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     London African
    Communities HIV
 Prevention Partnership:
Commissioning Intentions
      2007 – 2010




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Part 1: background and rationale
1     Rationale
1.1   The rationale for joint commissioning African HIV Prevention is to:
         ensure consistency of approach.
         reduce wasteful duplication and overlap of services;
         reduce transaction costs for commissioners and provider agencies;
         achieve economies of scale;
         encouragement of partnership as good practice
         promote the development of specialist providers;
         ensure that overall provision is strategic and programmatic and to
          avoid „postcode lottery‟ provision;
         provide stability for providers in a 3 year commissioning cycle;
         provide a core set of services London-wide to meet the needs of a
          highly mobile population and recognise the needs of geographically
          mobile populations
         support and complement local HIV prevention activities and NAHIP
          work
         facilitate ongoing monitoring and evaluation of effectiveness

2     Background
2.1   In 2004 here were an estimated 58 300 (range: 54 700 – 63 400)
      people living with HIV in the United Kingdom (UK), of whom 19,700
      (range: 16,100– 24,800) were unaware of their infection
2.2   The 2005 Health Protection Agency surveillance report for the United
      Kingdom (UK) describes a worrying situation with undiminished and
      high levels of transmission of HIV and other sexually transmitted
      infections (STI‟s) among men who have sex with men (MSM), a steady
      increase in the number of HIV-infected black Africans in the UK, limited
      but compelling evidence that heterosexual transmission of HIV within
      the UK is slowly rising, and corresponding continuing high transmission
      of other STI‟s.
2.3   Whilst constituting less than 1% of the UK population, Africans account
      for 35% of new HIV diagnoses each year. Africans make up a
      significant proportion of people infected with and disproportionately
      affected by HIV in the UK. In 2005, 8331 Africans diagnosed and living
      with the HIV virus were resident in London; this is a 16% increase from
      the previous year and exceeds the overall London prevalence
      increase, which is 12% for the same period


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2.4    Anonymous unlinked survey data identifies that around half of all
       heterosexually acquired infections are currently undiagnosed in the UK.
       It is therefore reasonable to estimate that there are around 16,000
       African people living with HIV, are resident in London

2.5    The annual number of infections newly diagnosed in the UK relating to
       heterosexual men and women born in sub-Saharan Africa remained
       high in 2004, when there were a total of 2315 such diagnoses. Over
       90% of heterosexually acquired HIV infections diagnosed in the UK
       during 2004 were probably acquired in high prevalence countries of
       origin, mainly sub-Saharan Africa. The prevalence of previously
       undiagnosed HIV infection in heterosexual sub-Saharan Africa born
       attendees at GUM clinics was 2.7% in London and women born in sub-
       Saharan Africa had the highest prevalence 2.38%

2.6    While relatively low, the number of black and minority ethnic (BME)
       adults acquiring HIV through sexual contact in the UK is rising steadily

2.7    Qualitative data has shown that among migrant African communities
       fears of an HIV diagnosis and HIV-related stigma and discrimination
       are key factors among those reluctant to uptake voluntary confidential
       testing for HIV.

2.8    There is limited routinely collected data on the country of origin;
       however Table 1 shows the Health Protection Agency report that the
       top 10 countries for heterosexual cases of HIV diagnosed in UK in
       2004 were, 8 of which are African countries. National Statistics figures
       for populations within London who have been born outside the UK are
       also provided. It should be noted that whilst useful, this data should be
       viewed in the context of patterns of asylum and migration to the UK
       and a limited data collection method.

Table 1. Countries for heterosexual cases diagnosed in the UK (2004)

                          Country of Origin             Estimated population in
                                                        London born outside of
                                                        the UK - June 20061
           1              Zimbabwe                                 29,000
           2              UK                                     5,068,913
           3              South Africa                             60,000
           4              Nigeria                                  68,000
           5              Malawi                                    2,000
           6              Uganda                                   30,000
           7              Zambia                                   10,000
           8              Thailand
           9              Kenya                                   67,000
           10             Ghana                                   74,000

       1
           National Statistics 2006


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2.9   Table 1 shows that based on these 8 countries alone, the population
      figures in London already exceed 300,000, notwithstanding both other
      African countries of origin, nor migration and asylum

3     Health Status
3.1   HIV infected Africans tend to be diagnosed at a later stage of their
      infection than other populations in the UK. They are more likely to test
      HIV positive at a more advanced stage of disease progression, with
      low CD4 counts and at least one AIDS defining illness.
3.2   In 2003, of all Africans diagnosed with AIDS:
           8% were children,

           36% had tuberculosis,

           18% had more than one AIDS defining illness.

3.3   Low levels of testing and late diagnoses reduce the likelihood of
      access to clinical monitoring, anti-HIV treatments and the opportunity to
      make informed choices about appropriate behaviour modification.
3.4   Issues of social exclusion have led to wider health inequalities for
      African communities in the UK. These serve to limit their access to
      primary health care and health promotion messages, as well as
      exacerbating health and care related needs for HIV positive Africans.


