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Reaching disenfranchised youth and mobile populations in Ghana through voluntary counselling and testing services for HIV Susi Wyss , Joyce Ablordeppey , Jane Okrah & Abigail Kyei Published online: 11 Nov 2009.

To cite this article: Susi Wyss , Joyce Ablordeppey , Jane Okrah & Abigail Kyei (2007) Reaching disenfranchised youth and mobile populations in Ghana through voluntary counselling and testing services for HIV, African Journal of AIDS Research, 6:2, 121-128, DOI: 10.2989/16085900709490406 To link to this article: http://dx.doi.org/10.2989/16085900709490406

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Reaching disenfranchised youth and mobile populations in Ghana through voluntary counselling and testing services for HIV Susi Wyss1*, Joyce Ablordeppey1, Jane Okrah2 and Abigail Kyei1 1

JHPIEGO Corporation, 1615 Thames Street, Baltimore, Maryland 21231, United States Family Health Foundation, PO Box SK 890, Sakumono, Tema, Ghana * Corresponding author, e-mail: [email protected]

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This paper documents the evaluation of a 20-month project to provide voluntary counselling and testing (VCT) to a mobile population of youth surrounding the Agbogbloshie market in Accra, Ghana. The specific objectives of the evaluation were to determine: 1) to what extent targets for providing VCT services to the specified population were reached; 2) how HIV prevalence among clients compared to that of the general population; 3) to what extent former clients self-reported behaviour change; and 4) whether useful lessons could be drawn regarding fees, hours, and location of services, as well as use of peer educators to increase use of VCT services among the target population. Various methodologies, including questionnaires, focus group discussions, a review of the service statistics and an exit poll of clients were used to evaluate the project. The service statistics demonstrated that the project exceeded the life-of-project target for number of clients by nearly 40%. Prevalence for the VCT client population (aged 15–25) was higher than for the general population (aged 15–24), although the gender differentials were similar. Focus group data suggested that clients may have adopted behaviour changes as a result of VCT. Finally, focus group discussions and VCT service trends showed that the high number of clients was largely influenced by three factors: services being free, location and hours of services being convenient to the target population, and use of peer educators to promote the services. In addition, the evaluation highlighted the importance of the counselling component of VCT, even as counselling can get short-changed at the expense of HIV testing when large numbers of clients are involved. The evaluation stressed the need to appropriately remunerate peer educators for their work whenever possible. Finally, VCT programmes continue to face challenges such as: HIV stigma as a barrier to people coming to be counselled and tested; insufficient availability of medication, support and services for HIVpositive clients; and difficulty of ensuring the sustainability of VCT programmes. Keywords: Africa, migrant workers, outreach programmes, peer education, programme evaluation, self-reporting, VCT, vulnerable groups

Introduction With over 24.5 million people living with HIV in sub-Saharan Africa, UNAIDS reports that youth and mobile populations are considered to be more vulnerable and at higher risk of becoming HIV infected than the general population (UNAIDS, 2001; UNAIDS, 2006). Although roughly half of new HIV infections occur in young adults, interventions do not sufficiently prioritise adolescents (Naranbhai & Karim, 2006). The programmes that do address HIV prevention for youth generally are implemented through schools and families, thus not reaching adolescents at highest risk (that is, disenfranchised youth who are out of school and/or have left their families) (Aarø, Flisher, Kaaya, Onya, Fugelsang, Klepp & Schaalma, 2006; Baptiste, Bhana, Peterson, McKay, Voisin, Bell & Martinez, 2006; Clark, Friedrich, Ndlovu, Neilands & McFarland, 2006; Jewkes, Nduna, Levin, Jama, Dunkle, Khuzwayo, Koss, Puren, Wood & Duvvury, 2006; Stigler, Kugler, Komro, Leshabari & Klepp, 2006). Similarly, although short-term mobility between rural and urban areas has been associated with sexual risk behaviours in sub-Saharan Africa, including West Africa,

more HIV prevention efforts that address migrants are needed (Lagarde, Schim van der Loeff, Enel, Holmgren, Dray-Spira, Pison, Piau, Delaunay, M’Boup, Ndoye, Coeuret-Pellicer, Whittle & Aaby for the MECORA Group, 2003; Lydié, Robinson, Ferry, Akam, De Loenzien & Abega, 2004). To date, interventions for HIV prevention in mobile populations have been primarily through treating sexually transmitted infections (STIs), and promoting condom use and behaviour change through poster campaigns and peer education (UNAIDS, 2001). Voluntary counselling and testing (VCT) services for HIV have proved to make a significant impact on people’s behaviour and, as a result, on HIV infection rates (Voluntary HIV-1 Counselling and Testing Efficacy Group, 2000). Moreover, clients that are HIV-positive can be referred to medical treatment for opportunistic infections and antiretroviral treatment (if they are eligible and antiretrovirals are available and affordable). They can also be referred for supportive services, including psychosocial services, to ensure that they take precautions to reduce their chance of

