Planning an HIV prevention intervention is not simply about determining what can be done. Instead, assessment of the context in which the work is to be carried out helps planners to determine what should be done in order to have the greatest impact. This section utilises a planning model that begins with consideration of local need and available resources before determining whether an intervention should target African people themselves, or the structures that influence the lives of African people. Once that decision is made, planners must consider:
- WHO the target of any intervention will be, and;
- WHAT particular need the intervention aims to meet; prior to specifying;
- HOW a particular intervention will best meet that need for a speciﬁc sub-group of African people, or those providing services to them.
In the past, it has been assumed that HIV prevention interventions beneﬁtting African people should begin with extensive needs assessments and consultations with local people. While local needs assessments were often seen as a prerequisite for work they often served as delays or obstacles to action. The development of national data sources and frameworks makes far-reaching local enquiry largely unnecessary. The survey data collected through Bass Line (Dodds et al. 2008, Hickson et al. 2009)
The third National Survey of Sexual Attitudes and Lifestyles was begun in 2010, and will be collecting data until the summer of 2012. The findings are likely to contribute to our understanding of the sexual lives of African people in the UK, alongside all others included in this general population sample. The results of that survey will not be published until 2013, although results of the one undertaken a decade ago can be of use in this context (Fenton et al. 2005)
Additional qualitative and quantitative data among somewhat smaller subsets of the population further illuminate key areas of need (see for instance, Dodds et al. 2004, Flowers et al. 2006, Doyal et al. 2007)
Planning for interventions can begin by estimating the size of the local population of African adults. In the absence of up-to-date Local Authority estimates, data provided by the 2001 Census can help. Given the increase of net migration from Africa to the UK over the past decade, it is likely that the results will provide an underestimate of your local population, but having some sense of the size of the population is useful for funding applications and planning.
- Go to the Neighbourhood Statistics website operated by the Office of National Statistics.
- Follow the instructions by giving a postcode or area name for which you want data, and click on the ‘Local Authority’ statistics option, and press SEARCH.
- You can choose from an array of topics on the next page. We suggest you select the second topic in the list: ‘2001 Census: Key Statistics (31 datasets)’. Detailed information across more areas (without percentage summaries) is available from the ﬁrst topic in the list ‘2001 Census: Key statistics’ (61 datasets)
- A range of basic demographic areas will be listed in these topic pages. Ethnic group and country of birth categories will probably be of greatest use.
Knowing the overall size of the population is a start. If you want to ﬁnd out about Census information in greater detail, call the helpful ONS staff on 0845 601 3034 or email firstname.lastname@example.org.
Census data collected in 2011 is just starting to be published on a distinct part of the ONS website, however, the first data release launched in July 2012 simply gives a national impression of population change and growth across England as a whole, rather than giving any detailed data on ethnicity or locality. However, there is important information on overall population change broken down by regional level that is given in this first data release, and we advise that it will be useful for planners to refer back to this section of the ONS site regularly, as data will be released incrementally in the coming months and years. At the moment, you may find it useful to use the local authority and regional comparator tool made available by the ONS. At the moment this only compares local features such as age and gender, but it does give a sense of the local population profile in these basic terms very quicly and easily. In time, the new census data will provide us with much more up-to-date information about the number of African people living in the UK.
Consulting with local experts, and using data collected by the Health Protection Agency will help in the development of estimates of your local population in the key target groups (ie. African people with diagnosed HIV). The Health Protection Agency website provides regular reports on HIV prevalence as well as information from routine surveillance that monitors all those under the care of an HIV specialist, called SOPHID. Very detailed local data gained through SOPHID is not always provided online, in order to protect identities where numbers are very small. Where information is restricted, it is worth contacting the person who commissions HIV and/or sexual health services in your area, as they may be able to share some figures with you while also protecting patient confidentiality at the local level.
Beyond just knowing about the population of African people in your locality, it is crucial to ensure that you understand how other organisations and individuals are working locally to meet the needs of this population. To this end, we recommend:
- List the local policy makers and commissioners, as well as statutory and voluntary service providers concerned with the health and social care of African people.