4     Guidance on the standard of care and commissioning
      HIV prevention services

4.1   This strategy draws on guidance in national and regional reports,
      including the National Sexual Health and HIV Strategy (2001) and the
      National Strategy for Sexual Health Implementation Action Plan (2002),
      which emphasise, amongst other things the importance of access to
      good quality sexual health advice and supporting adherence to drug
      regimes, good practice in skills development for people living with HIV,
      and minimising bureaucracy.
4.2   The Strategy identifies African people as a population affected by
      inequalities, social exclusion and high rates of HIV infection among
      adults and children, and therefore in need of targeted HIV prevention
      activities. The Strategy recommends that Commissioners, service
      providers and health professionals should:
           Focus sexual health promotion and HIV prevention on identified
              local need, set targets in line with national priorities and monitor
              progress as appropriate to local populations.
           Support all staff to develop their skills through work-based and
              other dedicated education and training programmes, in line with
              national priorities.


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             
             Ensure prevention is integral to service delivery.
             
             Co-ordinate local information campaigns with national
             information campaigns and ensure they meet good practice
             benchmarks.
           Work towards achieving a target to reduce the number of newly
             acquired HIV infections. 2
4.3   The White Paper Choosing Health: Making Healthy Choices Easier
      was published in November 2004. It establishes a requirement to
      develop sexual health services (amongst others), which are delivered
      in a near-patient manner.
4.4   The Department of Health has also issued a guidance document:
      Effective Commissioning of Sexual Health and HIV services 3, which,
      amongst other things emphasises the importance of lead and joint
      commissioning structures, the use of Health Act (1999) flexibilities, the
      involvement of service users, and clarifies that “the purpose of
      commissioning is to maximise the health of a population and minimise
      illness by purchasing health services, and by influencing other
      organisations to create conditions which enhance people‟s health”.
4.5   The toolkit identified three key priorities:
                  1)    To ensure policy making is more joined up and strategic,
                  2)    To make sure that public service users, not providers, are
                        the focus by matching services more closely to people‟s
                        lives,
                  3)    To deliver public services that are of a high quality and
                        are efficient. 4


4.6   The Toolkit highlights the importance of commissioning in a transparent
      way, and involving service users and voluntary community
      organisations (VCO) in the process:
             “PCTs can ensure a level playing field for statutory and
             voluntary    organisations.   Robust    and     transparent
             commissioning processes can be established to ensure VCOs
             have the same opportunities to tender for and deliver
             appropriate services as PCTs and NHS Trusts.

             Wherever possible, three year funding agreements could be
             considered, with constructive and supportive contract
             management to back this up.



      2
          Ibid, p 21.
      3
       A sexual Health and HIV Commissioning Toolkit for Primary Care Trusts and Local
      Authorities, Department of Health, January 2003.
      4
          Ibid. p. 7.


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              PCTs can also ensure that VCOs delivering services have
              access to local capacity building and work with local
              Workforce Development Confederations. Capacity building
              and support will be particularly important for small community
              based organisations such as African HIV community groups.” 5
4.7    The London HIV Strategy 6 confirms the importance of pan-London
       working and notes that key issues facing commissioners and providers
       of services in London include:
             ensuring provision of effective evidence-based Pan-London HIV
              prevention.
             Service redesign – “over the past few years there has been an
              under developed focus upon service redesign such that current
              service systems in the capital are designed to meet the needs of
              smaller STI and HIV epidemics.”
             Resource pressures – “the growth in the numbers of people being
              diagnosed with HIV is presenting, and will for the foreseeable
              future, continue to present a significant financial challenge for
              PCTs.
4.8    The London Strategy identifies the need for priority to be given to co-
       ordinated HIV prevention work targeting Black African communities. It
       recommends that a programme of pan-London HIV prevention work
       targeting Black African communities be developed, which is informed
       by the national African HIV Prevention Framework and recognises that
       it would be beneficial for local and pan-London African HIV prevention
       programmes to dovetail in a complementary way.

4.9    London Assembly: Living with the Virus: The report of the London
       Assembly Health Committee scrutiny of HIV services in London
       identified the need for regional approaches and recommended that the
       commissioning and funding of services be strengthened at the
       following levels:
                    The coordinated planning            of   pan-London primary HIV
                     prevention services,

                    Pan-London assessment of the changing needs of PWHIV,

                    Appropriate and equitable distribution of funding for voluntary
                     sector services.
4.10   DoH: Creating a Patient-Led NHS (HCC 2005). Building on the „NHS
       Improvement Plan‟, this document describes the steps that NHS
       organisations must take to become patient-led, “responding to their
       needs and wishes.” Key points include:
             Giving patients more choice and control wherever possible