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re-exposure. Moreover, with the availability of rapid tests, VCT services are more accessible and acceptable than ever to potential users of VCT (DeGraft-Johnson, PazSoldan, Kasote & Tsui, 2005). Peer education has been documented as an effective tool in HIV prevention, including peer education for youth and mobile populations (UNAIDS, 2001; Molassiotis, SaralisAvis, Nyirenda & Atkins, 2004; Wolf & Pulerwitz, 2003). However, there is a dearth of literature concerning the use of peer educators to promote the use of VCT in general, and more specifically VCT for out-of-school youth and mobile populations. Because youth in particular are greatly influenced by their peers, the concept of using peer educators to promote VCT services seems logical. In Ghana, the estimated adult HIV prevalence is 2.2%, and the female to male ratio (1.8:1) is one of the highest shown in population-based studies in Africa. Prevalence among all youth aged 15–24 is under 1%, but, as in many African countries, the disparity in prevalence between males and females is especially striking within this younger population (1.1% HIV prevalence among women aged 15–24, as compared to 0.1% among men in the same age group) (Ghana Statistical Service, Noguchi Memorial Institute for Medical Research & ORC Macro, 2004). These demographic and health survey data do not differentiate for socio-economic factors within the youth group, and HIV prevalence is likely to be higher among disenfranchised youth. Nor does the data include HIV prevalence for mobile populations in Ghana, though it is generally understood that these groups, like in other parts of Africa, have relatively higher prevalence than what may exist nationally. Data from a study in Uganda, for example, showed that HIV seroprevalence was 5.5% for people who had not changed their address during the study period, while it was 11.5% (or twotimes greater) among people who had moved during the same period (UNESCO/UNAIDS, 2000). Finally, the proportion of Ghanaians who are aware of their HIV status is still low: according to Ghana Statistical Service et al. (2004) only 7% of Ghanaians aged 15–49 have been tested for HIV. Based on data from the Central African Republic, South Africa and Zimbabwe, factors potentially contributing to low VCT coverage include: testing fees, inconvenient location and hours of services, and fear and stigma surrounding a potentially positive HIV test result (Grésenguet, Séhenou, Bassirou, Longo, Malkin & Bélec, 2002; Kalichman & Simbayi, 2003; Morin, Khumalo-Sakutukwa, Charlebois, Routh, Fritz, Lane, Vaki, Fiamma & Coates, 2006). Intervention In response to these challenges, JHPIEGO, an international NGO working in health and linked with The Johns Hopkins University, launched a project to provide VCT services to a high-risk mobile population of youth in Accra, Ghana. Funded by the United States Agency for International Development (USAID) through a Pact Community REACH Program grant, this project was implemented from January 2003 through June 2005. The project’s goal was to provide quality and accessible VCT services to high-risk, marginalised youth aged 15–25 surrounding Agbogbloshie market,

