Njoo tuzungumze! Come, let's talk! A comprehensive program seeks to change behavior and promote HIV counseling and testing in Tanzania.

Project manager Anatory Didi held up a newspaper cartoon at a recent staff meeting for Angaza, an organization that promotes HIV testing and counseling in Tanzania. "Angaza is truly a household word, and people understand our mission!" he said excitedly. The cartoon depicted a woman in the market bargaining with the butcher about the quality of a chicken for sale. The butcher held up his hands in exasperation and said, "If you don't believe this chicken is healthy, take it to Angaza!"

The cartoon proved that after an intensive four-year communication campaign, Angaza had become a recognized, trusted and accessible resource for Tanzanians seeking quality counseling and testing.

In the age of HIV/AIDS, health communications tread upon layered fields of sexual behavior, stigma and morality. Perhaps like no other health issue, HIV/AIDS has forced development professionals to push cultural and clinical boundaries to reach the public with effective prevention, care and treatment messages. Voluntary counseling and testing (VCT) has increasingly been recognized as an HIV prevention tool. In 2001, the African Medical and Research Foundation (AMREF)/Tanzania was awarded a grant from the U.S. Agency for International Development to enhance counseling and testing services across Tanzania. The program, dubbed Angaza (meaning "shed light" in Swahili), now supports 65 voluntary counseling and testing sites and has seen almost 365,000 clients.

From the program's inception, Angaza's communication strategy has challenged the notion that knowledge of HIV status equals a loss of hope. The strategy aims to influence (1) knowledge about VCT availability, (2) attitudes toward knowing one's HIV serostatus, and (3) HIV prevention behaviors, including participation in VCT.

In a country with an HIV prevalence rate of 8.8 percent, communications must captivate the public and encourage behavior change. While 75 percent of Angaza baseline survey respondents in 2001 reported wanting to be tested at one time or another, and more than 90 percent expressed the attitude that knowing one's serostatus has benefit, only 12 percent reported having ever taken an HIV test. This gap between attitudes and practices proved to be an enormous challenge.

Different angles and media

Angaza provides individuals and communities with information about HIV prevention, local support for HIV-positive clients and treatment options. Strategic communication for behavior change can include many streams, including the use of mass media through advertisements or entertainment education, community mobilization, advocacy, and social marketing. Angaza uses precisely this formula to change behavior in Tanzania.

Angaza also works within health care settings to stimulate referrals for service. For example, Anna Yoeza, a 36-year-old mother of six, tested HIV-positive while at the hospital for prenatal care. "After the results, I was worried what would become of my baby when it [was] born," she says. "How would I break the sad news to my husband?" Though she told him that same day, he never revealed his own HIV status. He died the following year. "As I cleared his stuff after the funeral, I found ARVs [anti-retroviral medication] in his briefcase. This was the first and last indicator to me that he knew he was HIV-positive but never told me. I had never suspected anything."

Yoeza is now a leader of Angaza's post-test club operated at Selian Lutheran Hospital in Arusha. Her youngest child was recently tested at the center. "He was found to be HIV-negative, which reduced a lot of burden from my mind," she says. The club has 72 members and holds weekly meetings. "I get my strength for continued living from the support of Angaza's post-test club. Some of us give testimonials at church and in this way educate our fellow Tanzanians about HIV/AIDS," she says. Angaza is working to build client demand for service, to provide quality counseling and testing, and to follow up with psychosocial support for clients.

Focus on counseling

To develop a communication strategy based on both research and contemporary marketing principles, Angaza turned to an advertising agency for assistance in 2001. The original communication brief sought creative direction to reorient the target audience's thinking about fundamental emotional and behavioral issues. Angaza's communications therefore needed to be simple and factual, and to resonate with the audience's view of their environment. The tone was intended to be real-life, edgy, captivating and "human."

After circulating a request for media pitches, Angaza entered into partnership with M&M Communications Ltd., in Dares Salaam. Social marketing techniques were used to "sell" the idea of behavior change for the promotion of VCT service as well as HIV/ AIDS prevention. A brand name and logo for the VCT program was developed, tested and promoted, with the intention of creating brand awareness, establishing credibility and building popularity of services.

The program also focused its message primarily on counseling rather than testing, to side-step the stigma associated with testing. Therefore, the key message communicated was "Come, let's talk (Njoo tuzungumze)." The service descriptor was "The professionals in counseling and testing (Wataalam wa ushauri nasaha na kupima)."

Reaching people where they are

A key part of the plan was to use the most effective means of communication to reach the audience. Angaza used the following media to get the word out:

* Radio was the most essential media channel, since more than 75 percent of respondents in Angaza's baseline survey owned a radio, and radio was cited as the most common vehicle of media exposure among people of different ages, genders and socioeconomic status living in Tanzania's largest cities.

* Television was a powerful visual communication tool, promoting Angaza by sparking interest, conveying emotion and maximizing impact. However, while 54 percent of Tanzanian survey respondents watch television programs regularly, less than 20 percent of them have a television in their own home.

* Print media was used to reinforce brand benefits and provide detailed information about Angaza site locations. It also allowed for "recycling" of information, since newspapers are often shared among people and families.

* Outdoor advertising was used to maintain top-of-mind awareness, creating visibility and continuous promotion of Angaza. In particular, billboards were positioned at highly populated centers. T-shirts, khanga (women's sarong skirts) and other items were "branded" and distributed at community mobilization events.