       5
           Ibid. p 20.
       6
           London Specialised Commissioning Group, January 2005.


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          Building on current practice in shared commissioning with the aim
           of creating a far simpler contract management and administration
           system which can be professionally managed and provide better
           analysis

          Offering patients an informed choice of treatment options, treatment
           providers and location for receiving care
          PCTs will not be expected to direct patients to particular providers
           but PCTs will need to ensure that patients have all the help they
           need to make choices

4.11   Maximising Influence (and Effectiveness) Rationale: Saving Lives:
       Our Healthier Nation (Department of Health, 1999) emphasised the
       importance of moving from competition to co-operation among those
       involved in service planning and delivery in the NHS. It is suggested
       that, given the complex influences on people‟s health, no single agency
       can hope to meet all the health-related needs of any population. In
       London, no agency even has exclusive access to or exclusive influence
       over any one individual. Complementarity of approach is therefore
       paramount within HIV health promotion.

4.12   Maximising Efficiency Rationale: Having a programme can lead to
       greater efficiency and reduces the cost per strategic outcome as
       duplication can be reduced. The HIV health promotion activity map for
       Greater London 1999-2000 (Hartley et al., 1999) shows many high
       volume low intensity interventions (mass media adverts, leaflets and
       websites for example) are duplicated. Scene It Done It 99 (Hartley et
       al., 2000) shows us that single high volume low intensity interventions
       reach high percentages of the target population making it very clear
       that this duplication is inefficient.

4.13   Monitoring and Evaluation Rationale: A programme makes it
       substantially easier to design and implement core monitoring
       instruments. In subsequent years this will enable Strategic health
       agencies and PCT‟s to make judgements regarding funding using data
       on the precise number of their local residents benefiting from a service.


4.14   While advancing the case for a pan-London programme, it is crucial to
       draw on the experiences gathered from successful local initiatives
       commissioned by the PCTs and promising national projects currently
       facilitated through the National African HIV Prevention Programme
       (NAHIP) by the African HIV Prevention Network (AHPN). Given the
       high mobility of the African population, and the higher incidence of HIV
       infection in London, it has been strongly argued that current works will
       be seriously undermined without a coordinated pan-London
       programme.
4.15   Doing it Well (AHPN 2005). As part of the National HIV Prevention
       Programme (NAHIP), the „Doing it well‟ good practice manual


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       highlighted the need for skills development in HIV prevention services
       among African communities. The manual also suggested specific
       methods to be used by both African service providers and
       commissioners to ensure quality services are provided in an effective
       and collaborative way.

4.16   A Framework for African HIV prevention
       The National African HIV Prevention Framework published in 2005
       identifies a core set of HIV prevention needs for Africans living in
       England, regardless of their HIV status:
               “The need for knowledge: Basic information is needed
              about HIV transmission, testing and treatment, including the
              role of traditional practices.

              The need for skills: Skills in the negotiation of safer sex that
              is culturally appropriate and sensitive to the needs of both
              partners, especially where only one spouse lives in this
              country.

              Building a safer sex culture: There must be agreement
              within communities that HIV is real and undesirable and that
              safer sex is necessary and desirable. Only then will consistent
              behaviour change be achieved.

              The need for accessible and appropriate services: Some
              services are culturally insensitive; others are directly or
              indirectly racist. Shifting sexual health services into community
              settings should be urgently considered. Institutional racism
              must not be tolerated. Service providers and African
              communities together must ensure that those with uncertain
              immigration status are aware of the confidentiality of sexual
              health services.

               The need not to suffer HIV related stigma and discrimination:
               HIV is heavily stigmatised in African communities, as well as
               mainstream communities. Such discrimination is unacceptable and
               can inhibit disclosure, undermine self-esteem and can lead to
               domestic violence against women and family break-up.”7




       7
           Ibid.


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Part 2: The strategy
5     Strategy
5.1   This document outlines the principles, strategic aims and targets for a
Regional Programme of primary HIV prevention work with African
Communities in London for the period 2007-2010

      Definitions

       1)    In line with the National AIDS Trust report focussing on the
             development of a London HIV Prevention Strategy:
       2)    The term „African‟ will henceforth be used to refer to individuals
             from high prevalence African countries now resident in the UK.
             Use of this term is intended neither to suggest that all Africans in
             the UK come from high prevalence countries, nor that „Africans‟
             are an ethnically homogenous group
       3)    Primary HIV Prevention is defined as “activities focused on
             preventing uninfected people from becoming infected.
             Secondary HIV Prevention is aimed at enabling people living
             with HIV to stay well and to prevent the onward transmission of
             HIV. Tertiary HIV Prevention aims to minimise the effects of ill
             health experienced by someone who has symptomatic HIV”-
             (Doing it Well)

5.2   HIV prevention and sexual health promotion activity is focussed on
      long-term health gain as well as behaviour change. Knowledge alone is
      insufficient to change behaviour, and so a range of methodologies that
      improve skills and confidence or aim to influence a specific behaviour
      are required.

