Boosting Prevention: The Join-In Circuit on AIDS, Love, and Sexuality

This 36-page publication describes an adaptable HIV prevention tool and the results of its use to date in more than 18 countries. Initially developed by the German Federal Centre for Health Education (BZgA), the "Join-In Circuit on AIDS, Love, and Sexuality" takes the form of a workshop with 5 or more stations, at which trained facilitators help participants learn critical information about HIV through interactive problem-solving, games, and conversation. Throughout each 75-minute session, facilitators engage participants in lively forms of dialogue about how HIV is transmitted, how to talk about sexuality and love, condom use, non-verbal communication, living with HIV, and so on - all the while emphasising 3 main messages: "Be informed; protect yourself and others; show solidarity."

As detailed here, by the end of 2007, with Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) support, the Join-In Circuit had been adapted and used in HIV prevention in Bangladesh, Mongolia, and Nepal; the Russian Federation and Ukraine; Mozambique, Zambia, and Zimbabwe; and Ecuador and El Salvador. Evaluators contend that cooperation with ministries of health and education often supported the quick uptake of the Circuit, as officials understood how it could be used to advance toward national prevention goals. The flexibility of the Circuit, they found, allowed it to address prevention among many different groups, such as schoolchildren, young adults, and adults working as soldiers, prisoners, factory workers, sex workers, teachers, and so on. Wherever possible, organisers tailored the content and format to reflect the experience of the group being addressed - in the most realistic, sensitive, and explicit manner possible. For example, if pictorial representations are felt to be too scandalous, organisers ask themselves how presentations might be altered to make them more socially acceptable. ("While remaining culturally sensitive, it is necessary, especially in countries where the virus is transmitted mainly through unprotected sexual intercourse, to allow participants to understand the risks they face.") In Zimbabwe, the representation of anal intercourse was made socially tolerable by depicting the couple lying in bed, covered by a blanket.

The report presents a number of findings gleaned from the experiences of adapting the Circuit in different contexts. On the whole, evaluators found that "Most organizers and facilitators agree that the Join-In Circuit is an effective tool for HIV prevention among young people. Though primarily viewed as a vehicle for providing information, subjective evidence suggests that the Circuit has a positive influence on people's attitudes (towards people living with HIV, for example) and helps people to change their behaviour (use condoms, etc). Surveys of participants before and after they have been through versions of the Circuit in Ethiopia, Bangladesh, Ecuador, El Salvador, Kazakhstan and Mongolia also indicate that they increase their knowledge..."

Challenges are encountered, however, and are outlined here. For instance, in most secondary schools the condom demonstration had to be left out, and many countries reported difficulties in distributing condoms to participants. Yet, "However well they learn about the use of condoms, and their benefits, they will continue to have unsafe sex if they leave the Circuit without clear information about where to get them. Social marketing of condoms through the Circuit is therefore critical, as experience has shown that access can be an obstacle for participants to follow through on what they learn."

Furthermore, "Learning and effective inter-personal communication can be a particular challenge, especially in countries with authoritarian communication structures. This applies not only to facilitators, who must become accustomed to speaking ex tempore in front of groups, but also to the participants, who may not be accustomed to being asked for their opinion. An additional challenge in terms of effective training is that the facilitators not only need practice in the methodology, but they must also be taught the basic information necessary for their work..." Evaluators stress that facilitators need: more than 3 days of training, regular supervisory visits, regular refresher courses, appropriate pay, continued opportunities to present the Join-In Circuit, and opportunities to exchange information and learn from other teams of facilitators.

Along these lines, "Experts agree that, despite appearances, the Join-In Circuit is actually complex and requires considerable effort. It calls for solid financial backing and human resources, sophisticated interaction with target groups, and careful logistic planning. At least a year of preparation time (and financial support) should be provided before the programme can stand alone....Slide presentations and films are available to help decision-makers, the press and potential facilitators to understand the process for developing and implementing the Circuit. They may also want opportunities to discuss the full potential and possible pitfalls of the J-IC with experienced organizers..." [Editor's note: For a detailed, step-by-step handbook for the Circuit, as well as manuals and guidelines for facilitators on CD-ROM, please contact Susanne.Pritze-Aliassime@gtz.de at GTZ Health Section, Sexual and Reproductive Health.]

Several concrete suggestions are offered for overcoming these and other challenges, thereby enhancing and sustaining the benefits that this strategy appears to offer. Many focus on communication-centric ways forward; for instance, "Members of the target group can help in adapting and implementing the Circuit. They can be invited to represent their own interests during the first adaptation phase. They can participate in designing the national Join-In Circuit. They can be trained as facilitators, or asked to evaluate the content of the Circuit during a test phase or first phase of implementation. Whatever approach is used, participation by members of the target group is a key to the success of the Circuit and evidence suggests that its use of interactive, playful or non-threatening teaching tools enables participants to begin thinking about their attitudes and behaviour and make positive changes....External peer-reviewers found the Join-In Circuit highly innovative but could improve its content regarding communication between the genders. Discussion of male sexual pleasure and condom use and local myths (e.g. the virus comes from condoms) should be improved. This would make the Circuit even more sensitive to local cultural and gender issues and more effective."