What Works in HIV Prevention for Women of Color

Chapter 4: Models of Effective Programs

The programs described below have helped thousands of people reduce their risk for HIV infection and lead healthier lives. The HIV prevention models and the CBO programs that are presented provide examples for other organizations hoping to expand or enhance their HIV prevention strategies. This is by no means a comprehensive list of programs, but rather highlights innovative approaches that may be useful. Contact information is provided for each CBO program.

Prevention Model: Peer Education and Outreach

Peer education and outreach programs have long been a mainstay of HIV prevention efforts. They tend to incorporate a number of traditional behavioral theories and models in one form or another. "AIDS 101" information is often delivered in peer interventions using the health belief model to raise awareness of HIV and AIDS. Peer models also borrow elements from the theory of reasoned action and social learning theory, which emphasize the importance of peer groups and role modeling. Finally, the importance of social networks in determining behavior change modeled by diffusion theory suggests an important role for peer educators in encouraging behavior change.

Although these programs incorporate proven methods, it is important to examine the degree to which peer educators are effective in their delivery of HIV prevention messages. Shared identity and common experience create an important foundation for communication, but the successful transfer of ideas is equally, if not more, important. Transfer of information using a peer education model involves walking a tightrope between biology and ideology. Although having a peer deliver an HIV prevention message may engage an individual, the appropriateness and accuracy of the ideological content of the message is critical to ensure that HIV prevention strategies are understood and incorporated. The converse, in which an educator in no way resembles the intended audience, may fall short of expectations as well.

CBO Program: Asian Pacific Islander Coalition on HIV and AIDS (APICHA)

The Asian Pacific Islander Coalition on HIV and AIDS Women's Peer Education Program recruits and trains peer educators to inform women about the risks of HIV infection.

Six Japanese-American women founded the Asian Pacific Islander Coalition on HIV and AIDS (APICHA) in 1989 after being inspired by the people of color AIDS conference that took place that fall. The founding members were concerned about the lack of attention paid to the needs of Asian Pacific Islanders in the design, implementation, and evaluation of HIV prevention programs. Even at the most basic statistical level, Asian Pacific Islanders failed to be counted in the AIDS epidemic. [At that time, Asian Pacific Islanders and Native-Americans were combined in the "other" category of AIDS cases, and APICHA and other organizations began advocating for recognition in the epidemic.] Initially, APICHA was run by volunteers, but grants allowed the organization to expand and hire staff, and it currently has two offices in the New York City area.

The women's project at APICHA trains approximately ten paid peer educators and additional community volunteers to do outreach and HIV education in Asian Pacific Islander communities. Paid peer educators are expected to attend monthly trainings that cover basic AIDS information, current trends of HIV infections, and community resources available to both HIV-positive and negative women.

APICHA's peer education efforts were evaluated internally in 1999. Focus groups were conducted with peer educators from all of APICHA's outreach programs. These efforts were undertaken to address the lack of theory and principle guiding HIV prevention and education in Asian Pacific Islander communities. The groups sought to identify current outreach strategies, highlight success stories, and build upon these lessons to improve prevention efforts. Each project conducted focus groups with six to twelve peer educators about their experiences, and the women's project conducted groups in two languages: one in English and the other in Bengali.

Focus groups indicated that targeting social networks and communities was the most effective way to deliver HIV prevention messages that addressed the ways in which immigration, acculturation, and cultural norms exacerbate HIV risk factors. Efforts to cultivate popular opinion leaders among women in various Asian Pacific Islander communities have been developed that integrate lessons about HIV prevention into everyday conversation. For example, some south Asian women immigrate to the U.S. at a date later than their husbands. Bringing these women together to discuss this common experience offers an opportunity to incorporate HIV risk reduction strategies into a larger context of life experiences.

Networking among grocery store owners in Bangladeshi neighborhoods also was successful in disseminating HIV education and prevention information to women in a neutral setting. Peer educators indicated that they were more comfortable presenting HIV education materials in neutral settings.

Prevention Model: Comprehensive Women's Health Promotion Model

". . . Emphasis should also be placed on applying existing knowledge about HIV prevention and treatment in women by enhancing use of available health services and including greater use of antiretroviral therapy options, treating depression and drug use, facilitating educational efforts, and providing social support to reduce competing needs that prevent women from taking control of HIV prevention and treatment."