Wyss, Ablordeppey, Okrah and Kyei

in particular the kayayée, or young women who come to Accra from rural areas, especially at the end of the harvest season, in search of work, and who often end up living and working near the marketplace as female load carriers. The project also sought to provide quality care and support services to clients testing HIV-positive, and through communication campaigns, peer education and advocacy activities, to empower kayayée and other youth not only to seek VCT services, but to make other improvements in their lives that would subsequently put them at less risk of exposure to HIV and gender-based violence, and also help them be less likely to remain in a cycle of poverty. The targets set for the life-of-project were: 3 000 youth receiving VCT, 20 counsellors trained, referral linkages established, and information and education campaigns conducted. To reach these goals, JHPIEGO teamed up with the Family Health Foundation (FHF), a local NGO working in family planning and HIV prevention, to set up quality, accessible and free VCT services via a mobile clinic near Agbogbloshie market.1 The services were available on Sundays (the only day free from work for the target population) and were provided in low-tech, temporary tents set up to ensure clients’ privacy. Twenty-four counsellors2 were trained to provide counselling services, with their knowledge and skills consistent with national protocols, and six of these counsellors were trained per national protocols to do rapid HIV testing using the Determine© test. In addition, a quality-assurance system was institutionalised at the site, in collaboration with the Ghana AIDS Commission, consisting of sending 10% of total samples to the Public Health Reference Laboratory for monitoring quality control and for establishing and maintaining infection prevention procedures, environmental sanitation, and counselling techniques. Two trained nurses supervised the VCT services. The project also sought to link clients to other existing services in Accra. Clients testing HIV-positive were referred to Korle-Bu Hospital for medical care and to appropriate support groups for psychosocial support, including Wisdom Association (out of Korle-bu Hospital), Tema AIDS support union, and Winneba support group. Finally, FHF and JHPIEGO established a peer support group for the target population, and arranged stakeholder meetings with organisations in Accra that were providing similar services, in order to coordinate efforts and share experiences. To encourage demand for the VCT services, JHPIEGO and FHF initiated: a communication campaign that consisted of training and deploying 20 peer educators, theatre presentations that started several months into the project (initially every week, and then monthly),3 and discussions about the Agbogbloshie VCT services during a weekly, Saturday radio show on Adom FM. In addition, even though the target group was considered mobile and transient, the help of formal and informal community leaders was enlisted to support and promote the use of VCT. Research methodology In May 2005, an end-of-project evaluation was carried out to determine: 1) to what extent goals for providing VCT to

the target population were reached; 2) how HIV prevalence in the target population compared to that of the general population; 3) to what extent former clients self-reported behaviour change; and 4) whether any useful lessons could be drawn regarding the fees, hours, and location of VCT services, as well as the use of peer educators to increase use of the services among the target population. The evaluation drew upon a combination of qualitative and quantitative methodologies, specifically: 1. a review of service statistics; 2. a questionnaire directed to 10 of the VCT counsellors; 3. a questionnaire seeking programmatic information from FHF regarding the effectiveness and use of peer educators; 4. a focus group discussion of seven peer educators; 5. three focus group discussions of 33 former clients; 6. a comparison of the service statistics of the Agbogbloshie site with those of a private VCT site and a surveillance site; 7. a tabulation of risk-reduction plans from a random sample of 100 client records; and, 8. an exit poll of 50 clients on one day of VCT services. Results Review of service statistics Over 21 months, from October 2003 through June 2005, 4 189 clients — all between age 15 and 25 — were provided with VCT services (pre-test counselling, testing, and post-test counselling), exceeding the life-of-project target of 3 000 by nearly 40%. Due to the marginalised and transient nature of the target group, no official data exist on the overall size of the target population. Moreover, the size of the target group most likely fluctuated by season. However, the data were reviewed to determine to what extent the clients served actually belonged to the intended target group (i.e. mobile, female youth aged 15–25 years), with the following findings emerging: 1. All clients were between age 15 and 25 (numerous people were turned away from the VCT services because they were older than the age for clients as set by the project). 2. Data on client mobility was not collected at the time of VCT services; however, in their discussions with counsellors and peer educators, clients often provided information regarding where they were from or plans to return to their homes, primarily in Northern and Upper West regions of Ghana. In subsequent interviews with five counsellors, five peer educators and one tester, the estimates ranged from 80%–95% of clients having been transient. 3. Services were provided almost equally to males and females, with 2 092 (49.9%) male clients and 2 097 (50.1%) female clients served. Although the original target for this intervention was the more vulnerable group of young women, specifically the kayayée, the project never intended to exclude men. Rather, the attendance of these men was welcomed, not only because they were also at-risk youth but also because