5.3   However as no single intervention, or even a single agency, is likely to
      impact on the incidence of HIV in any significant way interventions
      must be targeted, context-specific and ideally part of a programmatic
      approach across a range of clinical and community settings. The
      proposed programme will focus primarily on primary HIV Prevention
      interventions, but will be linked into secondary and tertiary work.
5.4   A regional, programmatic approach has been shown to be highly
      effective in the commissioning of gay men‟s HIV prevention work and
      treatment information provision.       A similar approach to the
      commissioning of African HIV primary prevention services will enable
      the sharing of cost and risk, and the implementation of best practice
      across sectors. This would make it possible to pool resources and
      minimise the duplication of projects by PCTs and Voluntary Sector
      providers.
5.5   Working at a pan-London level will also facilitate the evaluation of
      African HIV prevention activities, enabling achievements and
      recommendations for improvement to be acknowledged centrally and


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      implemented across a wide geographical area. Integral to the design of
      a Pan London Programme would be the need to ensure it
      complements both local and national work.

5.6   Health promotion skills development, and organisational development
      will be an explicit part of the programme and PCTs will continue to
      support and enable a range of organisations and agencies to deliver
      effective sexual health promotion to African people
6     Programme Aim
6.1   To develop a culture of awareness of, and support for, HIV related
      issues amongst African communities in London in order to reduce:
         the sexual transmission of HIV infection among Africans living in
          London and their partners ,
         vertical transmission of HIV among Africans living in London,

         The prevalence of undiagnosed HIV infections in Africans living in
          London,

         The stigma associated with HIV among Africans living in London,

7     Social and Sexual Migration
7.1   There are a limited number of African social and cultural venues in
      London, some of which cater to specialised communities, whilst others
      are more generic African settings.
7.2   The Mayisha study identified that African communities are
      characterised by flux – i.e. they are geographically mobile, moving
      between boroughs for educational, employment, family, sexual and
      residential purposes.
7.3   Extensive sexual and social mixing within, and between, communities,
      with social networks existing between Africans of different nationalities
      and cultures, and in different geographical areas.
7.4   Likely to travel to access services provided outside their borough /
      health economy of residence.
7.5   The Mayisha report also identified that a significant number of people
      will travel to their country of (familial) origin, with 48% of women and
      43% of men having travelled “back home” in the last five years. Of
      these rates, 17% of men and 9% of women reported having had a new
      sexual partner whilst there.
8     Critical Mass and Economy of Scale
8.1   Africans constitute less than 1% of the UK population. In London as a
      whole this figure is higher overall, but this proportion varies significantly
      across individual local authority and health economy boundaries.
8.2   The African population is not homogenous, but is comprised of a
      number of cultural sub-populations. There are many areas of diversity


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       within London‟s African communities, according to education, class,
       age, country of origin, religious, linguistic, and gender-based factors.
       In any given area, some of these sub-populations may be small in
       number, yet in significant need of HIV prevention interventions.
8.3    Some interventions require a critical mass of potential service users,
       which mean that they would not be feasible to deliver locally. These
       interventions lend themselves to be planned, coordinated and delivered
       on a London wide level, as they will be more likely to reach an effective
       number of people from target populations across the region.

9      Core principles of the programme

9.1    Interventions need to be –
        Based on current epidemiological evidence, so as to be needs
           based in terms of the communities targeted.
        Provide good value for money.
        Sensitive to the linguistic and cultural needs of communities they
           are designed to reach.
        Based on evidence of effectiveness and appropriateness.
        Targeted according to mapping of communities across London.
        Underpinned by rigorous evidence of need and evaluation
        Provide monitoring of outputs and outcomes and these findings
           used to inform development of the programme.
        .

9.2 A key challenge is how to achieve comprehensive coverage of the whole
       African population given the sub-cultures, mobility and diversity of the
       collective community. If the are to be equitable there has to be at least
       a basic „safety net‟ level to the interventions proposed aimed at the
       whole or majority of the population

9.3    The challenge is therefore to achieve maximum coverage within limited
       funding and consequently identifying those methods or interventions
       that lend themselves to this approach and are cost effective for
       contributing PCT‟s

10 Commissioning Intentions

10.1   Different methodologies are needed to work effectively with and within
       different communities and settings due to different needs. Knowledge
       alone is insufficient to change behaviour, and so a range of
       methodologies that improve skills and confidence or aim to influence a
       specific behaviour are required

10.2   Commissioners recognise that some interventions are best delivered at
       a local level and have prioritised key interventions, which are likely to
       be most effective, delivered across London. It is recognised that other
       interventions lend themselves to this approach and recommend the



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       adoption of an incremental approach to the commissioning of the
       programme.

