rings and framed photos. Two local agencies were commissioned to create and execute the different elements of the campaign. Place P: We held the campaigns at high traffic areas within the districts. The areas were assessed beforehand, by the teams on the ground, who had conducted outreach services in those areas. Two high traffic areas in each district were chosen, with the team spending one full week at each area. Co creation through social markets New Start, works in close collaboration with the provincial and regional governmental departments including the Department of Health, Department of Education and Department of Social Development. SFH is funded by PEPFAR, through the Center for Disease Control and Prevention (CDC), and works closely with the NDOH and CDC to co-create the HCT programme to respond to the needs of the community. Systematic planning SFH utilises a marketing strategy process called DELTA. This process evaluates the following questions: Where are we now: looks at the current situation Where do we want to go: looks at objectives to be met How do we get there: looks at the 4 Ps to create a marketing plan How are we doing: outlines research, workplan and budgets to achieve the plan A DELTA was conducted for the HCT programme. The strategy team consisted of the key site management team, as well as SFH marketing experts. The strategy focussed on the human centred approach, in order to get to a plan that satisfied the needs of the communities in which we serve. A key outcome of this process was a marketing campaign addressed to the key target audience of couples and supported programme objectives and planning. The underpinning theory that SFH uses in the development of each campaign and in this one specifically, is that behaviour change is affected by OAM : Opportunity, Ability and Motivation. Opportunity refers to the institutional or structural factors that influence an individual s chance to perform a promoted behaviour. Ability refers to an individual s skills or proficiencies needed to perform a promoted behaviour. Motivation refers to an individual s arousal or desire to perform a promoted behaviour. The planning process entailed marketing taking the lead for the briefing, and management of the creative agencies. Once a suitable idea was decided on, it was presented to the site teams for their feedback and suggestions for how to improve it, as well as where to conduct the two week long campaign. The site management team was tasked with local government engagement. Page 4 The below-the-line activities were run by a specialist agency who employed additional mobilisers, with a dedicated campaign manager at each site. The criterion for success was number of people who tested. We did not monitor knowledge and attitudes. Therefore our monitoring and evaluation teams pulled together the routine programme data for actual number of tests. Results and Learning The campaign objective was to increase the percentage of people who tested as a couple from 7% at the beginning of the campaign to 10% at the end of the campaign. This was achieved: Total couples tested during the campaign period: 1265 (2530 individuals) Growth August 2014 vs August : increase by 391% Growth August 2014 vs. July 2014: increase by 152% The learnings from the campaign include: The campaign worked due to the great branding work that was done. There was one message that was followed through all the elements consistently. The campaign did not look or feel like a health campaign. It was bright, bold and engaging, with the Vegas feel, therefore it broke through the clutter It worked because of several factors, including: That it was convenient for the couples to test when they were together That there was a message which resonated with them i.e. giving each other the greatest gift That New Start has built up a reputation over ten years to be a high quality service provider and therefore our target audience had confidence in our ability to deal with their barriers 3 This is with the same teams and resources as the previous year Page 5 References Dunkle, K, Stephenson, R, Karita, E, Chomba, E, Kayitenore, K, Vwalika, C, et al. (2008), New heterosexually transmitted HIV infections in married or cohabiting couples in urban Zambia and Rwanda: an analysis of survey and clinical data, Lancet; 371: Shisana, O, Rehle, T, Simbayi LC, Zuma, K, Jooste, S, Zungu N, Labadarios, D, Onoya, D et al. (2014) South African National HIV Prevalence, Incidence and Behaviour Survey, Cape Town, HSRC Press. World Health Organisation (2012), Guidance on couples HIV testing and counselling including antiretroviral therapy for treatment and prevention in serodiscordant couples: recommendations for a public health approach. Geneva, WHO Press. Page 6 Appendix Page 7
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