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This document is being maintained for historical purposes, but is now out of date.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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                            HEALTH EDUCATION
                                   AND
                        RISK REDUCTION ACTIVITIES
                                    
                    Individual and Group Interventions

Health education and risk reduction activities are targeted to reach
persons at increased risk of becoming infected with HIV or, if already
infected, of transmitting the virus to others.  The goal of health
education and risk reduction programs is to reduce the risk of these events
occurring.  Activities should be directed to persons whose behaviors or
personal circumstances place them at risk.  Street and community outreach,
risk reduction counseling, prevention case management, and community-level
intervention have been identified as successful health education and risk
reduction activities.

                      Street and Community Outreach

Street and community outreach can be described as an activity conducted
outside a more traditional, institutional health care setting for the
purposes of providing direct health education and risk reduction services
or referrals.  However, before conducting any outreach activity in a
community, an agency must define the specific population to be served and
determine their general needs.  Based on this definition and determination,
an agency can then decide appropriately where to conduct intervention
efforts.  Street and community outreach may be conducted anywhere from a
street corner to a pool hall, from a parish hall to a school room.  To
determine the setting, an agency need only decide that the setting is
easily, readily, and regularly accessed by the designated client
population.

Outreach demonstrates an agency's willingness to go to the community rather
than wait for the community to come to it.  Often, agencies enlist and
train peer educators to conduct the outreach activities.  It is recommended
that the content of the outreach activity be contingent upon the setting. 
The nature of activity varies in scope and intensity; the activity is best
determined before an outreach team or individual educator goes out.  Yet,
flexibility is also very important.  Remember, everything is not
appropriate everywhere, all of the time. A street corner may be an
appropriate place to conduct a brief HIV risk assessment, but it is not an
appropriate place to conduct HIV counseling and testing.

While street and community outreach can be complementary service components
of a single agency, some agencies, based on needs assessment findings and
staff capacity, may choose to provide one service and not the other. 
Street outreach and community outreach can also be "stand alone" pieces. 

Street Outreach

Street outreach commonly involves outreach specialists moving throughout a
particular neighborhood or community to deliver risk reduction information
and materials.  The outreach specialist may set up an HIV/AIDS information
table on a street corner.  They may supply bleach to injecting drug users
at shooting galleries and condoms to commercial sex workers and their
customers at the hotels or locations that they frequent.  The fundamental
principle of street outreach is that the outreach specialist establishes
face-to-face contact with the client to provide HIV/AIDS risk reduction
information and services.

Effective street outreach staff:

  - Know the target group's language.

  - Have basic training and experience in health education.

  - Are sensitive to community norms, values, cultural beliefs, and
    traditions.

  - Have a shared identity with the population served, stemming from shared
    common personal experiences with the group.

  - Are trusted by the group they serve.

  - Act as role models to the clients they serve.

  - Advocate for the population served.

  - Act as liaisons between the community and the agency.

  - Are informed about community resources and use them.

Street outreach is not simply moving standard agency operations out onto
the sidewalk.  A number of specific issues are unique to the delivery of
services through this type of outreach and must be considered before
instituting a program of street outreach.  These matters are usually
addressed in an agency's street outreach program plan and include the
following:

  - Regular contact among educators, outreach specialists, and supervisors.

  - Observation of potential outreach areas to determine the locations,
    times of day, and the day of the week that are most productive for
    reaching the population to be served.

  - A written and comprehensive field safety protocol that is regularly
    updated.  (See Figure 1 Table_Fig1.)

  - Establishment of and adherence to regular and consistent schedules of
    activities, including times and locations.  (See Figure 2 Table_Fig2.)

  - A mechanism for measuring the use of referral services. 

  - Creation and maintenance of a positive relationship between the agency
    and the local law enforcement authorities.

  - Identification and development of collaborative relationships with
    gatekeepers (key informants) in the community. 

  - Activities for building and earning the trust and respect of the
    community.

  - Descriptions of skills-building exercises relevant to stated program
    objectives.

  - Establishment of mechanisms for maintaining client confidentiality.