- List the local commercial and community venues that serve African people.
- List the expatriate African social groups or networks within the area and establish the extent to which these are utilised by various sub-groups of African people.
- List the local commercial and community venues that disproportionately serve young people and establish what proportion of their service users are African.
- List the lesbian, gay, bisexual and transgender (LGBT) social groups or networks within and adjacent to the area and establish the extent to which these are utilised by African people.
- Obtain ﬁgures on the current statutory spend in the areas of sexual health, STI and HIV prevention for your local area. Start out by asking local commissioners if they have this data.
- Obtain key strategy documents.
The local assessment exercise outlined here is primarily a desk-based activity. It does not involve ﬁeldwork or community consultation. It gives rise to a plan for local work, starting with a decision on whether it is best to undertake an intervention that directly targets African people (a direct contact intervention), or one which operates to boost the infrastructure which supports African people (a structural intervention).
There have been indications that health commissioning in the future will be driven by national outcome indicators (see the Policy Context section below). Where planners of HIV prevention interventions for African people are able to clearly articulate likely outcomes by strengthening the connection between local need, intervention activities and proposed outcomes, they will be more likely to gain funding. Due to the economic climate, the attainment of statutory sector funding in future years will be increasingly competitive especially since HIV prevention has not been a domestic priority for some years (National AIDS Trust 2007).
The UK coalition government has put plans in place to dramatically reshape the future work of the Department of Health, and the NHS (including the way in which Public Health services will be provided). This sub-section aims to describe this process of change, including the provision of updates as new plans and processes are announced.
This government's reframing of health provision was first set out in Equity and excellence: Liberating the NHS (2010), which describes a Department of Health that aims to:
- put patients at the heart of everything the NHS does;
- focus on continuously improving health outcomes; and
- encourage clinicians to innovate, with the freedom to focus on improved services.
There was a wide-ranging consultation undertaken at the time, including questions about the practical functioning of GP consortia for NHS commissioning. Documentation relating to that consultation, as well as responses and related fact-sheets can be found here.
Another key component of the NHS restructuring proposals was outlined in the coalition government's public health White Paper, Healthy Lives, Healthy People (2010). Central to these proposals is the development of a new public health service, called Public Health England (PHE). PHE will be responsible for delivery of improvements in public health, working closely with local authorities and other partners. PHE and local authorities will jointly appoint directors of public health who will be responsible for the health of their local populations. In April 2012 PHE is expected to absorb the functions of the Health Protection Agency, the National Treatment Agency, and the regional and specialist Public Health Observatories. At a local level, transition activities will lead up to formal transfers of public health powers to Local Authorities by April 2013.
**Most Recent Policy and Practice Updates**
- Februrary 2013: Public Health England and the Local Government Association publish Sexual Health Commissioning: Frequently asked questions. This document is intended to provide further information for Local Authority commissioners and service providers about the way in which sexual health services will be commissioned by Local Authorities from April 2013.
- October 2012: The Department of Health ends funding for HIV-specific telephone helplines, although THT Direct will run a reduced service using alternative source of funding. The I Do it Right Helpline, (formerly the African AIDS Helpline) operated by Black Health Agency is now no longer in service.
- October 2012: The Department of Health publishes a range of factsheets on the health intelligence requirements for local authorities to be implemented by April 2013. This information will be critical for all of those seeking to understand who will be responsible for collecting, holding and sharing various forms of data on health and social deprivation at national and local population levels.
- October 2012: The Department of Health implements a new policy for free and open access to HIV treatment for all who need it, regardless of immigration status.
- Sepember 2012: The Department of Health publishes its factsheet on how Health Protection in Local Goverment will be managed after April 2013. It includes mention of local public health directors' role to develop "local plans and capacity to monitor and manage acute incidents to help prevent transmission of sexually transmitted diseases, to control outbreaks and to foster improvements in sexual health".