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as current or potential partners for the women, their participation was seen as potentially benefiting the women. Of the 4 189 clients, 94 (2.2%) were HIV-positive. Of the 2 097 women, 71 (3.4%) were HIV-positive, and of the 2 092 men, 23 (1%) were HIV-positive — mirroring national gender differentials for HIV prevalence among youth. Figure 1, depicting HIV prevalence for the female and male clients as compared to that of the general population aged 15–24, is striking for two reasons: 1. Women in the intervention group were three times as likely to be HIV-positive than men in the group, a statistically significant difference (chi-square test, p < 0.001); this underscores how much more vulnerable the young women in the target group were to exposure to HIV. 2. Prevalence for both male and female clients in the intervention group (aged 15–25) was higher than in the general population (within virtually the same age group, youth aged 15–24). A one-year difference in the age groups and the difference in sample size make it not possible to test for statistical significance; even so, it is notable that in comparison to the general population, the male clients were more than ten-times more likely to be HIV-positive, and female clients were three-times more likely, suggesting that targeting mobile youth for VCT is an effective strategy for identifying HIV-positive clients for referral and treatment. Finally, a review of trends in the number of Agbogbloshie clients served per quarter (shown in Figure 2) is revealing in the context of programme activities. Comparing the peaks and dips in services delivered over the quarters with demand-generating activities provides helpful information concerning what programme inputs are effective for demand generation. Between the second and third quarters of 2004, the number of clients who came for services increased by 70.5% (from 577–984). This increase is due primarily to two interventions: the change to a per-client payment for peer educators, and the introduction of drama and dance on-site. The subsequent quarter saw a slight decline in uptake (from 984–648 clients), due in part to the Ramadan holiday.4 Although in subsequent quarters the

HIV PREVALENCE (%)

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Programme clients 2004 DHS

3.5 3 2.5 2 1.5 1 0.5 FEMALES

MALES

Figure 1: HIV prevalence for VCT clients in the study evaluation (aged 15–25 years) and for the general population (aged 15–24 years)

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NUMBER OF CLIENTS

1100 1000 900 800 700 600 500 400 300 200 100 Q4 2003

Q1

Q2

Q3 Q4 2004 QUARTER

Q1

Q2 2005

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Figure 2: VCT clients served per quarter at the Agbogbloshie site (unpublished data provided by Family Health Foundation)

numbers of clients served never reached the level achieved in the third quarter of 2004, the levels of service delivered always remained higher than before the per-client payment to peer educators and the drama intervention. Questionnaire for the VCT counsellors A questionnaire was applied to 10 of the VCT counsellors to obtain information regarding their perceptions of the project. The most important reasons that counsellors gave for why they thought clients came for VCT were: to know their HIV status (cited by nine counsellors), for information about HIV (cited by five), and to receive condoms (cited by three). Moreover, seven of the 10 counsellors thought that one reason clients selected the Agbogbloshie site for VCT services was its convenient location; seven believed that a reason was the presence of the counsellors themselves; and six thought a reason was because the services were free. The responses also indicated that the VCT counsellors appreciated the important role of peer educators to inform potential clients of the services available: eight stated that they believed that peer-educator referrals accounted for 80% or more of clients. Finally, based upon their post-test counselling discussions, the counsellors pointed out that there was a high intention among clients following VCT to change their behaviour to reduce their risk of exposure to HIV. Seven of the 10 counsellors estimated that 80% or more of their clients had made a commitment to behaviour change at the time of post-test counselling. Questionnaire for the NGO This questionnaire was used to obtain programmatic information regarding the effectiveness and use of peer educators, and it was filled out by the FHF staff through group discussion and consensus. The filled-in form described the process by which each peer educator had their own colour card that they gave to clients to hand in when they registered for pretest counselling. At the end of the day, the card total for each peer educator was noted. Compiling data for 2004, FHF determined that 2 079 of 2 597 total clients who tested during this 12-month period, or 80%, came for VCT services via