Community Outreach: Workshops and Presentations

Workshops and presentations are typical activities of community outreach. 
Because they usually follow lecture formats, they can be highly structured
health education and risk reduction intervention efforts.  While they
supply important opportunities to disseminate HIV/AIDS prevention
information, their impact on behavior change is limited because they are
usually single-encounter experiences.  Although they provide crucial
technical information that raises awareness and increases knowledge and may
be a critical first step in the change process, the information alone is
usually inadequate to sustain behavior change. 

To maximize their benefit, workshops and presentations should be planned
carefully with knowledge goals and objectives specified before the
individual sessions.  To the extent possible, presenters should be informed
about the setting where the workshop or presentation will take place, as
well as the composition and knowledge level of the anticipated audience. 
The following are examples of issues the presenter might consider before
conducting a presentation or workshop:  

  - Where will the workshop or presentation be held?

  - What is the age range of the participants/audience?

  - What is the language(s) of the participants/audience?

  - What audiovisual equipment is available?

A well-planned, detailed outline, which allows flexibility, can prove
useful and beneficial to the presenter and the participants/audience.  Such
an outline helps keep the presentation on track and focused.  If a pretest
evaluation is to be used, an outline can ensure that all relevant material
will be covered in the lecture.

In a workshop or presentation, audience participation is to be strongly
encouraged.  Time must be allotted, usually at the end of the presentation,
for a question and answer session.  However, some questions may be so
pressing, or some participants so persistent, that the presenter will have
to address some questions and concerns during the presentation.  The
presenter should answer the questions succinctly and return to the original
order of the presentation.  

To increase the number of workshops and presentations they are able to
provide, some agencies will elect to develop speaker's bureaus to augment
their paid staff.  Recruitment, training, and retention of volunteers
present complex programmatic questions and are not to be undertaken
lightly.  Several references related to volunteers are provided at the end
of this document and should be reviewed carefully.

A more detailed list of important points to consider for workshops and
presentations is contained in Appendix C.  The points below are relevant to
agencies providing workshops and presentations either by paid staff or by
volunteers in a speaker's bureaus.  Effective presenters:

  - Possess organizational and public speaking skills.

  - Are well informed and comfortable talking about the subject.

  - Ensure that the presentation is linguistically appropriate for the
    audience.

  - Elicit and encourage audience participation.

  - Are adaptable to logistics and audience needs.

  - Are non-judgmental.

  - Assess the nature of questions to make appropriate responses, i.e.,
    whether better answered in private.

  - Seek accurate answers to difficult questions and provide information in
    a timely manner.

A few items specifically needed in a Community Outreach Program Plan are
listed below.

  - A comprehensive workshop/presentation curriculum.  (See Appendix C.)

  - Assurance that curricula provide for discussion of related issues. 

  - Detailed workshop/presentation outlines.

  - Logistical guidance for workshops/presentations (e.g., time and
    location, room arrangement, number of participants, number of
    facilitators).
    
  - Methods to assure that the audience is informed about workshop/
    presentation goals and objectives and that discussion of subject matter
    is facilitated.

  - Descriptions of skills-building exercises relevant to stated program
    objectives.

  - Training in the operation of audiovisual equipment and the use of
    diverse forms of audiovisual equipment.

 -  Recruitment of staff with organizational and public speaking skills.

Peer Educators

Agencies that provide street and community outreach will frequently engage
peer educators to conduct intervention activities.  Peer education implies
a role-model method of education in which trained, self-identified members
of the client population provide HIV/AIDS education to their behavioral
peers.  This method provides an opportunity for individuals to perceive
themselves as empowered by helping persons in their communities and social
networks, thus supporting their own health enhancing practices.  At the
same time, the use of peer educators sustains intervention efforts in the
community long after the professional service providers are gone.  

Effective peer educators:

  - Have a shared identity with the targeted community or group.

  - Are within the same age range as the targeted community or group.

  - Speak the same "language" as the community or group.

  - Are familiar with the group's cultural nuances and are able to convey
    these norms and values to the agency.

  - Act as an advocate, serving as a liaison between the agency and the
    targeted community or group.

Peer education can be very powerful, if it is applied appropriately.  The
peer educator not only teaches a desired risk reduction practice but s/he
also models it.  Peer educators demonstrate behaviors that can influence
the community norms in order to promote HIV/AIDS risk reduction within
their networks.  They are better able to inspire and encourage their peers
to adopt health seeking behaviors because they are able to share common
weaknesses, strengths, and experiences.