* Angaza counselors also play a major role in promoting counseling and training to communities. Counselor Bahati Mwitula intentionally wears his Angaza-branded shirt to social events to stimulate discussions about VCT among acquaintances at restaurants, bars and friendly gatherings. "People ask many questions, especially youth," he says. "Sometimes I am surprised by the misinformation and beliefs people have about HIV. It is gratifying to share my knowledge and know it impacts their lives. Counseling is a full-time job!"

Counselor Nuru Kilimba agrees, describing how she has given talks at "kitchen parties," Tanzanian bridal showers where women gather to share gifts and advice with brides-to-be. "Some women have commented that discussion of HIV at a kitchen party is bad luck, but young women appreciate the outreach. They want to be empowered to make the right decisions for themselves and their families. Information sharing is essential," Kilimba says. Khanga are often exchanged at kitchen parties, and Angaza recently printed branded khanga with health messages to distribute to women at such gatherings.

Overall, Angaza has used media to build its image through communication of its benefits and to establish Angaza's brand name as the icon for professional, quality, confidential HIV counseling and testing. Media placement strategies were employed to constantly remind potential clients of the reasons to visit Angaza.

Positive impact

Angaza's monitoring and evaluation studies were important for capturing where the target audience stood along the behavior change continuum, and to allow for modifications and innovations.

The first two Angaza communication campaigns (2002-2004) were evaluated to gauge their impact on client attendance and related behaviors. Quantitative and qualitative research was conducted to understand the links between client sources of information and gender, age, education, marital status, geographic area and HIV serostatus. Relating client utilization and media placement also demonstrated the impact of mass media, as client numbers soared during periods of heavy advertising.

Analysis of almost 100,000 client intake forms from 2002-2004 demonstrates that compared with other information methods, radio and TV were the most prominent sources of information about Angaza, cited by 41 percent of all clients, followed by friends and family (22 percent), and posters and billboards (16 percent). Only 4 percent of clients recalled learning of Angaza through their sexual partners. Among HIV-positive clients, friends and family (39 percent) were a more commonly cited source of information about Angaza, compared with radio and TV (27 percent). Evaluation of the communication led Angaza to complement mass media with community mobilization and local advertising efforts.

Broader lessons

The behavior change communications campaign for Angaza provides many lessons for programs throughout Africa. Targeted media methods have demonstrated success in reaching specific groups, including youth, couples and high-risk populations.

A theoretical model provided a backbone to strategy development, guiding messages, approaches and expected outcomes. The approach of extending positive messages based on interpersonal communication, influencers of behavior and empowered decision making has yielded promising results for encouraging the use of services. Carrying these messages in a multimedia format has also served to reinforce key themes and characters.

As new Angaza facilities open across the country, and as the organization broadens its array of programs and services to include PMTCT (prevention of mother-to-child transmission), post-test support groups, and stronger referral networks for care and treatment, effective, appropriate communication is essential to keeping the public informed and poised for action. The program is also being transformed by developments in the country, such as the national government plan to make anti-retroviral treatment available to 400,000 Tanzanians by 2008. With new options available for people in Tanzania to live with HW, Angaza's communications strategy will continue to evolve.

Business and HIV/AIDS: The cost of the epidemic

The Global Business Coalition on HIV/AIDS is an alliance of more than 200 international companies that battles the AIDS epidemic by using the business sector's unique skills and expertise. The organization posits that HIV/AIDS is more than a medical issue: It threatens employees, customers and communities, and affects a company's bottom line through decreases in productivity and profitability. Here are some statistics on the global impact of the pandemic on businesses and what they can do.

* In its 25-year history, AIDS has claimed the lives of 25 million people. Every day, 8,500 people die of the disease, and another 14,000 people are newly infected with HIV.

* A U.S. study among the most sought-after consumers funded by the Global Business Coalition found that an overwhelming majority (71 percent) believe that companies should be "actively" involved in fighting AIDS.

* AIDS attacks people in their most productive years.

* New HIV infections can cost between 3.4 percent and 10.7 percent of annual salaries depending on skill level, associated benefits and prevalence in the area.

* By 2001, 13.4 million children under the age of 15 had lost parents to the disease, a number expected to rise to 25 million by 2010.

* With globalization comes increasingly porous international borders; no company is immune to the disease.

* Emerging markets in China, Eastern Europe and India are the regions where the epidemic is growing fastest.

What businesses can do

* Partner with international institutions, donor governments and foundations to achieve prevention and treatment goals.

* Implement global and national awareness campaigns.

* Get involved in collective bargaining for global action on HIV policies and HIV-related commodities for testing and treatment.

* Promote advocacy by CEOs and other business leaders about the urgency of the crisis.

* Get involved with business associations and coalitions in tackling AIDS at a national level.

* Implement a comprehensive workplace response to HIV that includes antidiscrimination policies, promotes awareness and prevention (including distribution of condoms), and provides workplace testing (in-house or off-site).

* Provide care, support and treatment for employees.

* Extend workplace HIV-prevention and treatment programs to employees' families and local communities.

SOURCE: Global Business Coalition on HIV/AIDS (www.businessfightsaids.org)

creative strategies

Angaza supplements more common forms of communication, such as TV, radio and print advertising, with less traditional tools. For example, khanga (sarong skirts) are printed with health-related messages and the Angaza name and then distributed to women at "kitchen parties" (bridal showers).

Lisa McArthur Daly, MPH, is former program manager for behavior change communications at African Medical and Research Foundation (AMREF)/ Tanzania. Benedicta Mduma, M.D., MPH, is the program manager for voluntary counseling and testing/prevention of mother-to-child transmission. Dulle Robert is the monitoring and evaluation officer with AMREF/Tanzania.