10.3   The following interventions have been prioritised for tender in 2007/8
             Mass Media
             Small Media
             Health Promotion Skills Development
             Organisational Development
             Monitoring and Evaluation

       Further detail on each of these interventions is given below

11     A summary of the proposed African Prevention Services

11.1 Careful attention needs to be paid to quality standards, if the prevention
     initiatives are to be maximally effective

             Effective support for African HIV prevention organisations
             Prevention should be life long
             The information, advice and support given must be accurate, up
              to date and comprehensive
             A programmatic approach needs to be well maintained with clear
              protocols for identifying gaps in provision, and for digesting and
              cascading the implications of new research and monitoring data
              from the programme itself
             There should be structured feedback from the intended
              recipients of all the proposed interventions, whether that be
              organisation or individual

       These standards will be explicitly specified in service specifications

11.2   The following table provides a summary of the key tasks proposed in
       the African HIV prevention work streams and the implications for the
       organisation providing the work


                     Task                         Implications for service
                                               commissioning and delivery
        Identify the whole population     Set goals to provide information to the
        of those at risk                  population as a whole or achieve
                                          critical mass coverage
                                          Develop specific targets around
                                          publicity, access to information and
                                          develop community based
                                          interventions
                                          Contact via the channels which
                                          provide the greatest and readiest
                                          access to the greatest number




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       Engage and interact with        Develop a network of organisations
       community organisations and     and individuals to consult and inform
                                       information and media campaigns
       individuals to identify high risk
       factors                         Develop strategy informing methods
                                       of campaign
       Offer information, advice and   Provide a critical mass of individuals
       referral campaigns tailored to and communities with information,
       those risk factors that were    advice and signposting via media
       prioritised                     campaigns
       Provide individuals who need A range of booklets and information
       them with relevant and          based in appropriate language format
       effective back up resources     which gives/discusses key advice in
                                       relation to identified risk factors
       Ensure that community           Identify agencies and
       organisations providing         workers/volunteers who have direct
       outreach/face to                contact with communities
       face/detached information and Develop training package based on
       advice are doing so with a      evidence and research around proven
       health promotion framework      outcome based health promotion
       and that the information being initiatives
       relayed is up to date, accurate Provide a range of health promotion
       and effective                   workshops/training sessions which
                                       provide the health promoters with
                                       accredited health promotion
                                       credentials
       Provide grass roots African     Identify the key areas of organisation
       organisations with the tools to development that are needed
       develop their business          Identify suitable organisations across
       capabilities and activities of  London to benefit from capacity
       business                        building
                                       Develop a tailored training sessions
                                       for individual organisations and also
                                       collective workshop opportunities for
                                       joint learning
       Verify the relevance and        Collect, analyse, aggregate and
       effectiveness of the services   report back from individuals, and
       offered                         community groups and organisations
                                       about their perception of how
                                       successful the interventions have
                                       been and in what ways
                                       Ensure there is a ring fenced budget
                                       for audit, evaluation and verification of
                                       the quality of the interventions
                                       Scale up success and decommission
                                       unsuccessful interventions


11.3   3-year contracts will be offered, with a review of the effectiveness and
       appropriateness of the programme-taking place during 2008/9. This



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       review, and regional commissioning developments, will be used to
       inform future priorities and commissioning intentions.

11.4   Commissioners will be assessing the “fitness for purpose” of providers
       to deliver the methods being tendered, so providers will be expected to
       demonstrate their experience of, capacity and ability to deliver the
       programmes.

11.5   Partnership arrangements will be encouraged these may reflect
       expertise within a specific aspect of service provision or geographical
       arrangements.

12     Work programmes

12.1 As previously discussed the programme is defined into 5 areas. The
   allocation or resources to these areas is detailed in Table 2.

Table 2: provisional allocation of funding to work streams over the 3 year period

        Workstreams                           Year 1 Year 2 Year 3
        Mass Media Campaigns                  30%    30%    30%
        Small Media Support                   20%    20%    20%
        Campaigns
        Organisational Development            25%      25%       25%
        Health Promotion Training             15%      15%       15%
        Monitoring, Verification and          10%      10%       10%
        Evaluation


13     Media Function
13.1   Mass media-definition: Use of channels of communication such as
       radio, TV, billboards, posters, newspapers, magazines to promote
       access to and increase awareness of specific issues related to HIV and
       HIV services and start influencing group/community norms and
       attitudes Includes display type media - on buses, tubes local train
       stations, social, workplace and commercial sites, schools, colleges,
       universities. Drama and discussion type programmes on radio and TV
       such as OBE channel

13.2   Small Media definition: A range of resources such as leaflets,
       booklets, postcards, information sheets, comics, CDs and supporting
       material such as telephone cards, badges, key rings, crafts, pens,
       wristbands etc to transmit information and increase awareness of
       specific issues related to HIV/HIV Services. Dissemination to be via
       outreach, at workshops etc

13.3   In order to use limited funding cost-effectively there is a shift of
       emphasis in this strategy away from expensive, glossy media
       containing brief messages, basic information and slogans, which are