Agencies often recruit and train peer educators from among their client
populations.  However, not everyone is an educator.  The model client does
not necessarily make the model teacher, no matter how consistently s/he
practices HIV/AIDS risk reduction or is liked by agency staff.  Peer
educators should be instinctive communicators.  They should be empathetic
and non-judgmental.  They should also be committed to client
confidentiality.

Peer educators will not replace an agency's professional health educators,
but they can complement the intervention team and enhance intervention
efforts.  Peer educators may act as support group leaders or street
outreach volunteers who distribute materials to friends.  They may be
members of an agency's speaker's bureau and give workshop presentations.  

They may run shooting galleries, keeping bleach and clean water readily
available to other (IDUs).  They may be at-risk adolescents who model
responsible sexual behaviors.  The role of the peer educator is determined
by the intervention need of the client population and the skill of the peer
educator.

Although some agencies will hire peer educators as paid staff, others will
not.  As in the case of speaker's bureaus, engaging volunteer peer
educators also involves issues of volunteer recruitment, training, and
retention.  Several references in the list of publications included at the
end of this document provide more information on this issue.  In addition
to the core elements identified for health education and risk reduction
activities, an effective peer education program plan contains the
following:

  - A written and comprehensive field safety protocol.  (See Figure 1 
    Table_Fig1.)

  - Establishment of and adherence to regular and consistent schedules of
    activities, including times and locations.  (See Figure 2 Table_Fig1.)

  - A description of skills-building exercises relevant to the stated
    program objectives.

                         Risk Reduction Counseling

The purpose of risk reduction counseling is to provide counseling and
health education interventions to persons who are at high risk for HIV
infection.  The interventions promote and reinforce safe behavior.  The
participants may range from a single individual to couples, families,
groups, or entire communities.

Risk reduction counseling is interactive.  Such counseling assists clients
in building the skills and abilities to implement behavior change.  These
programs offer training in the interpersonal skills needed to negotiate and
sustain appropriate behavior changes.  For example, sessions could
concentrate on delaying the initiation of sexual activity, on methods for
avoiding unsafe sex and negotiating safer sex, and on techniques to avoid
sharing injecting drug paraphernalia.  Risk reduction may be implemented in
a variety of formats.  The interventions may take the form of role plays,
safer sex games, small group discussion, individual counseling, or group
counseling.

Effective risk reduction counseling sessions: 

  - Emphasize confidentiality.  
    
  - Begin with an assessment of the specific HIV/STD prevention needs of
    the client(s).

  - Identify, with the group or individual, the appropriate goals/
    objectives (e.g., condom use negotiation skills for female sex partners
    of IDUs).

  - Use skills-building exercises designed to meet the specific needs of
    the client(s).

  - Include negotiations with the client(s) on suggestions and
    recommendations for changing and sustaining behavior change as
    appropriate to their situation.

  - Enable/motivate participants to initiate/maintain behavior change
    independently.

  - Enhance abilities of the participant(s) to access appropriate services
    (e.g., referrals to drug treatment).

Risk Reduction Program Plans

An effective risk reduction program plan includes the following:

  - Protocols and procedures specific to each activity and logistical check
    lists for implementation.

  - Development of innovative behavior modification strategies.

  - Provision for regular updates in techniques for skills building.

  - Provisions for updates on client-focused approaches to risk reduction
    activities.

  - Provision for updates in techniques for increasing facilitators' skills
    in managing group or one-on-one dynamics.

Conducting Groups

Groups can provide significant informational and therapeutic HIV risk
reduction interventions to individuals who are ready to initiate and/or
maintain specific health promoting behaviors.  Groups are usually formed
around common issues or problems.  Some groups, originally established to
provide information and skills training, may evolve into support groups,
which encourage maintenance of newly acquired behaviors.  Utilizing groups
suggests a systems approach to intervention.  Groups provide access to
social networks that enable and reinforce health enhancing behavior change
through peer modeling and peer support.

Although open-ended groups (e.g., support groups) may have less structure
than the more close-ended kinds of groups (e.g., educational or 
skills-building), both types should have clearly defined goals/objectives
and specifically defined processes.  The structure of a group should be
determined based upon the needs of the members.