- July 2012: The Local Government Association releases its Development Tool for Health and Wellbeing Boards. This document will help boards to keep on track in their planning over the next three years, and will be an important local advocacy tool for charities that seek to ensure their HWBs are functioning to the best of their capacity.
- July 2012: The structure of Public Health England is published. The new organisation will be fully operational by April 2013.
- April 2012: Shadow Health and Well Being Boards are implemented, with an aim to work towards transition into full statutory power in April 2013. Health and Well Being Boards will have strategic influence over commissioning decisions across health, public health and social care. The goal is for these boards to provide a greater role for integrated planning and commissioning across public health and social care at the local authority level. Local HIV service providers are strongly encouraged to seek out and establish contact with members of their Shadow Health and Well Being Board now, during this period of transition. The Department of Health has provided a summary of the role of the boards on their website, and is also undertaking a consultation exercise in June 2012, seeking input from a range of experts to determine what the statutory powers of the local Health and Well Being Boards should be.
- March 2012: Health Watch is envisaged by the Department of Health to be ‘the independent consumer champion for the public - locally and nationally - to promote better outcomes in health for all and in social care for adults'. There is as yet very little development in the way of what HealthWatch will be, but the intention is that it will collate evidence of public and service users' views and experiences in order to better influence planning, commissioning and delivery of health and social care. It will carry some of the roles of what was formerly known as LINKS, and will manage complaints as well as supporting peole through a range of service choices within the NHS. In March, there was a useful independent report released, called Shaping Health Watch, which documents work with 9 local authorities to help them consider and plan their arrangements in regard to their duty to commission the new Local HealthWatch organisations that are being created throughout England.
- January 2012: The Department of Health and the Local Government Association have published a guidance document, Public Health Transition Planning Support for Primary Care Trusts and Local Authorities. This document offers guidance to relevant bodies on their new public health roles, gives further clarity on the roles of the NHS Commissioning Board, Local Authorities, and Public Health England, as well as outlining key elements of the transition plan.
- December 2011: Further details about how the new Public Health system will function at national and local levels are made available in the New Public Health System Summary. At the same time, other relevant public health planning documents were made available on the Department of Health's Modernisation of Health and Care webpages.
- July 2011: An update and timeline of implementation for Healthy Lives, Healthy People offers the government's response to issues raised during the consultation, and spells out further details about the process. That document confirms the government's intention that HIV treatment will continued to be commissioned nationally by the NHS Commissioning Board, while the responsibility for commissioning comprehensive sexual health services (including sexual health promotion and screening) will be transferred to Local Authorities.
- June 2011: Following several months of extended consultation, the NHS Future Forum released a set of recommendations to government about what they regard to be necessary changes to the government's plans. Within a week the government gave a full response to the Future Forum's recommendations, setting out how they plan to proceed with commissioning arrangements. They clearly announced that Primary Care Trusts will cease to exist in April 2013, with interim measures in place for areas where commissioning consortia are not in place.
In this time of change, all stakeholders are strongly recommended to check the Department of Health's Modernisation of Health and Care webpages regularly, as these provide up to date, plain language summaries of ongoing policy developments, suggestions for reform, and government responses. In addition, The Lancet oversees a new website called UK Policy Matters that provides plain language summary of reviews of evidence pertaining to health policy impact. Stakeholders are invited to share their own examples of health policy impact evidence, which will be assessed for inclusion on that site.
Sigma Research is committed to updating relevant sections of this website on a bi-monthly basis, as new policy commitments are confirmed.
Our capacity to reduce the number of new HIV infections relies on collaboration between NAHIP agencies and organisations beyond the NAHIP programme, including non-HIV and non-African organisations. Our success rests on the commitment of a diverse group of organisations and individuals with different histories and constituencies. This diversity demands a multi-level approach to realise the goals of HIV prevention. To this extent, every person’s contribution to, and support of this vision is crucial.