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       distributed or broadcast at random. Similarly, in the past there have
       been variable standards of recording the distribution (and thus
       monitoring the uptake) of publications by African Communities. This
       has ranged from a subscription system (in the case of some
       newsletters) to the mere delivery of batches of publications to particular
       locations, with no further information gathered how many got picked up
       (and by whom). This latter approach has the potential for considerable
       wastage of funding and resources.
13.4   Instead, the emphasis of this Media Function is on providing
       comprehensive plain and appropriate language information and follow
       up information in sufficiently greater depth that will constitute the main
       effort of the programme. There is a shift in the mode of distribution
       towards handing out publications wherever possible only to those who
       are assessed to need them. Equally, the emphasis of skills needed in
       the publications function in the new programme will shift from „creative‟
       use of images and striking slogans, towards proven editorial ability to
       describe complex risk factors, situations, and circumstances as well as
       prevention techniques and coping strategies in plain and appropriate
       language.
13.5   Overall aim of the Media Function is to reduce acquisition and
       transmission of HIV in African communities in London.

       The specific prevention aims for mass media are:
            To increase knowledge about the relationship between HIV and
             sex
            To build a safer sex culture by addressing cultural barriers to
             safer sex
            To reduce HIV stigma and discrimination
            To reduce the prevalence of undiagnosed HIV
            Increased skills around negotiating safer sex and reproductive
             choices
            Reducing HIV stigma and discrimination

13.6   Principles
       The service will:
            Respond to the needs of different populations by producing
             inclusive materials in a range of languages including English,
             French, Kiswahili, Amharic, Portuguese, Luganda, Shona, Zulu
             English and French
            Recognise that over dependence on written interventions may
             not be appropriate
            Shape information around the needs of the target communities
            Avoid duplication, maximise resources, be integrated with
             national campaigns such as National African HIV Prevention
             Programme (NAHIP) and the small media work stream of this
             programme.
            Be of a high quality and conform to agreed quality measures e.g.
             comfortable (easy on the eye), welcoming, accessible and



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              responsive, and can be easily read and understood by people
              from all different backgrounds
             Make connections to brief and distribute small media resources
              to local outreach services servicing target populations
             Seek to reduce health inequalities
             Seek to continuously improve the resources by consultation,
              evaluation and feedback
             Ensure that the campaigns do not stigmatise African people
13.7   There will be three kinds of media publication.
          Two mass media campaigns per year initially. These will be tied into
           the supporting small media resources using a variety of press and
           media formats.
          A website developed for and supporting the campaigns which will
           have down loadable PDF versions of small media in community
           languages. The website will have an ordering facility for small
           media resources as well as a directory of and link to HIV services
           and support organisations/information across London and
           Nationally. Evaluation forms and process will be included on the
           website for feedback purposes
          Supporting material (or small media) for Mass Media campaigns
           which will be 3 topic based resources- that could include wallet size
           fold outs, postcards and 12 page A5 leaflets, sets of outreach aids
           which enable outreach workers to start conversations on the topics
           of the leaflets. Each leaflet to be printed with different languages
           according to the London population and have tear off evaluation
           page(s) for direct feedback form individuals

13.8   Key criteria for the work includes the following.
          Careful targeting in publications and web sites with large African
           communities readership to ensure maximum views per pound.
          Placement of posters throughout the identified access points
13.9   The purpose of the back-up resources (small media) is to build on the
       work of the Mass media campaign by providing individuals and
       communities with further or more in-depth information about risk factors
       and remedies. As such, its definitive form is likely to emerge and
       continually be updated.
13.10 These resources should include a number of different sections covering
      the range of the most important known areas of risk for unsafe sex. The
      following list is indicative only.
          Techniques of condom use and access to them
          Risks in relationships
          Understanding why you can‟t tell which of your sexual partners has
           HIV
          Risk where partners have unequal power relations


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          What you can do if you have unprotected sex (including post
           exposure prophylaxis)
          HIV testing
          Understanding the role of other sexually transmitted infections
          Sex between partners who are both HIV positive and informed of
           the other‟s status
          Common misconceptions
          How to volunteer and get involved
13.11 Other small media should only be generated at the behest of both
      community organisations and individuals. In other words, using the
      people that you are trying to target define how best and in what areas
      they need information
13.12 Under the proposed new contract routine feedback about the
      effectiveness, accessibility and usefulness will be collected for all
      publications in the following ways.
          The providers will record key data sets about the uptake of
           publications and encourage direct user feedback.
          Each publication will have a standard short (tear-off or attached)
           questionnaire asking for direct feedback to a Freepost address
           about the usefulness, accessibility and use made of that
           publication, together with suggestions for improvement.
       This will provide the editors of the Publications with timely information
       to tune the style and content of their rolling programme of publications.
13.13 Key indicators of success
       Routine positive feedback from African communities about the
         accessibility, relevance, and usefulness of publication(s).
          Feedback from African Communities on what they consider they
           have learnt from the publication(s).
          A rolling programme of technical peer review endorses the
           accuracy, relevance and objectivity of the information published.
14     Development of Health Promotion Skills and Practice of
       African Community Organisations

14.1   Whilst it is recognised that many African Community based
       organisations have considerable expertise and experience in the
       delivery of innovative HIV Prevention interventions, there is currently
       little formal accredited training and support to assist workers and
       volunteers in planning, delivering and evaluating community based HIV
       prevention interventions with African communities.

