Prevention in Focus

Fall 2010 

Let the adaptation begin: A potential solution to your programming dilemmas

By Christie Johnston

Adapting an existing HIV prevention program to meet the needs of the communities that you serve can be a reliable, simple and inexpensive way of developing a new front-line program. One Canadian organization looked beyond our borders for a program that would suit the needs of their community, and made use of a formal mechanism to learn about how to adapt a prevention intervention for their community. Black CAP, an AIDS Service Organization in Toronto, adapted a program that was developed in the US and distributed by a unique American program called the “DEBI Project.” The DEBI Project disseminates HIV prevention programs that have been proven to reduce HIV risk.

Can other Canadian agencies adapt programs to strengthen their home-grown approach to HIV prevention? What can we learn from those who have tried?

Canadian adaptation of an evidence-based intervention

Black CAP, the Black Coalition for AIDS Prevention, is an organization that works to reduce the spread of HIV in Toronto’s Black, African and Caribbean communities, and enhance the quality of life of Black people living with or aff­ected by HIV/AIDS. Currently, Black, African and Caribbean people account for more than one-quarter of all new HIV infections in Ontario;1 and HIV infection rates among Toronto’s Black communities have more than doubled since the year 20002. HIV-related stigma and discrimination, homophobia, racism, immigration issues, poverty and barriers to social inclusion also continue to affect Black, African and Caribbean communities in Toronto. These are the issues that Black CAP works to address.

Black CAP approaches its work in innovative ways. In 2007, through a literature search and a review of current programs for Black men who have sex with men (MSM) in Canada, the US and UK,3 Black CAP discovered that, in New York City, a lot of interesting work was being done with Black youth. In particular, research-based prevention programs for Black men who have sex with men were being adapted across the US by dozens of organizations through the DEBI Project.

One such program, called Many Men, Many Voices (or 3MV), was being implemented by People of Color in Crisis, a leading organization working with young black men who have sex with men. This program sought to address the same issues that Black CAP faced in their own community. And it was proven to work. In 2008, Black CAP was trained by People of Color in Crisis to deliver 3MV. Black CAP worked with the agency to adapt the intervention, to address the needs of young Black men who have sex with men in Toronto.

3MV: the original

3MV is a series of seven workshops facilitated by peers and delivered to a group of six to 12 men. 3MV participants “learn by doing” – the program is not lecture-based. It was originally developed by two community organizations and a university-based HIV/STI prevention and training program.5 

3MV is designed to help prevent HIV and STIs among Black men who have sex with men by addressing factors that influence risk behaviour, such as (1) cultural, social and religious norms, (2) the interactions between HIV and sexually transmitted infections (STIs), (3) the dynamics of sexual relationships and (4) racism and homophobia and the effects these have on HIV risk behaviours.

3MV works!

3MV was evaluated in New York City through a randomized controlled trial. This means that, of the more than 300 men enrolled in the program, half were randomly assigned to participate in 3MV immediately and the other half were assigned to a waiting list and could participate at a later date (the “comparison group”). The research team followed up with the men in both the 3MV group and the comparison group three months and six months after the end of the seven sessions to see if they had changed their behaviours and kept up these changes.  

Compared to the “comparison group,” the 3MV participants reported:

  • less unprotected anal sex with casual male partners;
  • fewer male sex partners; and
  • more HIV testing.

For more information on 3MV, please see the 3MV Fact Sheet.

What are “core elements” and why do they matter?

One of the major appeals of any DEBI Project program, including 3MV, is its promise of effectiveness. DEBI programs have been proven to meet certain objectives through evaluations conducted by researchers from various disciplines. 

Researchers have identified not only that the program works but also which parts of the program make it work. These are called “core elements.” When adapting an intervention, core elements should not be changed. They represent what is responsible for each intervention’s effectiveness.

Examples of core elements include:

  • The number of participants enrolled in a program
  • How skills are taught—for example, coping skills must be taught through role play; lectures will not work for this program

Visit the DEBI website for more information on DEBI and core elements.

3MV: the Black CAP version

Adapting an intervention like 3MV means modifying the program to fit a new context while respecting the elements of the program responsible for its success (the core elements).  

Some 3MV core elements include:

  1. Educating participants about HIV and STI risk
  2. Sensitizing participants to their personal risk for HIV and STIs
  3. Developing risk reduction strategies
  4. Training participants in risk-reduction behavioural skills
  5. Training in sexual assertiveness
  6. Providing social support and preventing “relapse”

If the participants are not educated about HIV and STI risk, for example, the program will not meet its intended outcomes. Each core element is achieved through many activities over the course of the seven workshops.