The local assessment should help planners to identify existing local HIV prevention interventions (provided by voluntary and / or statutory organisations). Not only will this help to avoid replication of local services, but it will also identify opportunities for working collaboratively with other organisations to achieve shared goals. For instance, those providing generic social services for African people, or clinical service providers seeking to increase uptake from Africans may beneﬁt from partnership working with agencies with African community expertise. Working in partnership can help to increase reach, improve acceptability and increase the likelihood of achieving sustained funding for an intervention.
A different way of considering partnership-working is to seek out best practice examples of interventions beyond the locality in order to determine if they might be feasible locally. Working together with others who have already devised successful interventions will help limited resources to go further, as there will be less trial-and-error with support from experts who have already undertaken similar work elsewhere. The structural interventions and direct contact interventions sections of this website offer ample case study examples, with links to the website of the relevant organisation should you wish to get in touch.
Partnership-working on a carefully selected policy agenda can prove to be particularly powerful, as evidence can be collated across agencies, and innovative approaches to exercising inﬂuence can be strategically applied by different actors, with a diverse range of targets.
One of the central aims of this site is to describe HIV prevention interventions in a way that clearly defines each element of the activity, so that strengths, weaknesses and outcomes can be seen clearly. The production, marketing and distribution of resources focused upon a particular theme (typiﬁed by the national NAHIP campaigns, for instance) is an important element of the direct contact interventions that occur with individual African people. However, it is necessary to understand the array of interventions that can comprise such campaigns - by starting to describe each of their parts in detail. A good way to begin breaking down interventions into their base elements is to pay close attention to the core aspects of the activities.
Different agencies and researchers describe and name interventions in different ways, with some focusing on settings (such as ‘schools work’), or target groups (‘sex worker project’), outcomes (‘empowerment intervention’) or activities (‘counselling’). There are also times when the same word (for instance, ‘training’) is used to denote very different types of activity (including: an HIV seminar day for African church-goers; health promotion staff induction; or an assertiveness skills course for young women).
These various ways to describe interventions make it difﬁcult to compare, review, learn about, evaluate, or standardise activities. As a result, UNAIDS’ recommended practice is to devise concise deﬁnitions for interventions that are generated through consensus, and that are primarily deﬁned by the activities or services and commodities provided (Sweat 2008). This enables all parties to have a shared understanding of what an intervention is, what it intends to achieve, and how it will do so.
This speciﬁcity helps to meet a range of needs:
- Funders will be clear what exactly is expected from interventions in order to ensure value.
- Planners and steering group members will be able to give adequate focus to each intervention, with detailed consideration about the most appropriate means of achieving a particular set of aims.
- Workers and volunteers will know how best to use different resources and skills in different contexts.
Direct contact interventions specifically address people whose behaviour puts them at risk of HIV exposure or transmission. Ten discrete types are described in the direct contact interventions section, classiﬁed according to their most basic common elements: talking and listening; reading and writing; and giving and taking. Classifying interventions in this way allows us to consider the modes of delivery and skills required for each.
Interventions can be bundled together to maximise their impact within programmes (Sweat 2008). In the direct contact interventions
Direct contact interventions
Sometimes the needs identiﬁed and the assessments of local resources and opportunities suggest the need for direct contact interventions with African people. Such interventions will aim to increase some element of African people’s knowledge, will and power to avoid involvement in HIV exposure and transmission.
For those who have identiﬁed direct contact interventions with African people as the desired course of action, careful consideration must be given to the particular target group that will most beneﬁt (WHO), the speciﬁc need that an intervention aims to meet (WHAT), and the intervention that is best suited to meet that need (HOW). This section provides details about each of these considerations.
WHO will beneﬁt from the direct contact intervention?: Not all African people are equal in their degree of HIV prevention need (Hickson et al. 2009) nor are all interventions useful or acceptable to all people
- which groups demonstrate greatest need when considering national and local data,
- which groups are immediately accessible,
- which community leaders / gatekeepers / or venues might be able to assist in accessing a particular target group.