14.2   The aim of the service is to develop the health promotion skills and
       capacity of staff and volunteers in African led community-based
       organisations and Faith groups engaged in providing HIV prevention,
       information, advocacy, advice and other support services for London‟s


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       African communities affected by HIV. This support will involve the
       provision of a modular health promotion skills training course, one to
       one coaching and small group updates on key issues

14.3   It is anticipated that the training module will be accredited within year 1
       Targeted at frontline staff and volunteers and designed to be
       responsive to the cultural sensitivities and context of African
       Communities in London

14.4   The service will:

            Offer two modular health promotion skills training courses per
             year, with target of 15 participants from identified and nominated
             agencies on each course
            “Doing it Well” and other best practice examples in HIV
             prevention work/approaches will inform modular programme.
            The modules to include a range of areas such as-
             -the HIV prevention needs of African Communities the UK
             -role of HIV and sexual health services.
             -HIV testing and treatment
             -tackling stigma and discrimination
             -theoretical models underpinning HIV Prevention interventions,
             - the range of HIV Prevention interventions
             -use of research, Needs Analysis and data analysis
             -planning evidence based HIV prevention programmes, use of
             ASTORS/SMART frameworks -monitoring and evaluating HIV
             prevention projects
            Identify academic partners to accredit the Modular Health
             Promotion Skills Training Course
            Provide sessions of 1-1 mentoring/organisational development
             tailored to the need of the nominated organisation
            Provide half day briefings on topical issues
            Identify potential participants through the African Health Forums.
            Identification of potential delivery partners drawing on the
             expertise of existing African work and workers
            Contribute to the development of an evidence base.
            Identify long term outcome evaluation tools

15     Organisational Development Programme

15.1   The aim of the service is develop the infrastructure and capacity of
       African led community-based organisations and Faith groups engaged
       in providing HIV prevention, information, advocacy, advice and other
       support services for London‟s African communities affected by HIV.
       This support will involve the provision of organisational development
       consultancy and training. It is anticipated that organisations will move


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       thorough the programme and that the level of input will taper off. (I.e.
       avoiding dependency and promoting skills acquisition). Organisations
       will be nominated by a local Commissioner A project steering group will
       support the project

15.2   Principles
       The service will be-
            Co-ordinated, integrated, avoid duplication with other
             organisational development programmes, maximise resources
             and cost effective.
            Delivered as locally as possible
            Available when most needed. ·
            Demonstrably effective therefore strong monitoring and
             evaluation arrangements integral to the service.
            Of a high quality and conform to agreed Quality Measures

15.3   The Service will deliver:
           Overall 200 Days Consultancy
           Supporting 15 organisations at any one time with 1-1
            consultancy between 5-10 Days per organisation.
           Delivered in the form of one to one training/mentoring in the
            organisations premises and following an initial diagnostic
            assessment and subsequent annual organisational development
            needs assessment
           A number of bank days to provide flexible support on ad hoc
            basis
           Group training days -10-20 participants

16     Monitoring, Verification and Evaluation

16.1   The purpose of this workstream is to ensure that the programme
       maintains its‟ focus in the process of translation and interpretation that
       takes place in the cascade from commissioners to senior managers to
       middle managers to front-line organisations staff and/or volunteers

16.2   It is a common experience in any sector of health for assumptions to be
       made about the quality of services, and for monitoring and evaluation
       to be „squeezed‟ under the pressure of other budgets. This strategy
       ensures that funding is secured to ensure that vital data is gathered
       without which there can be no robust evidence that the services being
       delivered are needed, appropriate, fit for purpose, and equitably and
       efficiently delivered.

16.3   There is a critical need for better understanding of the sexual
       behaviours and attitudes of Africans with, or at risk of HIV, in the
       context of cultural practices and beliefs, relationships, gender disparity,
       and economic status. Properly designed studies should do more that
       merely collect epidemiological data; they should directly assess HIV
       prevention and care need. This is a model successfully developed in


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       gay men‟s work by Sigma Research.” HIV & AIDS in African
       communities: A framework for better prevention and care (2005)

16.4   Good practice also highlights the need to evaluate work that has been
       commissioned in order to assess impact effectiveness

16.5   The overall aim is to evaluate the interventions commissioned through
       the pan-London African prevention programme. In particular to-
         Assess the impact of interventions.
         Determine coverage of interventions·
         Highlight challenges faced by delivering organisations·
         Determine needs within the communities·
         Recommend improvements

