AB-focused Prevention Intervention in the Military

The objective of this intervention is to strengthen and integrate the National Defense Forces of Ethiopia's

(NDFE) HIV/AIDS prevention, care, and treatment programs for soldiers and their dependents through

abstinence and be faithful (AB) activities using the MARCH (Modeling and Reinforcement to Combat

HIV/AIDS) model of behavior change. Research conducted in 2004 among 72,000 urban and rural male

army recruits indicated high HIV prevalence among the armed forces: an overall 7.2% among urban and

3.8% among rural recruits. Higher education levels in rural recruits were associated with higher HIV

infection. Members of the armed forces come from all parts of Ethiopia. They live a camp lifestyle, away

from family and friends, and are often exposed to rural and urban hotspots. In short, they represent a most-

at-risk population (MARP) requiring strong prevention intervention.

MARCH is a behavior-change communications (BCC) strategy promoting HIV prevention behaviors and

community care for people living with HIV (PLWH) and children orphaned by AIDS. The MARCH program

works with the NDFE to develop print-based serial dramas (PSD) in the form of comic books for use in peer-

led discussion groups. PSD attempt to reduce risky behaviors by addressing issues of: stigma and

discrimination; gender inequality; community support for those infected or affected by the virus; and most

specifically, correct and consistent condom use and early treatment of sexually transmitted infections (STI)

among the armed forces. The comic books employ role models who gradually evolve towards better

behaviors; the audience is encouraged to internalize the messages presented through peer discussion

groups. In these comic books, entertainment is incorporated to evoke emotion, empathy, and character

identification from the audience, while imparting a health message.

In FY06, the project trained 6,392 peer leaders, produced and distributed the first six editions of the comic

books, conducted peer-group discussions in the five divisions of the North and West commands, and

assigned project staff (creative team and project management) both at the headquarters and command

levels.

In FY07, 4,450 additional peer leaders were trained, and 6,674 peer groups were organized to hold

discussions every two weeks. Currently, peer leaders use the MARCH handbook as a guide for group

discussions and information sharing; they guide soldiers to reduce their risk of infection through modifying

their risky behaviors, adopting safe sexual behaviors, delaying sex, reducing sexual partners, encourage

positive living, and reducing stigma. A year's storyline of 26 episodes has been developed and more than

one million copies of the comic books have been printed and distributed for peer groups. In FY07, the scope

and depth of this program was strengthened through collaboration with Johns Hopkins University Centers

for Communication Program (CCP). The capacity of NDFE has strengthened at different levels to enable

NDFE to implement MARCH effectively and efficiently.

In 2007 MARCH was implemented in two commands. Based on the lessons learned from the two

commands, feedback collected from sites, and high demand created among the other commands, NDFE

plans to scale up MARCH in the remaining three commands of NDFE. This will achieve national coverage

and reach all members of the military. Also in FY07, MARCH activities and budgets were decentralized to

the command level, which has helped in tailoring MARCH implementation to individual soldiers' needs.

Since comic-book-format PSD have already been produced, the time required to implement in other

commands is minimal. However, due to the expansion to an additional three commands, the individual

reach and training targets significantly increase: 133,470 individuals will be reached through community

outreach and 8,900 individuals will be trained to promote prevention. In addition, the NDFE are distributed

to all parts of the country, giving the project national coverage. This significant increase in targets and

coverage area requires a 50% budget increase. The additional budget will be used for printing more copies

of PSD, additional staff, logistics and transportation, documentation, the production of additional IEC

materials, capacity building for staff, linkages with other services, and strengthening the monitoring and

evaluation system.

Due to high turnover and mobility in the military workplace, additional prevention activities besides MARCH

are also necessary. A number of existing opportunities and structures exist which can be used to build on

MARCH's messaging. Music and sports clubs, outreach development activities, national defense radio

programs, and the biweekly newsletter are all opportunities to help reach more target populations with

alternative approaches within the NDFE context.

NDFE will develop or adapt a curriculum to train individuals involved in implementing the above activities to

initiate discussion and distribute communication materials. CCP will also develop a branded communication

campaign of print and electronic materials. Defense Ministry radio will support the program through

interactive talk shows and radio spots. At the grassroots level, peer leaders trained by CCP will implement

the campaign and facilitate discussions.

This activity will leverage the structure and system designed for MARCH and resources of the NDFE

logistics department, as well as support from the Global Fund for AIDS, Malaria, and Tuberculosis. This is

advantageous in that adding an alterative approach (in addition to MARCH) does not require much

additional technical assistance.

This activity will also implement specific campaigns to increase service uptake of voluntary counseling and

testing (VCT), PMTCT, and ART by linking with UCSD. HIV-positive soldiers will share experiences and

become role models, promoting condom use, risk reduction strategies, and prevention with positives.

Soldiers' groups will also do outreach to communities surrounding military camps, as the military population

is closely linked to neighboring towns and cities. Military members are MARPs, linked socially and sexually

to other MARPS groups. The activity addresses issues such as male norms, comprehensive ABC

prevention, gender-based violence, and concurrent partnerships.