At times, the open-ended group with its open enrollment and extended life
is more suited to members' needs.  By being open-ended, potential members
are able to drop in when they need to and thus avoid the wait for new
groups to form.  This type of group is likely to appeal to the individual
whose commitment to the group's process is initially limited.  In the 
open-ended group, members determine their own topic of discussion at each
meeting.  For this reason, an open-ended model, that encourages drop-ins,
is perhaps less amenable to instructional sessions which usually need to
build on information presented at earlier meetings.  The open model,
because of its unpredictable structure and enrollment, may be more amenable
to process evaluation (i.e., percentage of agency's clients attending a
determined number of sessions).

The close-ended model will have a defined lifespan and is also likely to
set membership limits.  The closed group allows for important continuity
and facilitating the development of trust among members, as they get to
know each other over time.  Members can expect the same individuals to be
present each week, which can aid in building significant, supportive
relationships.  The closed group model is more suitable to the
establishment of client-specific outcome objectives that can be monitored
over time (i.e., self-reported reduction in number of sex partners at the
end of 8 weeks of group attendance).

There are significant advantages to both open and closed models, and
determination of which model to employ is based on the needs of an agency's
clients and on an agency's capacity to implement the model.  Whatever the
model selected, the size of the group is an important consideration.  Group
facilitation is not crowd control.  Smaller groups can be more manageable
and result in enhanced group dynamics.

Group facilitators or instructors may be peers or professionals; in some
instances, they may be both.  They should be skilled at promoting effective
group dynamics, encouraging reticent members to speak up and guiding the
dominant ones.  Skilled facilitators and instructors are astute observers. 
They not only listen to what is being said, but they also note nonverbal
cues.  Good observation skills are especially critical for support or
therapeutic group facilitators.  Skilled facilitators and instructors are
able to see changes in body language, hear sighs, and catch subtle changes
in facial expressions.

Groups are a naturally occurring phenomenon.  People come together for a
variety of reasons and left to themselves, they will develop informal but
powerful supportive networks.    Proactive HIV risk reduction programs can
tap into this resource and enhance program effectiveness.

                      HIV Prevention Case Management

HIV Prevention Case Management (PCM) is a one-on-one client service
designed to assist both uninfected persons and those living with HIV.  PCM
provides intensive, individualized support and prevention counseling to
assist persons to remain seronegative or to reduce the risk for HIV
transmission to others by those who are seropositive.  PCM is intended for
persons who are having or who are likely to have difficulty initiating and
sustaining safer behavior.  The client's participation is always voluntary,
and services are provided with the client's informed consent.

Prevention Case Management involves the assessment of HIV risk behavior and
the assessment of other psychosocial and health service needs in order to
provide risk reduction counseling and to assure psychosocial and medical
referrals, such as housing, drug treatment, and other health and social
services.  PCM provides an ongoing, sustained relationship with the client
in order to assure multiple-session HIV risk reduction counseling and
access to service referrals.  PCM should not duplicate Ryan White CARE Act
case management services for persons living with HIV.

Case managers work with clients to assess their HIV risk and psychosocial
and medical needs, develop a plan for meeting those needs, facilitate the
implementation of the PCM plan through referral and follow-up, provide
ongoing HIV risk-reduction counseling, and advocate on behalf of the client
to obtain services.   HIV Prevention Case Management creates bridges to
assist clients in obtaining services with which they are unfamiliar or that
pose special barriers to access.  Clients are active participants in
developing their PCM plan for risk reduction.  Prevention Case Management
may be carried out in a variety of settings, including the client's home, a
community-based organization's office or storefront, clinics, or
institutional settings.

Referral services may include HIV counseling and testing services (CT),
psychosocial assessment and care, other HIV health education and risk
reduction programs, medical evaluation and treatment, legal assistance,
substance abuse treatment, crisis intervention, and housing and food
assistance.  Additionally, HIV PCM services should assist the client in
obtaining STD prevention and treatment services, women's health services,
TB testing and treatment, and other primary health care services. A strong
relationship with STD clinics, TB testing sites, HIV counseling and testing
clinics, and other health service agencies may be extremely beneficial to
successfully recruiting persons at high risk who are appropriate for this
type of intervention.  PCM services are not intended as substitutes for
medical case management, extended social services, or long-term
psychological care.