referrals from peer educators, thus leading to the conclusion that peer educators were an effective means of promoting VCT services for this project. The filled-in form also described the NGO’s arrangements with the peer educators, who also had to set up and take down the tents on Sundays. Originally, peer educators were recruited in October 2003 as volunteers; but without remuneration, they were less available to the project as they pursued other endeavours that earned them money. In December 2003, FHF began to pay the peer educators a flat fee of 20 000 cedis per Sunday of VCT services. In April 2004, this was changed again to a per-client fee of 2 500 cedis (approximately US$0.26) in order to reward the peer educators based on how many clients they had contacted during the week and educated about the services, rather than for just showing up on Sundays. Focus group discussion with peer educators The focus group discussion with peer educators revealed that there was a common perception (by six of the seven peer educators) that one of the biggest motivators to get clients to agree to use the VCT services was the fact that services were free. The seventh peer educator indicated that the biggest motivator was ‘explaining to them how HIV/AIDS is acquired,’ presumably because upon hearing this information the potential client realised he or she was at risk of exposure to HIV and consequently wanted to know his or her HIV status. This focus group discussion also revealed useful information regarding the difficulties faced by peer educators, such as language barriers in the multi-lingual setting typical of work with mobile populations. Two peer educators said that language was an obstacle for them (one was an Akan who did not speak Dagbani and the other a Dagoma who did not speak the Konkomba language). Other difficulties cited by the peer educators include the long time it can take to provide information and to encourage people to attend VCT services, and they mentioned the dearth of medications and resources for people who test HIV-positive, resulting in people’s unwillingness to know their HIV status. One peer educator also spoke of the power of group influence (‘Many of the women porters walk in groups’), as this could have either a negative or a positive effect on a potential client’s decision to seek services. This group influence relates to the original rationale used for including a peer educator component in the project. Finally, the focus group discussion with peer educators evoked recommendations for nonmonetary motivators for peer educators, such as visits by the programme staff, verbal encouragement, and being treated respectfully. In addition, they suggested refresher courses with certificates given for participation in the courses, and certificates attesting that they are peer educators. Focus group discussions with former clients Three focus groups were held with a total of 33 former clients. Only one group (Group B; n = 12) consisted entirely of women; the other client groups were a group of youth (Group A; 3 males, 7 females) and a group of married persons, which included a few mature but single persons who were in relationships (Group C; 7 males, 4 females).5

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Findings from the focus groups showed client impetus to use the VCT services often came from the encouragement of other people: 88%, or 29 of the 33, said that either a peer educator, a family member, or a friend had encouraged them to go. These 29 former clients said that once they got information from the peer educator on how HIV is transmitted, they felt that they were at risk and should be tested. In addition, 15 people from this sub-group (or 52%) mentioned that they were motivated to use the services because the peer educator had let them know that the services were free. One participant stated: ‘If the services were not free I wouldn’t have gone for it.’ Nearly half of the focus group participants (15) stated that they could use VCT services only if they were available on weekends (particularly Sundays), indicating that the number of clients would have been reduced if VCT had been made available only during the week. When asked what they liked about the VCT services they had received, Group C (n = 11) unanimously said it was the reception, counselling and advice that they most appreciated (one participant also mentioned the same-day HIV test result). In Group A, six of the 10 stated what they liked was the information offered, and the other four said they had appreciated the counselling and advice. In Group B, 10 of the 12 women also stated they best liked the counselling and advice they had received, and three said that they liked the fact that the services were free. All 33 former clients participating in a focus group discussion knew that the Agbogbloshie VCT services were free. In Group A, 9 of 10 indicated they would not have gone if they had had to pay; in Group B, 8 of 12 said they would not have been able to go if services had not been free, while the remaining four would have been willing to pay up to 10 000 cedis. Participants in Group C seemed the most willing to pay for VCT, most likely because they were generally older than the other focus group participants and had more buying power. In that group, six were willing to pay up to 10 000 cedis, two would pay up to 15 000 cedis, and the remaining three were willing to pay 20 000–40 000 cedis. An important topic in the focus group discussions concerned the extent of clients’ behaviour change. As previously mentioned, the VCT counsellors indicated that clients showed a high willingness to change their behaviour at the time of their post-test counselling — not an unusual finding at the time of post-test counselling. Former-client focus-group participants were asked whether their behaviour had in fact changed as a result of VCT. (Although

