Warning:

This document is being maintained for historical purposes, but is now out of date. To view current guidelines please visit:

• HIV/AIDS Guidelines and Recommendations   at http://www.cdc.gov/hiv/guidelines/index.html

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Guidelines for Health Education and Risk Reduction Activities

April 1995
                
Centers for Disease Control and Prevention
Atlanta, Georgia

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                     Collaborations and Partnerships
                                    
The HIV prevention community planning process calls for health departments
and affected communities to collaboratively identify the HIV prevention
priorities in their jurisdictions.  However, some members of these affected
communities distrust health departments.  They  may feel that government
officials have not traditionally reached out to them until certain health
issues have also threatened the greater public health, i.e., the majority
community.  Sexually transmitted diseases, other communicable diseases, and
substance abuse have long been problems in disadvantaged and
disenfranchised communities.  Injecting drug users (IDUs) were dying of
endocarditis, hepatitis B, and drug overdose long before AIDS.  For years,
the tuberculosis epidemic persisted in poor African American and Hispanic
neighborhoods, while prevention and treatment resources dwindled. 
Consequently, developing collaborative working relationships with affected
communities for the purpose of HIV prevention may pose special challenges
to many state and local health departments.  

In the United States, public health officials frequently underestimate the
strengths and resourcefulness of affected communities.  As a result, state
and local health departments and communities have seldom come together in
partnership.  In many instances, state and local health departments have
not sought the support of, or consulted with, community members before
designing and implementing community intervention efforts.  At times,
public health officials may have inadvertently stigmatized communities in
their attempts to intervene and promote public health.  

Affected communities are acutely aware of the peculiarities of public
health as it relates to them.  Some have asked, "Is this a war on drugs or
on us?"  or "Why do you care?"  Despite government support for community-based organizations (CBOs), national and regional minority  organizations,
and HIV prevention community planning, many communities remain wary of
public health programs as they have been implemented by officials in their
communities.

As if this lack of confidence were not challenging enough to state and
local health departments, many communities genuinely suspect conspiracy
when health officials implement programs for them.  Many disadvantaged,
disenfranchised persons not only distrust the government, but they may also
fear it.  For African Americans, the Tuskegee Study continues to cast its
own specter of doubt as to whether or not public health officials are truly
committed to ensuring the public's health.   Hispanic farm workers continue
to struggle with government pesticide regulators who seem indifferent to
the dangers that farm workers face in the workplace.  For Native Americans
living on reservations, the quality of health is chronically poor, and life
expectancy is diminished.  Within many communities, there is a pervasive
belief that the government "does not care," or worse, that it "will
experiment on them."

Although the AIDS epidemic has illustrated the real value of developing
partnerships among local and state health departments and communities,
achieving communication, collaboration, and cooperation with these
communities and maintaining the relationships in a climate of distrust,
apathy, and even fear is daunting.  Such a task will surely require
cultural sensitivity, competency, respect, and the most critical of all
elements, time.  

In particular, for an effective HIV prevention community planning process,
state and local health departments must develop strong linkages and
collaborations with affected communities.  A working definition of
collaboration is the process by which groups come together, establishing a
formal commitment to work together to achieve common goals and objectives. 
Collaborative relationships are also referred to as coalitions or
partnerships.  Regardless of the term, the concept is a crucial one.

To facilitate the formation of effective community planning groups and
other partnerships, health departments need to understand not only the
knowledge and behaviors of their client populations, but also their
attitudes toward and beliefs about their own communities, the government,
and public health.  Health departments will want to assess these same
issues among their own employees.  In addition to this understanding, to
fully achieve cultural competence, to have the capacity and skills to
effectively function in environments that are culturally diverse and
composed of distinct elements and qualities, health department
professionals must also develop a respect for cultural differences.  They
must appreciate how culture and history affect their clients' perceptions,
beliefs, attitudes, and behaviors, as well as their own. 

For many health departments and community organizations, responding to the
AIDS epidemic means long-term institutional change.  Simply channeling HIV
resources to affected communities through community-based and national non-governmental organizations is not enough.  The epidemic compels the
formation of real working relationships among partners who perceive each
other as equal.  The community planning process addresses these issues by
emphasizing the importance of assuring representation, inclusion, and
parity in the planning process.  

An important program objective for health departments may be to gain
acceptance and credibility in the communities they seek to serve.  To
assume that these will come automatically or even easily may demonstrate
cultural insensitivity and incompetence.  Respect and regard for the
perceptions of those being served will help eliminate barriers to HIV
prevention and will build the bridges to better health. 

How Can Collaborations Help?

Collaborations can:

  - Facilitate strategic planning.
  - Help prevent duplication of cost and effort.
  - Maximize scarce resources.
  - Integrate diverse perspectives to create a better appreciation and
    understanding of the community.
  - Provide comprehensive services based on the client's needs.
  - Increase client accessibility to health services.
  - Improve communication between the health department and its
    constituents.
  - Provide liaison for clients unwilling to seek services from government
    organizations. 

