Alcohol Consumption and HIV Risk: A Peer Education Strategy for Bar Patrons

This case study explores the process and impact of the Collaborative HIV/STD [sexually transmitted disease] Prevention Trial, a 5-year research intervention that sought to study alcohol consumption and risky sex among male patrons of wine shops in the city of Chennai, in South India. Launched in 2002 by the nonprofit organisation Y.R. Gaitonde Center for AIDS Research and Education (Y.R.G. CARE), the behaviour change communication (BCC) initiative involved identifying, recruiting, and training peer outreach workers called Community Popular Opinion Leaders (CPOLs), who communicated messages about safer sexual behaviour through informal, yet structured, one-on-one conversation with their peers, with the hope of preventing HIV.

As reported here, at each stage of the intervention, the project team systematically gathered data to develop and then refine strategies. The team first pilot-tested the intervention at a few wine shops before scaling up to include more. Starting in 2002, the project conducted 3 cross-sectional surveys of 3,000 participants at 100 wine shops: baseline, first follow-up (18 months into the intervention), and second follow-up (24 months into the intervention).

Initial findings from the second follow-up cross-sectional survey conducted in 2007 reveal that there were increases in knowledge and self-reported risk reduction behaviours among patrons of wine shops targeted by the intervention. However, similar increases in knowledge and self-reported risk reduction behaviours were reported by patrons of bars that were not actively targeted or included in the intervention. A closer examination of this finding revealed that wine shop customers often patronise more than one wine shop, making it likely that CPOLs were delivering messages in wine shops that were not involved in the intervention. The reduction in risk behaviour in both intervention and non-intervention wine shops could also be the result of prevention services (HIV educational materials, access to counseling services, and condoms) provided to everyone in the geographical area.

At meetings of CPOLs that took place during the intervention, the project team gathered feedback about CPOLs' experiences with communicating project messages. Project staff learned, for example, that:

• People viewed CPOLs as a resource and respect them.
• CPOLs experienced a sense of increased self-worth because their peers and society in general see them as inspirational figures.
• Self-help group members in communities where CPOLs live invited them to speak at meetings about the dangers of mixing excessive drinking and unprotected sex.
• CPOLs referred peers with sexually transmitted infection (STI) symptoms to treatment centres.
• CPOLs reported using condoms consistently, drinking moderately, and practicing safer sex.
• CPOLs reported practicing monogamy.
• CPOLs reported that the sessions they led helped reduce HIV-related fear and stigma among wine shop patrons.

The case study includes details about what worked well in this project - for example, messaging focused on risk reduction rather than risk elimination, and peer-led delivery of personal messages ("I statements") to encourage change - as well as challenges that were encountered. Recommendations are also outlined, such as:

• Invest in high-quality formative research, and continue to use research data to inform each step of the project.
• Train CPOLs in effective and natural message delivery and build CPOLs' confidence by keeping them up to date on the latest information about hazardous drinking and HIV prevention.
• Cater to the information needs of the local context (e.g., the training manual was adapted to address specific local myths about drinking, sex, and the role that alcohol plays in sex).
• Reinforce and update prevention messages in each CPOL training session.
• Keep CPOLs motivated through frequent meetings and ongoing support.
• Strategise early about how to get gatekeepers (e.g., key wine shop owners and pimps) on board.

The case study concludes with a discussion of future programming directions - for example: "The future of programming in alcohol-related risk behaviors will depend on the creation of an enabling national policy environment." (India does not have a national policy or law that controls the manufacturing, packaging, advertising, taxation, or distribution of alcohol. Nor are there strict laws enforcing the legal drinking age in establishments.)