The case manager needs a thorough knowledge of available community social
and medical services as well as HIV prevention, treatment, and related
services.  This includes specific knowledge of the scope of services
available, the protocol for accessing these services, and contact persons
working with local agencies.  Case managers are usually skilled in
providing individual or couples' HIV risk-reduction counseling on an
ongoing basis.  Case managers usually have an academic background or
special training in psychosocial assessment and counseling (e.g., social
work, drug and alcohol treatment counseling, nursing, health education). 
Prevention Case Management supervisors need the academic training and/or
experience to adequately develop PCM protocols, case documentation, and
policies.  The following provides further information on counseling and
testing issues:  HIV Counseling, Testing, and Referral: Standards and
Guidelines, U.S. Department of Health and Human Services, Public Health
Service, Centers for Disease Control and Prevention, May 1994. 

Staff Characteristics of the Prevention Case Manager 

Effective case managers are:

  - Non-judgmental in addressing the needs of the client.

  - Empathetic and critical listeners.

  - Skilled in dispute mediation.

  - Skilled in individual and relationship counseling.

  - Skilled in conducting a thorough behavioral risk assessment and
    psychosocial assessment at client intake and skilled in developing an
    individualized case plan.

  - Comfortable working in the home environments of their clients as well
    as in street settings, if necessary.

  - Continually concerned about the protection of the client's rights,
    including confidentiality, and always respectful of guidelines in the
    agency protocol document.

  - Sensitive to the client's ability to read literature and comprehend
    oral presentations.
 
  - Responsive to the financial resources of clients in regard to case
    planning and referrals.

Additionally, case managers:    

  - Maintain communication with case managers from other agencies working
    with the client to assure a coordinated treatment plan.

  - Identify resources and services for the client and assist them in
    accessing service needs.

  - Take into account and provide for cognitive impairments that may be
    related to the health status of the client.

  - Reinforce behavioral change accomplished by the client at all
    opportunities.

  - Troubleshoot episodes of client's unsafe behavior and relapse to
    identify barriers to practicing safer behavior and provide support and
    skills-building counseling.

  - Establish a rapport with clients and maintain open communication with
    them and their partner(s).

  - Act as an advocate in gaining access to services for clients.

Characteristics of the Prevention Case Management Program Plan:  

  - Includes specific, measurable, realistic, and time-phased program
    objectives.

  - Assures that all services in the plan conform to agency policies and
    local, state, and Federal laws (for example, confidentiality of
    information).

  - Assures the development of a written, formal PCM protocol for service
    delivery.

  - Provides for the development of specific, measurable, realistic, and
    time-phased objectives in each client's case plan.

  - Provides for regular meetings with each client to assess changing
    needs, monitor progress, and revise the service plan accordingly.

  - Assures that each case manager negotiates a risk reduction plan with
    the client, referring to the plan at each session in order to assess
    progress.

  - Assures the development and use of a comprehensive HIV risk assessment
    instrument to assess the behavioral variables influencing the client's
    risk taking.

  - Assures the development and use of a comprehensive psychosocial
    assessment instrument to assess psychosocial and medical service needs
    of the client as well as financial resources, language preferences,
    barriers to accessing these services, etc.

  - Assures that prevention case managers and their supervisors meet
    frequently for case presentations and supervision.

  - Defines collaboration with other local service providers through
    memoranda of agreement and regular meetings between agencies to
    facilitate access to other social and health services as well as to
    discuss and coordinate treatment plans for individual clients.

  - Assures that the memoranda of understanding among agencies are
    periodically updated, accurately reflecting collaborative activities.

  - Assures that the assessment of progress in meeting the case plan is
    communicated to the client for review and comment.

  - Assures that case records include documentation that acknowledges
    voluntary client participation and mutually satisfactory case plans.

  - Assures that an updated written or computerized database of service
    referrals and a system for documenting successful referrals are
    maintained.

  - Assures that regularly scheduled staff meetings are held to discuss
    challenges, successes, and barriers encountered by case managers;
    adequate time must be allocated for staff to share concerns,
    frustrations, grief, and other emotions experienced through the close
    work with persons at risk or with persons living with HIV.