The goals of adaptation

Black CAP adapted 3MV to:

  1. Better meet the needs of the community it serves
  2. Suit existing program timelines to ensure human and other resources would be available
  3. Accommodate the preferences and make use of the expertise of the staff members facilitating it

Most significantly, Black CAP understood from experience that the risks that Black men who have sex with men face often have to do with the emotional and mental distress that can result from experiences of stigma and homophobia, or a variety of other oppressions. This was an issue that was not addressed in the original 3MV intervention.

“A lot of us are walking around with a lot of stuff that can keep us from making the choices that are best for us, particularly in relationships.”
– David Lewis-Peart, MSM Prevention Coordinator, Black CAP

The process of adaptation

As part of their adaptation of the original 3MV, Black CAP:

  1. Developed Community and Academic Advisory Committees to ensure that the program would be informed by community members and researchers
  2. Researched what others had done to address issues related to stigma, stress, homophobia and racism, including stress management and stress inoculation techniques, hypnosis, guided affirmations and visualizations
  3. Developed a new manual for 3MV facilitators
  4. Piloted and evaluated 3MV; the feedback of the participants informed further revisions

Six adaptations to 3MV

Black CAP adapted 3MV in the following ways:

1. Recruitment strategy: To recruit participants, Black CAP staff consulted popular opinion leaders, community gatekeepers and social networking sites. They recruited HIV-negative men, HIV-positive men and men of unknown HIV status, unlike the original version of 3MV, which included only HIV-negative men and men of unknown HIV status.

2. Participants: Whereas 3MV was originally designed for men who have sex with men (MSM) of all ages, Black CAP targeted young Black MSM.

3. Format: The original 3MV was offered over a series of seven sessions. Black CAP felt that a weekend retreat would be a more effective format and would allow more of the enrolled youth to finish the program. Retreats and other shorter formats had previously been tried, with success, by US organizations.

4. New activities: Exercises were added to address the emotional and mental distress that can result from experiencing stigma, homophobia and other oppressions. These exercises were designed to help participants focus on their thoughts, feelings, histories and motivations for doing, or not doing, what is “right” for them.

  • Some new activities use techniques like positive affirmation and visualization.
  • Mentors are a new and critical part of the program. Older black men who have sex with men are invited to act as mentors, to support young people and model the behaviour of personally and professionally fulfilled Black MSM from their communities.

5. Information: Black CAP increased the intervention’s emphasis on HIV and STI testing. Supporting the notion of peer modeling, Black CAP’s adaptation of 3MV includes a tour of a local STI clinic and the viewing of a rapid HIV test, so that the participants can view the whole testing process, how results are given, etc. This activity can help to demystify the notion of HIV testing and address related concerns. 

6. Follow-up: Black CAP’s 3MV graduates are recognized at a ceremony that concludes the program. The participants stand in front of friends and family to receive a certificate of participation and talk about what they got out of the program. Many have remarked on how the program helped them build self-esteem and feel validated, often for the first time. 

Learning from the experience of others

Black CAP strengthened its work with young Black men who have sex with men by adapting a program aimed at preventing HIV and STIs among Black men who have sex with men. From their example, it seems clear that other AIDS service organizations might also benefit from building on existing programming to improve their home-grown work.

The DEBI Project ensures that the best programs are shared with hundreds of American organizations (and some Canadians). Perhaps there is a way for Canada to learn from this example and develop our own more formal method of sharing best practices among Canadian front-line organizations.

The Programming Connection: Shared experience, stronger programs, a new CATIE service attempts to help front-line agencies do just that: learn from what others have done, to build on each others’ successes and lessons learned, and not reinvent the wheel of front-line programming. The Programming Connection will include information on various programs, including Black CAP’s 3MV, so that service providers can not only learn from what other organizations have done, but also understand how and why programs were developed and what tools were used to implement them (such as training materials or manuals). Stay tuned for this project, which will be launched at the end of 2010.

References

About the author(s)

Christie Johnston is the Coordinator of Community Prevention Programs at CATIE. She holds a Masters degree in Anthropology and International Relations. Before joining CATIE, Christie worked on a number of community-based research and knowledge exchange projects at the Ontario HIV Treatment Network (OHTN), AIDS Committee of Toronto (ACT) and abroad, and acted as Volunteer Program Coordinator for the AIDS 2006 Local Host Secretariat.