The following activities will be implemented in FY08:

1) Training of peer leaders in three new commands to strengthen comprehensive HIV/AIDS prevention

activities to reach army personnel in the five commands through a biweekly interactive peer group

discussion using the printed serial drama.

2) Adopt existing training manual for work with the military, and train peer leaders for all five commands and

Activity Narrative: headquarters

3) Produce and distribute 2,077,632 copies of 26 PSD issues

4) Conduct various interactive education programs and discussion groups at NDFE music and sports clubs,

radio programs, newsletters, and peer support structures

5) Produce and distribute military-specific, information, education, and communication/behavior-change

communication (IEC/BCC) materials on condom use, STI and other issues for peer discussion groups.

Augment the comic books and fill the gaps identified during the peer discussion groups.

6) Strengthen the AIDS Resource Centers (ARC) at NDFE through: procurement of audio-visual materials;

collection and documentation of available IEC materials on HIV-related topics; production of military-specific

IEC materials,; creation of linkages with national ARC; improvement in functionality of the ARC website; and

training on production of IEC/BCC materials

7) Establish and furnish project offices at ten divisions in the five commands, as well as strengthen the

headquarters and command offices with training and material support

8) Conduct sensitization and review meetings with NDFE officials at headquarters and command level

9) Capacity building and training for project staff and NDFE staff at different levels (headquarters,

command, division, regiment, and unit).

10) Strengthen the link between MARCH and HIV services to increase service utilization and treatment

adherence through reinforcement activities

11) Strengthen the established collaborations with University of California at San Diego (UCSD) and

Department of Defense (DOD), and organize activities to increase service uptake of ART, VCT, STI, TB,

and HIV/AIDS

12) Monitor and evaluate activities, including supportive supervision and outcome evaluation. The funding

for the outcome evaluation will come through the CCP MARCH technical assistance budget. CCP will hire

an external consultant to conduct the evaluation of NDFE MARCH.

Since these activities are designed to reach the military population with a comprehensive ABC message, all

targets will be counted under other prevention, though abstinence and be faithful is a significant part of the

comprehensive prevention program.

Addition 10/7/08

The NDFE HIV/AIDS prevention intervention using the MARCH model was initiated in FY03 in selected two

commands. Currently the MARCH program is scaled up and is being implemented in all commands of the

NDFE. In FY06, the project trained 6,392 peer leaders, produced and distributed the first six editions of the

comic books, conducted peer-group discussions in the five divisions of the North and West commands, and

assigned project staff both at the headquarters and command levels. In FY07, additional peer leaders were

trained in the existing new commands, and over 9000 peer groups were organized in all the five commands

to hold discussions every two weeks. In FY 07, 806,700 copies of the Print Serial Drama (Edition 1 to 13),

4,500 copies of IEC/BCC materials and around 10,000 copies of the MARCH hand book were distributed to

all the commands. In addition, in FY07, MARCH activities and budgets were decentralized to the command

level, which has helped in tailoring MARCH implementation to individual soldiers' needs.

There is a strong organizational commitment at different levels of the NDFE leadership structure. NDEF has

also developed and used standing structures for training, dissemination, implementation and reporting.

Currently, more than 9000 discussion groups have been formed and are meeting regularly to discuss on

different issue of HIV/AIDS using the print serial drama and MARCH handbook as a guide for group

discussions and information sharing; they guide soldiers to reduce their risk of infection through modifying

their risky behaviors, adopting safe sexual behaviors, delaying sex, reducing sexual partners, encourage

positive living, and reducing stigma. In general, the scope and depth of this program was strengthened

through collaboration with Johns Hopkins University Centers for Communication Program (CCP). The

capacity of NDFE has strengthened at different levels to enable NDFE to implement MARCH effectively and

efficiently. In FY07, NDFE has successfully achieved its targets both on reach and training.

This funding will be used to strengthen the existing NDFE MARCH program and scale up MARCH program

to peace keeping forces in Liberia and Sudan. The activity also involves building the capacity of NDFE

Medias ( Print, Radio and Audio visual media) for better reporting of HIV/AIDS educational messages,

advocacy of HIV/AIDS prevention, care and treatment services. This activity will create an opportunity to link

the existing MARCH program with the NDFE Medias to expand the reach and coverage of the program.

Military HIV Prevention Activities

The objective of this intervention is to strengthen and integrate National Defense Forces of Ethiopia's

(NDFE) prevention, care, and treatment for soldiers and their dependents through Other Prevention

activities, including correct and consistent condom use, issues of male norms and manhood, alcohol use,

and others, using the Modeling and Reinforcement to Combat HIV/AIDS (MARCH) model of behavior

change. Research conducted in 2004 among 72,000 urban and rural male army recruits indicated high HIV

prevalence among the armed forces: an overall 7.2% among urban and 3.8% among rural recruits. Higher

education levels in rural recruits were associated with higher HIV infection. Members of the armed forces

come from all parts of Ethiopia and live a camp lifestyle, away from family and friends, where they are often

exposed to rural and urban hotspots. In short, they represent a most-at-risk population (MARP) requiring

strong prevention intervention.