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self-reported behaviour is not synonymous with actual behaviour, it is often used as a proxy measure because of the obvious difficulties in measuring actual behaviour.) In all three focus group discussions, all sexually active participants stated that they had changed their behaviour after using VCT services, mostly in terms of abstinence, being faithful or reducing their number of sexual partners. One stated: ‘Formerly, I was having sex with three girls in the week. Now I only have one girlfriend.’ In addition, three participants said they were now using condoms. Table 1 shows the results by focus group and type of reported behaviour change in descending order of frequency. Finally, the former clients’ discussions were interesting in what they revealed about the continuing stigma and discrimination faced by people with HIV, as well as the effect this can have on a person’s decision whether or not to seek VCT services to learn his or her HIV status. When asked whether there were any disadvantages to being tested for HIV, many pointed to the fear of knowing one’s HIV status. ‘Societal conception of the disease is such that even the mere fact that a person goes for a test is seen as an admission of a promiscuous life and this discourages people,’ said one respondent. Moreover, the fact that affordable treatment is still not generally available in Ghana is a disincentive to seek out VCT services: ‘The fear of a positive result and subsequent death makes people prefer not to know,’ explained another focus group member. Comparison of the Agbogbloshie service statistics with comparable sites In order to gauge the relative effectiveness of this project in reaching clients, the service statistics were compared with those from other VCT sites. Since the Agbogbloshie project was the only one of its kind in Ghana, there were no other market-based VCT site services for comparison. Instead, the sites chosen for comparison were the Salvation Army’s VCT site and the Maamobi Clinic, both in Accra. Statistics for the Salvation Army’s site, a private clinic open on weekdays, which charged a fee, showed that only 185 clients had been tested in 2004. Maamobi Clinic, a sentinel site that was primarily testing pregnant women who came for antenatal care on weekdays, and which did not charge a fee, had provided VCT services to 468 clients in 2004. Neither of these sites used peer educators to motivate potential clients. Agbogbloshie’s service statistics for 2004 are considerably higher (2 539 clients) than either of the other two sites

Table 1: Self-reported behaviour change in focus group discussions with former VCT clients Behaviour change Faithful to one partner Abstinence Use condoms ‘Able to make decisions on my sex life unlike in the past’ Reduced number of partners Not sexually active prior to nor after HIV test ‘Understand my partner’s sexual needs [better] so he does not go out chasing other girls anymore’ ‘Sexually upright life’

Group A

Group B6

Group C

Total

%

3 3

6

7 2 1

16 5 3 3 2 2

47.1 14.7 8.8 8.8 5.9 5.9

2 1

5.9 2.9

2 3 2 1

1 2

1

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(more than 13 times the number of clients for the same period at the Salvation Army site, and more than five times the number of clients at Maamobi). Given that the Agbogbloshie VCT services were only available on Sundays as compared to five days a week at the other sites, the difference in numbers of clients suggests that the use of peer educators and radio publicity, as well as offering services for free and at convenient hours and locations, are all useful strategies for increasing VCT coverage. Tabulation of risk-reduction plans from client records A tabulation of a random sampling of 100 client interview forms showed that 100% of clients committed to some form of behaviour change at the time of their post-test counselling. Table 2 summarises the most common actions committed to by gender. Abstinence, discussing HIV test results with a partner, and faithfulness were the most common responses, with some differences between men and women in terms of emphasis. For women, condom negotiation was cited as the fifth most common risk-reduction action, while men cited avoiding sharing sharps (probably related to shaving). Exit poll of clients To better understand to what degree offering VCT services for free had affected the number of people using the Agbogboshie services, an exit poll of 50 clients was conducted on Sunday, 8 May 2005. The clients were asked how much money they would be willing to pay for VCT services: 23 (46%) stated they were not willing to pay anything for services, 11 (22%) were willing to pay 5 000 cedis, 7 (14%) were willing to pay 10 000 cedis, and 5 (10%) were willing to pay 15 000 cedis. Only 4 (8%) stated that they were willing to pay 20 000 cedis or more. Conclusions Findings from the evaluation indicate the feasibility and effectiveness of providing VCT to high-risk youth and mobile populations. The project demonstrated success in terms of exceeding the predetermined target for number of clients within a specified age group. The clients, who were also reported by peer educators and counsellors as being predominantly mobile, had a higher HIV prevalence than youth for almost the same age group in the general population. Self-reported behaviour change among clients in focus groups suggests that the education component of the services may also have resulted in some behaviour change. Viewing service statistic data over time also showed the relative impact of demand-generating interventions, particularly the use of peer educators. Comparative data from