At the same time, public health agencies must be aware of some of the
difficulties inherent in collaborative relationships:

  - Organizations and individuals may have hidden agendas.
  - Intra-agency trust may be difficult to develop.
  - Decision-making processes may become complicated.
  - Organizations have to collectively take the responsibility for program
    objectives, methods, and outcomes.
  - The group may lack a clear sense of leadership and direction.
  - The group may lack a clear sense of its tasks and responsibilities.

What Influences the Success of a Collaborative Effort?

Many factors influence the success of a collaborative effort; however, the
following factors are vital:

  - The group must develop a sense of mutual respect, trust, purpose, and
    understanding.

  - There must be an appropriate representation of groups from all segments
    of the community for whom the activities will have an impact.

  - All members must "buy into" and develop ownership in the development
    and outcome of the process.

  - Effective communication among members must be constant and ongoing.

  - The group must position itself as a leader in the community, eager to
    work with persons from all communities in developing effective
    prevention strategies.

  - The group must be willing to try non-traditional strategies.

The development and maintenance of collaborative relationships are
challenging and rewarding tasks.  Collaborations can make positive,
significant changes in communities, if they are developed in a way that is
culturally competent and respectful of the people for whom interventions
will be developed.  Health departments must also consider whether efforts
are cost-efficient, appropriate, duplicative, and accessible; they must
determine where community-based organizations fit into the overall realm of
prevention activities.  Collaborations should be structured with long-term
results in mind.  They should serve as a bridge to better relations between
state and local health departments and the community, ultimately effecting
better health in the community.

Contracting With Community-Based Organizations

Request for Proposals
    
In many cases, a health department may determine that the best approach for
reaching affected populations is by contracting with community-based
organizations that have experience serving specific populations.  In these
situations, the health department may issue a Request for Proposals (RFP)
from community-based organizations.  The RFP should be clear and directive
to assure that proposals will address the areas that have been identified
as priorities.  The RFP might require the following:

  - Specific, time-phased, and measurable program objectives and program
    plans that target populations whose behaviors place them at high risk
    for HIV, STD, and tuberculosis (TB). 

  - Interventions that are:

     -- culturally competent (function effectively in environments that are
        culturally diverse and composed of distinct elements and
        qualities);
            
     -- sensitive to issues of sexuality and sexual identity;
            
     -- developmentally appropriate (provided at a level of comprehension
        that is consistent with the learning skills of persons to be
        served);
            
     -- linguistically specific (presented in dialect and terminology
        consistent with the target population's native language and style
        of communication); and 
            
     -- educationally appropriate.

  - Coordination and collaboration with other organizations and agencies
    involved in HIV/STD prevention programs, particularly those targeting
    the same populations.

  - An evaluation plan.

The RFP also should be clear in outlining the eligibility requirements.  A
CBO may be defined as:
    
  -     A tax-exempt organization.
    
  -     An organization with a significant number of the affected
        populations in key program positions.
 
  -     An organization with an established record of service to affected
        communities.

The following additional points should be considered in the RFP process:

  - RFPs should be disseminated widely.

  - The initial award should be competitive; multi-year assistance is
    allowable only after an initial competitive award.

  - A procedure should  be in place to assure that funds are awarded to
    CBOs in a timely manner, no longer than 90 days.

  - The RFP should provide details on the application procedures and how
    eligible applicants can obtain technical assistance in the application
    process, including a contact person and phone number.  

Review Process
    
A review panel should judge applications strictly against the criteria
outlined in the RFP. Members of the review panel should include qualified
persons representing the target communities who do not have a conflict of
interest in reviewing proposals.  Other criteria for membership to the
review panel should include the following:
    
  -     Members who reflect the characteristics of the epidemic in the
        population.

  - Members who have expertise in understanding and addressing the specific
    HIV prevention needs of the populations they represent.
  
Technical Assistance

A person or organization (on staff or through contract) should be
designated as the health department resource for technical assistance (TA)
to CBOs.

Types of technical assistance should include the following:

  - Assessing current and projected needs for HIV/STD prevention and early
    medical intervention.

  - Developing strategies for meeting identified needs.

  - Developing strategies for overcoming barriers to prevention. 

  - Planning, implementing, and evaluating prevention programs.

  - Providing program management.

  - Establishing a protocol for active monitoring and quality assurance
    (QA) of CBO activities.

As previously stated, linkages and coordination among organizations
providing HIV/STD prevention activities are essential.  This is
particularly important among funded CBOs and health departments to avoid
gaps in services and duplication of services.  The HIV prevention community
planning process plays a major role in assessing needs and identifying
overlapping services.  

In addition to contracting with CBOs, many health departments have 
full-time staff whose primary responsibility is to provide health education
and risk reduction services to affected populations.  The criteria outlined
in these Guidelines apply consistently to services provided directly by
health department staff as well as those provided through a contract with a
community-based organization.  


Note: For further reading on collaborations and partnerships see Chapters
1-3, "Handbook for HIV Prevention Community Planning," Academy for
Educational Development, April 1994.  For further reading on contracting
with CBOs, see Cooperative Agreements for Human Immunodeficiency Virus
(HIV) Prevention Projects Program Announcement and Notice of Availability
of Funds for Fiscal Year 1993.

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