MARCH is a behavior-change communications (BCC) strategy promoting HIV-prevention behaviors and

community care for people living with HIV (PLWH) and children orphaned by AIDS. The MARCH program

works with the NDFE to develop print-based serial dramas (PSD) in the form of comic books for use in peer-

led discussion groups. PSD attempt to reduce risky behaviors by addressing stigma and discrimination,

gender inequality, community support for those infected or affected by the virus, and most specifically,

correct and consistent condom use and early treatment of sexually transmitted infections (STI) among the

armed forces. The comic books employ role models who gradually evolve toward better behaviors; the

audience is encouraged to internalize the messages presented through peer discussion groups. In these

comic books, both entertainment and health messages are incorporated to evoke emotion, empathy, and

character identification from the audience.

In FY06, the project trained 6,392 peer leaders using the newly developed MARCH handbook; produced

and distributed the first six editions of the comic books; conducted peer group discussions in the five

divisions of the North and West commands every two weeks; and assigned project staff (creative team and

project management) at both the headquarters and command levels.

In FY07, activities initiated in FY06 were continued—4,450 additional peer leaders were trained, and 6,674

peer groups were organized to hold discussions every two weeks. Currently, peer leaders use the MARCH

handbook as a guide for group discussions and information-sharing. They guide soldiers to reduce their risk

of infection by modifying risky behaviors, adopting safer sexual behaviors, delaying sex, and reducing the

number of sexual partners. They also encourage positive living, and address the issue of stigma. A year's

storyline of 26 episodes has been developed and more than 1 million copies of the comic books have been

printed and distributed for peer groups. In FY07, the scope and depth of this program was strengthened

through collaboration with Johns Hopkins University Centers for Communication Program (CCP). The

capacity of NDFE has strengthened at different levels to enable NDFE to implement MARCH effectively and

efficiently.

Due to high turnover and mobility in the military workplace, additional prevention activities besides MARCH

are also necessary. A number of existing opportunities and structures exist which can be used to build on

MARCH's messaging. Music and sports clubs, outreach development activities, and national defense radio

programs and the biweekly newsletter are all opportunities to help reach more target populations with

alternative approaches within the NDFE context.

NDFE will develop or adapt a curriculum to train individuals involved in the implementation of the above

activities to initiate discussion and distribute communication materials. CCP will also develop a branded

communication campaign of print and electronic materials. Defense Ministry radio will support the program

through interactive talk shows and radio spots. At the grassroots level, peer leaders trained by CCP will

implement the campaign and facilitate discussions.

This activity will leverage the structure and system designed for MARCH and the resources of the NDFE

logistics department, as well as support from the Global Fund for AIDS, Malaria, and Tuberculosis. This is

Activity Narrative: advantageous because adding an alterative approach (in addition to MARCH) does not require much

additional technical assistance (TA).

The following activities will be implemented in FY08:

1) Conducting training for 4,450 new and existing peer leaders in the three new commands. This will

strengthen comprehensive HIV/AIDS-prevention activities to reach more than 133,470 army personnel in

the five commands through biweekly interactive peer-group discussions using the PSD.

2) Adopting existing training manuals for work with the military, and train peer leaders for all five commands

and headquarters

3) Producing and distributing 2,077,632 copies of 26 PSD issues

4) Conducting various interactive education programs and discussion groups at NDFE music and sports

clubs, and via radio programs, newsletters, and peer-support structures

5) Producing and distributing military-specific information, education, and communication/behavior change

communication (IEC/BCC) materials on condom use, STI, and other issues for peer-discussion groups,

augmenting the comic books, and filling the gaps identified by peer discussion groups

6) Strengthening the AIDS Resource Centers (ARC) at NDFE through: procurement of audio-visual

materials, collection and documentation of available IEC materials on HIV-related topics, production of

military-specific IEC materials, creation of linkages with national ARC; improvement in functionality of the

ARC website; and training on IEC/BCC materials production

7) Establishing and furnishing project offices at ten divisions in the five commands, as well as strengthening

the headquarters and command offices with training and material support

8) Conducting sensitization and review meetings with NDFE officials at headquarters and command level

9) Conducting capacity building and training for project staff and NDFE staff at different levels

(headquarters, command, division, regiment, and unit)

10) Strengthening the link between MARCH and HIV services to increase service utilization and treatment

adherence through reinforcement activities

11) Strengthening the established collaborations with UCSD and Department of Defense (DOD) activities,

and organizing activities to increase service uptake of ART, VCT, STI, tuberculosis, and HIV/AIDS

12) Monitoring and evaluation of activities, including supportive supervision and outcome evaluation. The

funding for the outcome evaluation will come through CCP's MARCH technical assistance budget; thus,

CCP will hire an external consultant to conduct the evaluation of NDFE MARCH.

Since the PSD and reinforcement peer discussions are designed to reach the military population with a

comprehensive ABC message, all targets will be counted under Other Prevention, though abstinence and

be faithful (AB) is a significant part of the comprehensive prevention program.