another private VCT site in the same city indicate that one Sunday per week of VCT services at Agbogbloshie market had a much higher frequentation than five weekdays of VCT services at the other site. The data indicates that this relatively high number of clients was largely influenced by three factors: the services being free, the location and hours of services being convenient to the target population, and the use of peer educators and other methods to promote the services. A summary of the lessons learned from the Agbogbloshie experience can be useful to similar programmes targeting disenfranchised youth and mobile populations, while bearing in mind the challenges that remain for widespread adoption of VCT services. Lessons learnt VCT programmes need to set their fees carefully based upon the target population’s ability and willingness to pay for services — The evaluation results indicate that a high proportion of the clients were motivated by free services. In the focus group discussions with former clients, the majority indicated that they used the services because they were free, and the exit poll showed that nearly half (46%) were not willing to pay any amount. The question of whether clients should pay for VCT is a controversial one, especially in private-sector settings where the sustainability of the programme will depend on fees. In the case of this project, the VCT services ended with the term of the grant, although assistance was provided to FHF to write proposals to continue the services with funding from other grants. With the research findings suggesting that approximately half the clients served by this project were willing to pay something for services, each VCT programme needs to decide whether or not to set a fee, and if so at what rate. The higher the rate, the less turnout it will likely have, all other factors being equal. Sliding-scale fees might be another way to encourage participation from lower-income groups. When reaching youth and mobile populations, it is critical to consider non-traditional working hours and locations — Of all focus group participants, nearly half could only attend services if they were available on Sundays or weekends, indicating that the numbers of clients would have been reduced if VCT had been made available only during the week. Although former clients were not specifically queried about the location, 70% of the counsellors thought that one reason for clients selecting the Agbogbloshie site for VCT services was its convenience. The use of low-tech, temporary tents that could be set up and taken down again at the end of the day helped to keep the programme costs low. However, a drawback to using

Table 2: Most common actions in risk-reduction plans for the men and women (n = 100 VCT client interview forms) Men (n = 47) Avoid places that increase chances of high-risk behaviour Abstain till I know the HIV status of my partner Discuss HIV test with partner Abstinence till marriage Discuss and practice faithfulness with partner Avoid sharing sharps

Women (n = 53) 30% 30% 26% 21% 21% 17%

Avoid places that increase chances of high-risk behaviour Abstinence till marriage Discuss and practice faithfulness with partner Abstain till I know the HIV status of my partner Discuss HIV test with partner Negotiate condom use with partner

49% 47% 32% 30% 28% 19%

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tents was their wear and tear and also their vulnerability to poor weather conditions, especially rain. Clients do not come for VCT services just to know their HIV status, they also come for counselling and advice — Findings from this project indicated that the majority of clients came also to obtain more information and they sought out VCT services because counselling was an important part of the services. While ministries of health may seek to scale-up VCT services in order that a larger percentage of the population come to know their HIV status, some are questioning the feasibility of providing the counselling component to larger numbers of clients (especially pre-test counselling). This evaluation suggests that dropping counselling altogether could reduce the numbers of clients using VCT, and thus national coverage — not to mention the effect that omitting pre-test counselling might have on behaviour change, quality of services, and the information or misinformation that VCT clients leave with. At minimum, pre-test counselling in a group format should be offered. VCT programmes that use peer educators should consider paying them for their work — Although this topic is controversial because of long-term sustainability of their role, the findings from this evaluation suggest that a small investment in paying peer educators will ensure higher attendance at VCT sites. The change from volunteerism to a payment system for peer educators led partially if not entirely to a 150% increase in number of clients from one quarter to the next. While deciding what payment might be appropriate for peer educators, programme managers should look at what other NGOs pay workers in the same setting, so that they are competitive but do not crowd out or conflict with other programmes. Finally, the terms, conditions and responsibilities of the peer educator must be clearly explained prior to making a mutual commitment, including the terms of remuneration, project length/goals/activities, and a peer educator’s role and responsibilities. If possible, these should be documented and reviewed in person, and signed by both parties. Programme managers should also consider a per-client payment scheme for peer educators, as this rewards performance. Continued challenges HIV stigma continues to be a barrier to people wanting to use VCT services, even when peer educators are involved in promoting the services. When the mere fact that being a client is seen as an admission of a promiscuous life, people are discouraged from seeking out VCT, particularly at a venue close to their peers. Until misinformation about HIV transmission is clarified across the population, until HIV infection is no longer regarded as ‘a death sentence,’ and until testing for HIV is perceived as a norm, turnouts for VCT services will continue to be low, as they are nationally in Ghana. The VCT counsellors expressed recurring frustration over the lack of medication, support and services for HIVpositive clients in Ghana. This situation not only makes it harder to inform a client that they are HIV-positive, but it also discourages people from seeking out VCT services in order to know their status, since they regard HIV infection