16.6   The evaluation will take into consideration the targeting of specific
       groups, how the programme has responded to their needs. How the
       programme has avoided duplication, maximised resources, and been
       integrated with national and mass media campaigns, made
       connections with local services and sought to continuously improve the
       interventions by consultation, evaluation and feedback

16.7   The data collected should provide:
         Identification and evidence of a collaborative and inclusive
          approach to setting the mass media campaign function and content

             linked data on the back up publication(s) offered and the uptake
             Data and evaluation on provided via the website
             brief data collected in a single simple format from all service
              users asking them to give their feedback and assessment of the
              interactive interventions and publications they receive. This
              provides an unmediated opportunity for service user involvement
              potentially from any and every service user;
           verification/audit data to check the accuracy, integrity and
            appropriateness of monitoring data;
           evaluative data that allows ongoing and formative critical review of
            methods and approaches to identify potential for efficiencies and
            improvements in the quality, format and delivery of information.
16.8   In order to achieve the collection and functional reporting of the useful
       data described above, the workstream will need to establish and
       maintain the following systems.
           A bespoke database.
           Initial developmental work to support commissioners/providers in
            identifying the full range of known risk factors and remedies,
            defining the detailed data fields required and assisting provider
            managers in developing internal management systems for
            compliance with the data requirements.



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          Active real-time monitoring.
          Verification and audit.
          Evaluation.
16.9   Key criteria for each of these systems are described below.
          A bespoke database will be collecting comparable data sets for
           aggregation and comparison of quality standards and quantity
           targets across the programme.
          Whilst it is normal in the industry for the software to be licensed to
           the programme, and the preferred option would be a database
           hosted on the software provider‟s servers, the data will be owned
           by the Commissioner.
          Provision for addition of new data tables and fields as new needs
           and services develop.
          Secure hosting and storage on servers with adequate capacity and
           bandwidth, and industry standard back-up systems, including
           copies of the database kept off site.
          The database would ideally need to be developed in time to be fully
           functioning (and with time allocated for training in its use) at the
           beginning of the newly commissioned services in April 2007.
           However it is recommended that up to 6 months is allowed for this
           process of development, i.e. the database development work
           should be commissioned by the beginning of October 2006.
          The collection of data should analyse and report on emerging
           trends in meeting targets, uptake of interventions, effectiveness of
           outcomes and newly identified needs, and make relevant
           recommendations to the Commissioner;
          Analyse and report on direct feedback data from clients to ensure
           the involvement of African Communities in informing service
           development.
          In order to be fit for purpose in terms of monitoring real-time results
           and emerging needs the monitoring should lead to relatively
           frequent reporting in the first few months. Thereafter, assuming
           smooth running of the reporting system, data analysis and
           reporting may be extended to quarterly or even six-monthly.

17     Verification and audit
17.1   It is recognised best practice in the great majority of clinical services to
       audit various different aspects of the treatment or advice provided,
       conduct exceptions analyses, and in general use a variety of peer
       review methodologies to verify that quality standards are being met,
       and to apply remedial actions if they are not being met.
17.2   This present strategy therefore ensures that a budget is set aside for a
       rolling programme of verification of the quality standards and quantity
       targets for each service. The order of deployment is likely to emerge


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       from routine analysis of the basic monitoring data and/or from specific
       feedback, complaints or other exceptions.
17.3   Verification strategies deployed should include direct follow-up surveys
       of clients to elicit specific feedback about the services or publications
       they have received;

18     Evaluation
18.1   It is important to distinguish evaluation from monitoring, verification and
       audit.
18.2   It is equally important to recognise that there is no existing consensus
       in the field about the function and format of evaluation. The purpose of
       evaluation in the present strategy, however, is explicitly defined as
       applied research, using scientifically valid methodologies to collect data
       in order to analyse what benefits different groups of clients are
       receiving from a particular service, what relevant needs remain unmet,
       and how working practices could be improved to provide the client with
       a more effective, efficient or cost-effective service.
18.3   An explicit evaluation budget will be set aside for each of the three
       main workstreams.
18.4   Although each different service will need to evaluate aspects of the
       service that are unique to itself, there should also be a common core of
       standard types of data collected in each evaluation. For example, each
       evaluation should collect data about units of service output delivered
       and outcomes achieved, as well as direct feedback about customer
       complaints and satisfaction.

18.5   Key indicators of success should include the following.
            The data sets defined and collected are fit for purpose and focus
             on outcomes rather than processes.
            Provider agencies fully comply with monitoring requirements,
             and data is directly entered onto the electronic database in a
             timely and accurate manner.
            The completion and evaluation of the Online feedback function·
            The completion and promotion of the printed feedback function·
            A comprehensive list of collaboration agencies and onward
             referral agencies which are both HIV and Sexual Health specific
             and generic
            Direct link/collaboration with agencies delivering on the mass &
             small media contracts·
       END




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