PCM staff training plans usually include the following:

  - Staff training in established PCM protocols, agency policies, and
    referral mechanisms.

  - Periodic training addressing the local services available for client
    referral.

  - Skills training to improve the HIV risk reduction counseling provided
    to clients.

  - Training that addresses how to effectively intervene with clients who
    are in extreme states, such as persons who are combative, in emotional
    crisis, mentally ill, or under the influence of drugs and/or alcohol.


                      Community Level Intervention

Community Level Intervention combines community organization and social
marketing -- a strategy that takes a systems approach.  Its foundation is
an assumption that individuals make up large and small social networks or
systems.  Within these social networks or systems, individuals acquire
information, form attitudes, and develop beliefs.  Also, within these
networks, individuals acquire skills and practice behaviors.

The fundamental program goal of Community Level Intervention is to
influence specific behaviors by using social networks to consistently
deliver HIV risk reduction interventions.  Although the intervention
strategy is community-based, Community Level Interventions target specific
populations -- not simply the community in general.  The client populations
have identified shared risk behaviors for HIV infection and also may be
defined by race, ethnicity, gender, or sexual orientation.

In order to influence norms that support HIV risk reduction behavior,
Community Level Interventions are directed at the population, rather than
at the individual.  The primary goal of these interventions is to improve
health status by promoting healthy behaviors and changing those factors
that negatively affect the health of a community's residents.  A specific
intervention may take the form of persuasive behavior change messages, or
it may be a skills-building effort. Whatever its form, an intervention
achieves reduced HIV risk by changing group norms to improve or enhance the
quality of health for members of the client population.  These norms may
relate to condom use, contraceptive use, or needle-sharing.  They may also
focus on diagnosis and treatment of sexually transmitted diseases or HIV-antibody counseling and testing.

It takes time to change social norms.  Social norms cannot be changed
quickly or at the same rate that knowledge acquisition or skills
development can occur.  Change occurs as a result of sustained, consistent
intervention efforts over time.  The intervention must be implemented
thoroughly throughout the social networks.  A firm grounding in behavioral
theory is essential to the development and implementation of Community
Level Interventions. 

Community-based needs assessment is critical to the development and
implementation of Community Level Interventions. This phase is important
for identifying and describing structural, environmental, behavioral, and
psychological facilitators and barriers to HIV risk reduction.  To
successfully conduct this intervention, a program must identify the sources
for and patterns of communication within a social network.  Peer networks
must be defined and described.  

Note: Community Level Intervention is referred to as Community Intervention
Programs in Program Announcement #300.

The following questions should be considered in designing community level
interventions: 

  - Who are the gatekeepers to the client population?

  - What are the important points of access?

  - What are the appropriate and relevant risk-reduction messages, methods,
    and materials?  

  - What are the linguistic and literacy needs of the client population? A
    needs assessment should yield this vital information. 

For further reading on the developmental steps of Community Level
Intervention, see Cooperative Agreement for Human Immunodeficiency Virus
(HIV) Prevention Projects Program Announcement and Notice of Availability
of Funds for Fiscal Year 1993.

A variety of methods exists for collecting the answers to these questions. 
It is recommended that programs select the method that is most appropriate
for their professional orientation (e.g., social work, health education). 
Whatever method is chosen, it is critical that the formative activity be
community-based and as collaborative as possible with the client
population.

The information gathered during the formative phase provides the foundation
on which an effective program can be built.  Completing this activity
should result in culturally competent, developmentally appropriate,
linguistically specific, and sexual-identity-sensitive interventions that
promote HIV risk reduction.

Members of existing and relevant social networks can be enlisted to deliver
the interventions.  Other peer networks may also be created and mobilized
to provide intervention services.  This, of course, means volunteer
recruitment and management.  Community Level Intervention strategies offer
opportunities for peers to acquire skills in HIV risk reduction and, in
turn, reinforce these abilities when the peers become the teachers of these
same skills to others.

In this manner, Community Level Interventions become community-owned and
operated; thus, they are more likely to be sustained by the community when
the program activity is completed.  Social norms changed in this way are
likely to have a long-lasting and effective impact upon HIV risk reduction. 

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