WHAT is the aim?: The eight KWP behavioural aims for African people help planners consider the speciﬁc HIV prevention need that interventions should meet. Each of the eight aims require many needs to be met, and an intervention may be designed to focus on a particular sub-aim of one of these larger aims. For instance, in order to reduce sexual HIV risk behaviours (Africans aim 1), African people will need to know that HIV exists, the harm it can cause, and how to reduce risk; they will need the motivation to reduce the risk of transmission, and the power to act to reduce HIV transmission risk (see Africans aims)
HOW will the aim be achieved?: The blue direct contact interventions section
Evaluations of direct contact HIV prevention interventions have routinely found that face-to-face, prolonged, skills-related, culturally appropriate and theoretically-grounded interventions were most likely to demonstrate impact on HIV prevention need.
The pyramid illustrates the relationship between cost, efﬁcacy and likely reach of the different types of direct contact interventions described here. Reading and writing interventions probably have less impact than other interventions but they reach the largest number of people, and have the capacity to reach those who will not attend more intensive interventions in person. They probably have the lowest per person cost (although often a high overall spend), and should form part of national or regional programmes. They can also help build service recognition, and may draw users into face-to-face or telephone contact with services.
At the other end of the scale, Talking and listening interventions that aim to achieve therapeutic change, or build skills, are necessarily resource intensive and are among the most costly to deliver per person. It is therefore vital that high unit-cost interventions such as these are carefully targeted to ensure that those in greatest need access them. In the main, the goal of targeting at this end of the spectrum is to ensure that limited resources are not spent on intensive interventions for people whose needs could be met with cheaper interventions.
These considerations help to underline the added value of partnership working (achieving outcomes such as cross-referrals, shared expertise, and shared use of resources). Selection of an intervention for a particular sub-set of African people, to meet a speciﬁc HIV prevention need, should never be undertaken in isolation. Direct contact interventions are planned and delivered within the context of an array of activities undertaken by the same agency, and by others in the local area. Bundling of interventions into programmes helps to increase uptake by improving people’s capacity to select the most appropriate intervention for them. It also ensures that interventions are not contradictory and that referral pathways are clear.
Structural interventions are undertaken with those who have inﬂuence over the target population. They are sometmes called facilitation interventions. Just as direct contact interventions are undertaken across a broad range of agencies in diverse settings, so too are structural interventions. It is through working in partnership that the impact of all of our activities is multiplied. Therefore, agencies working to implement KWP should regard themselves as part of a network of mutually beneﬁcial relationships with others working on a variety of levels.
Deciding to work at the strategic level, by strengthening the formal and informal structures that support African people in their daily lives, requires no less planning than the provision of direct contact interventions. In addition, such work can be difﬁcult to evidence, so attainment of funding can be challenging. Structural interventions are almost always more likely to achieve success through partnership working, whether it involves the targeting of a organisation that you aim to inﬂuence by working with them, or by joining together with other agencies to advocate for policy change.
WHO is the target of structural interventions?: Not only is it necessary to identify speciﬁc organisations, services and people that will be the targets of strategic interventions, the local assessment should also indicate the individuals and particular post-holders who will provide an immediate point of contact. Identiﬁcation of the target will be closely tied to the resources available. Although it can provide widespread impact, seeking to achieve national change can require long-term commitment and the capacity to network and meet with other advocates from distant places. On the other hand, sometimes local issues can be addressed with swift and persuasive interventions. Identiﬁcation of the targets for a strategic intervention are closely tied to the needs identiﬁed and the type of intervention that is planned.
WHAT is the aim?: The structural targets and aims section provides considerable detail relating to an array of organisational aims and policy aims. Prior to implementation, it will be necessary to articulate what speciﬁc aim will be central to success. It is critical to establish concrete outcomes that will serve as markers to indicate how much progress toward an aim has been made.
HOW will the aim be achieved?: The structural interventions section offers a wide array of structural or facilitation interventions that will help to establish an environment in which African people are more likely to have their HIV prevention needs met. Determining the style or approach of such interventions will depend in large part on who is being targeted, and the aim of the intervention.