-- Hader et al., March 2001, pp.1191.

The comprehensive women's health promotion model focuses on individual risk and behavior change, not unlike the peer education model previously outlined. This program, however, incorporates broader health and social themes and provides support above and beyond the delivery of HIV prevention information. The model focuses on overall health and wellness and attempts to mitigate some of the "extra-individual" factors that make protection against HIV and other sexually transmitted diseases difficult for women. These factors include: the fact that women are often underinsured compared to their male counterparts and that their caregiver responsibilities may make access to health services and information more difficult (Hader et al., 2001).

Many activities that place someone at-risk of HIV infection are also associated with other health issues. Psychological distress and a lack of social support and stability frequently coincide with increased risk taking. By addressing more immediate as well as routine health concerns, the comprehensive women's health promotion model allows women to consider their susceptibility to HIV infection and develop strategies for HIV prevention in light of their total health. Programs emphasizing health and wellness increase individual knowledge and self-protection against HIV infection in addition to improving overall health outcomes.

CBO Program: Women of Color AIDS Council (WCAC)

The Women of Color AIDS Council (WCAC) was founded in the Boston area in 1992. The program is peer-led and peer-driven and was created by women in the community, five of whom were HIV-positive at the time. WCAC seeks to improve self-esteem among women of color. The organization offers a wide range of services to meet the needs of this population including: health workshops, counseling and case management, referrals, wellness groups, and a Drop-In Center.

The Drop-In Center is located in Dorchester, Massachusetts, in an area easily accessible to the target audience of women of color. The service population is women of color who are at risk primarily because of homelessness, substance use, or sex work. Fifteen paid employees and a number of volunteers staff the center. Funding comes from federal, state, and local governments.

The Drop-In Center was developed in response to a statewide survey on women's HIV prevention needs that found that women needed a place to go where they could feel comfortable. Since WCAC provides a wide range of services, not limited to HIV prevention and risk reduction, their outreach with women of color has been fairly successful. The Drop-In Center is not a shelter or emergency room. It is a neutral setting that helps increase women's comfort levels with their health status, including HIV risk reduction. In addition, the center has a nurse practitioner on-site so women can ask questions and address their non-urgent health needs in a safe environment. The Drop-In Center is also a good place to deliver messages about HIV risk reduction. Information is presented in a non-judgmental manner that attracts women into the center for support. The organization does some outreach work, but by and large women come by the Drop-In Center because they have heard about it through a friend.

Prevention Model: Multifaceted Empowerment Model for Women

Much like the comprehensive health promotion model implemented by WCAC, the multifaceted empowerment model program expands the traditional notion of HIV prevention to incorporate a number of "extra-individual" factors that affect the lives of women of color although it does not include direct medical services. HIV prevention strategies that specifically address the historical position of women of color empower women politically and educationally. This concept is central to the multifaceted empowerment model.

By focusing on issues beyond HIV, this model enables women to address the social factors that may cause them to face competing demands that affect their attempts to minimize HIV risk behaviors. Individual feelings of powerlessness in relationships are addressed, but overall leadership, involvement, and activism are encouraged to reinforce individual behavior change. This program empowers women as architects of their own solutions rather than passive gatherers of information.

CBO Program: Mujeres Unidas y Activas

In 1990, the Mujeres Unidas y Activas was created by Latina women for other Latinas in the Mission District of San Francisco. Five paid staff members currently serve 200 women, although volunteers initially ran the organization's programs. Mujeres' mission is to improve the economic, social, and political status of Latina women, irrespective of naturalization status.

Mujeres offers a variety of services. General meetings are larger and address a myriad of issues affecting Latinas and their health. Self-esteem support sessions and friendship circles are smaller versions of these meetings and often discuss more sensitive issues like domestic violence, substance use, and female sexual rights. HIV workshops are also offered that specifically address virus transmission, condom use negotiation, and HIV testing and counseling. In addition to these workshops, participants are encouraged to become involved in leadership and volunteer roles both within the Latina community and at Mujeres.