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as something with fatal consequences. Although care and treatment have become more available in Ghana, its availability continues to be outweighed by the need for these services — particularly if VCT becomes more widely used, resulting in more HIV-positive people knowing their status and needing additional services. Deciding what to ask clients to pay for and what need not be paid for, continues to be a challenging subject, especially in the context of creating sustainable VCT programmes. For instance, the issue of whether to pay peer educators needs to be weighed with the effectiveness of this payment to motivate them to bring in more clients. The decision of whether to provide services for free, knowing that charging fees may reduce the number of clients but increase the burden on the programme, is an equally difficult one. However, these deliberations should be weighed in the overall context of HIV prevention and treatment efforts. If sustainability is given as the primary reason for not providing free VCT or for not paying peer educators in a country, then which is actually less sustainable: paying US$0.26 to a peer educator for motivating a client to come for VCT services, or paying thousands of dollars annually to keep a single person on an antiretroviral regimen? Notes 1

2

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4

5

6

A document review turned up only one other example of marketbased, mobile VCT services, in Zimbabwe. That study, which demonstrated the acceptability of HIV testing in community settings, tested 1 099 individuals at 12 marketplaces over an 18month period; the study, by Morin et al. (2006), did not use peer educators to encourage demand for services. At the start of the project, 20 counsellors were trained; midway through, the need for more Dagbani-speaking counsellors was identified, and four additional Dagbani-speaking counsellors were trained. Another example of the use of theatre to promote VCT services took place in Malawi, where drama was helpful in raising knowledge levels regarding VCT, as well as in promoting a positive attitude toward VCT. The study by Rumsey, Brabin, Mfutso-Bengo, Cuevas, Hogg & Brabin (2004) did not include specific data on the effectiveness of drama to increase the use of VCT Services. Much of the targeted mobile population were Muslims from the north, many of whom travelled back north to join their families for Ramadan fasting and then for the end of the fast. Other potential Muslim clients who were fasting were unwilling to go for HIV testing because they felt it was not good to do so while fasting. In addition, some peer educators travelled back home at this time. Initial plans for the focus groups of former clients were to facilitate one focus group made up of men and one of women. This was not logistically possible as the men did not appear at the focus group location at the same time. Because all the clients were not ready at the same time, participants were grouped as they became available. Although there were 12 participants in Group B, total responses equal 13 because one respondent said she had adopted two behaviour changes (she now had only one boyfriend and used condoms).

Acknowledgements — Financial support was received from the Office of HIV/AIDS, Bureau for Health, U.S. Agency for Interna-

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tional Development, under a Community REACH grant from Pact International. The opinions expressed herein are those of the authors and do not necessarily reflect the views of Pact International or USAID. The authors would also like to thank the following individuals for their input and support during the writing of this article: Julia Bluestone, Kelly Curran, Deb Estep, Cyndi Hiner, Yaa Mensah, Barbara Rawlins and Laurence Reale. We also thank the Family Health Foundation for their commitment to implementing the project. Finally, we gratefully acknowledge the counsellors and peer educators who worked tirelessly to provide VCT services to the programme’s target population around Agbogbloshie market, and we thank the traditional leaders in the Agbogbloshie community who welcomed the project and helped make it work. The authors — Susi Wyss is the Acting Deputy Director for the HIV Centre of Excellence of JHPIEGO Corporation, a Johns Hopkins University-affiliated organisation based in Baltimore, Maryland. Trained as a public health professional, she has lived and worked in West and Central Africa for over eight years, and she provided backup support for the JHPIEGO programme in Ghana from 2000 to 2004. Joyce Ablordeppey is a public health professional and currently the maternal and neonatal health specialist on the Quality Health Partners Project in Ghana. She has worked with JHPIEGO since 2002 and has been involved in pre-service and in-service training of healthcare providers in reproductive and child health, community-based health planning and services, malaria in pregnancy, and VCT among vulnerable youth in Ghana. A public health professional and demographer, Jane Okrah is currently the Chief Executive Officer of Family Health Foundation, a Ghana-based NGO. She has worked with the Ghana Midwives Association as a project director and helped to implement the USAID/DANIDA-sponsored programme on safe motherhood, family planning and HIV/AIDS counselling in all regions of the country. Abigail Kyei was the JHPIEGO Country Director in Ghana from 2000 to 2005; she is currently Country Director in Malawi. With a background in nursing and public health, she has been working for the past 21 years managing large-scale health programmes for JHPIEGO, DANIDA, and the ministries of health in Ghana and Malawi.

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