Community development (such as resource and skills sharing) and sector development interventions (such as the provision of newsletters, email updates, training, conferences or brieﬁng papers) are most likely to be selected and planned based on what is uncovered in the local assessment. However, sometimes the outcomes of policy development interventions can be externally shaped, as they may occur in direct relation to a critical event, or because of a consultation process that is driven by others. The identiﬁcation of key strategic aims and objectives in organisational planning can improve the extent to which the decision to participate in (or respond to) external events is in accord with an agency’s overall vision.
Targeted structural interventions are never undertaken in isolation, because they usually relate to a particular social, economic and political context shared by many stakeholders. Therefore, the identiﬁcation of those working toward shared goals can be vital in shaping how structural interventions are devised, as well as ensuring their ultimate success.
Effectiveness refers to the achievement of the desired outcomes among the population to whom the activity was directed. The limited evidence (Downing et al. 2006) about the effectiveness of direct contact interventions suggests:
- Interventions undertaken with groups, such as cognitive behavioural therapy, skills development and relapse prevention can inﬂuence the sexual behaviours of black and minority ethnic (BME) adults.
- Information and advice provided by peers, and interactive condom distribution in community settings inﬂuence behaviour among BME women, heterosexual men and adolescents.
- Culturally-grounded interventions (that account for cultural norms, rather than just being about visual representation of BME people) can increase information uptake in the target population.
This evidence was primarily collected in the United States, from interventions undertaken with African Americans, and we must be cautious about the successful transfer of interventions with BME community members in one cultural context (African Americans) to another (African people in the UK). However, the US Centres for Disease Control and Prevention have identiﬁed 18 best practice interventions (Lyles et al. 2007) and the most common elements shared by these interventions were:
- a clearly articulated reliance on a social theory or behavioural change model;
- facilitator characteristics that were shared with the target population;
- more than a one-off interaction, with many falling somewhere between 9 and 18 hours in duration; and
- a focus on skills-building including correct condom-use, communication, decision-making and interpersonal skills.
Reviews of best-practice therefore suggest intensive interactions that offer opportunities for sustained engagement and skills development. These ﬁndings offer promise for the development of such interventions in the UK, although maximising the utility, acceptability and efﬁcacy of interventions in this context will require ongoing evaluation and careful planning. No intervention occurs in a vacuum. Even where it may be difﬁcult to demonstrate that a one-off intervention (such as a mass media advert) has a direct impact on behaviour, all of these activities are likely to contribute to the broader aims of improved social norms regarding sexual health and sexuality, and also help to build the brand recognition of agencies whom service users may approach for further interventions.
There is also evidence regarding the effectiveness of structural interventions. A review (Bauermeister et al. 2009) found interventions offering technical assistance to HIV organisations that utilised multiple interactive education approaches, and those aiming to increase internal communication processes in organisations were most effective. The same reviewers also found that partnership working to reduce duplication of effort and link existing resources into bundles were successful.
A global review (The Global HIV Prevention Working Group 2008) of the common attributes of successful behavioural prevention interventions (including direct contact and structural interventions) highlights:
- Combination prevention: the simultaneous use of diverse strategies, from the individually-focussed, to changes in the socio-economic conditions and social norms of entire sub-populations.
- Ensuring proper scale: with attention paid to coverage, intensity and duration.
- Affecting knowledge, attitudes, practices and behaviours: which means not just aiming to increase knowledge to reduce risk, but also attending to the issues which will influence motivation to do so.
- Changing social norms: with regard to the social dynamics that influence individual behaviour.
- Access to HIV prevention technologies and commodities: including easy access to male and female condoms and PEP.
- Specificity to context: success depends on interventions that resonate with the intended audience, and address their needs and values.
All of these attributes of successful HIV prevention interventions underpin the content of this website.
In addition to evidence obtained by outcomes evaluations as described by those above, there is also an increasing amount of attention on the role of cost effectiveness evidence. The Centers for Disease Control and Prevention in the United States has produced an overview guide to assessing HIV prevention cost effectiveness that has relevance in all localities. A good understanding of cost effectiveness evidence and its application in intervention selection is a key feature of successful planning.
Page last updated: 26 February 2013