Mujeres does not specifically address HIV behaviors but rather presents HIV information in a larger health and empowerment context. Acknowledging broader socio-cultural issues is important for the Latina women in the program who face many challenges beyond the risk of HIV/AIDS. These include language barriers, lack of accurate information about HIV and AIDS, competing life priorities, and fear of accessing health services due to immigration status.

An evaluation of the program was developed in cooperation with the University of California at San Francisco Center for AIDS Prevention Studies. Women who agreed to participate in the evaluation were interviewed initially, after three months, and after six months. Their attendance at Mujeres workshops was documented. Researchers and staff correlated participation in program activities with changes in attitude using a survey/interview format.

Surveys and interviews found that women who participated in social and political activities at Mujeres in a volunteer or leadership role increased their level of comfort with sexual communication. This increase in comfort level was not observed in participants who attended smaller HIV and self-esteem workshops alone. Although condom use remained lower than desired, women who volunteered with Mujeres also seemed less likely to tolerate domestic violence and power imbalances in relationships.

Prevention Model: Cultural Affirmation Model

Although it may not look like other HIV prevention models, the cultural affirmation model is quite comprehensive in its approach. This program does not focus exclusively on women: HIV infection is viewed in a larger context to encourage individuals to change their own behavior and to become active in improving their local environment. The cultural affirmation model is empowering through positive reinforcement, rather than focusing on risk behavior and implicitly assigning blame for poor health.

This model incorporates race and ethnicity in HIV prevention because these factors are relevant to everyday life. Targeting both men and women in HIV prevention efforts promotes the idea that men and women share responsibility for protection against HIV infection. While drawing upon common bonds among women, the model also emphasizes the diversity within the community. Open dialogue increases everyone's comfort level and makes HIV prevention more manageable for both men and women.

CBO Program: Amassi Center of Los Angeles

The Amassi Center of Los Angeles focuses on building self-esteem, teaching harm reduction, and providing social services. The center does not view itself as an organization designed to serve individuals already in crisis. It addresses broader issues of stigma and limited access to health care while serving a diverse sexual, social, and ethnic population. The center was created to be a health and wellness promotion center that also conducts HIV/AIDS prevention rather than a traditional AIDS service organization. The founding members of Amassi believed that a crisis mentality hampers HIV prevention efforts.

The center serves mainly African-Americans and Latinos in Southern California and emphasizes the ways in which societal disparities and discrimination affect self-image. While many interventions focus on disease or sexual orientation, the Amassi Center seeks to highlight and affirm diversity within the African-American community as a means of preventing HIV infection. This strategy seeks to expand life options, self-respect, and cultural affirmation. Importantly, the center also is quick to point out that HIV is not just a poor person's disease, because such an attitude puts working class and middle class people of color at risk.

The center offers a wide range of services. Self-esteem workshops, math and English language tutoring, peer empowerment groups, and fitness classes all complement the center's HIV and AIDS programs. There are a number of groups specifically focusing on women, including Sustaining Our Sisterhood, the Black Women's Exchange, and the female Rites of Passage Program.

• Sustaining Our Sisterhood
  A bi-monthly meeting with a staff member who acts as a facilitator and engages the group of women in the discussion of a wide range of issues. Discussion is often loosely centered on relationships, nutrition, fitness, career, spiritual growth, love, and power. Women are able to express feelings, network, and explore changes in their lifestyle.

• Black Women's Exchange
  A discussion group focusing on the needs, concerns and strengths of same-gender loving and bisexual women. The group meets twice a month, also in the evening, and facilitators guide conversation in the direction of family issues, health, intimate relationships, self-esteem, and coming out. Regular attendance goes a long way to build trust within the group, and more sensitive topics are discussed along with very practical career and financial concerns.

• Rites of Passage Program
  A small group format with an intended audience of young women age 13-18. This program meets on weekend afternoons and deals with life, family, and career goals. The facilitator tends to take a more active role in steering discussion, and conversation also emphasizes empowerment and self-esteem.

The center also organizes an annual "Women in Jazz" benefit. The purpose of this event is two-fold. First, it seeks to display the talent of the artist as a means of furthering the organizational goal of cultural affirmation. Second, the artists and organizers use the forum to raise AIDS awareness in general in a positive environment. While this event specifically focuses on women, there are other fitness, tutoring, and creative expression programs that seek similar goals for the larger community.

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This article was provided by AIDS Action Council.