INTERVENTIONS IN THE LESOTHO APPAREL INDUSTRY

KNOWLEDGE, ATTITUDE & PRACTICES PROGRESS & OUTCOMES REPORT IN 2012

PRESENTATION BACKGROUND

Workplace HIV and AIDS programmes are a cornerstone of global response to the epidemic The ALAFA programme is well established and addresses HIV prevention, support and treatment in a very high prevalence context Two previous HIV prevalence and knowledge, attitude and practices (KAP) studies have been conducted (2007,2009) in factories where ALAFA programmes are run Previous findings have shown high knowledge and low stigma with high HIV prevalence among the predominantly female work force Positive changes and outcomes in relation to HIV prevention and stigma have been linked to ALAFA programme activities

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RESEARCH DESIGN & METHODOLOGY

The 2012 study included an HIV seroprevalence survey, KAP questionnaire and qualitative focus groups in 15 factories that were also sampled in 2007 and 2009 Managers, supervisors, skilled and unskilled factory floor employees, as well as administrative and other staff 15 focus groups were conducted with managers/ supervisors, male and female factory floor staff and peer educators Data was collected in Sesotho and English The HIV data was anonymous and unlinked and was collected via bloodspots from finger pricks, and analyzed at an external laboratory Ethical approval received from MoHSW in Lesotho

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STUDY STRENGTHS & LIMITATIONS

The study uses globally proven approaches for KAP, HIV and qualitative surveys and draws on extensive southern African experience of the research team Survey findings are representative of employees in apparel factories in Lesotho (n=2,800) Although comparison is made to previous surveys, this is not a cohort study so we cannot measure the extent of new infections directly Uptake of antiretroviral treatment programmes markedly reduce death rates, so increases in HIV prevalence do not necessarily indicate increases in new infection The qualitative study aids and strengthens interpretation of the quantitative findings

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KEY FINDINGS
- Topline data on HIV AIDS prevalence - Peak demographics & trends - Societal and personal impacts of HIV AIDS

MORE THAN 2 IN 5 OF THE WORKFORCE IS HIV+

At 42.7%, HIV prevalence amongst apparel industry workers in Lesotho is very high. Prevalence rates are similar amongst all employee categories. Migrant workers are at a slightly higher risk than those who live and work in the same area.
HIV Status
HIV NEGATIVE HIV POSITIVE

42.7%
POSITIVE

2012 Sample 1,195 2,800

2012 % 42.7%

2009 % 41.0%

2007 % 43.2%

Positive Total

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HIV PREVALENCE RATES ARE STABILISING

%

60 50 40 30 20 10 0
2007 2009 Women Men 2012

Between 2007 and 2012, HIV prevalence amongst women stabilized between 42.7% 44.7% Variations in the male population are difficult to interpret as the male sample is small (12% of total sample).

HIV positive Female Male

2012 % 44.7% 29.7%

2009 % 42.7% 28.8%

2007 % 44.2% 35.6%

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PREVELANCE RATES AND DEMOGRAPHICS

52.60% 41.80% 29.10%
43.90% 37.50%
FEMALE MALE

50.70%

27.30%

8.70% 18 - 24 25 - 29 30 - 34 35 - 39

Amongst women HIV prevalence peaks (52.6%) between 30 34. Over half the women between the ages of 35 39 surveyed were HIV+

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PREVELANCE RATES AND DEMOGRAPHICS

52.60% 41.80% 29.10%
43.90% 37.50%
FEMALE MALE

50.70%

27.30%

8.70% 18 - 24 25 - 29 30 - 34 35 - 39

For those who are younger; prevalence is significantly less than average at 29.1%

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PREVELANCE RATES AND DEMOGRAPHICS

52.60% 41.80% 29.10%
43.90% 37.50%
FEMALE MALE

50.70%

27.30%

8.70% 18 - 24 25 - 29 30 - 34 35 - 39

Among men HIV prevalence peaks (43.9%) between the ages of 35-39. The sample size for men was small.

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INTERPERSONAL EXPOSURE TO HIV AIDS

69% 48% 33% 17%
Told by someone they Attended funeral of Cared for a person sick Cared for a child are HIV+ someone who has died with an ARI orphaned AIDS related of an ARI illness

In the last year, just under half (48%) of the workers had attended the funeral of someone who had died of an AIDS related illness. 33% had cared for a person sick with an AIDS related illness. 1 in 6 workers had cared for a child orphaned by AIDS related illness.

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SEXUAL HEALTH
Nearly a half (47%) of respondents reported an unusual sore or discharge on their genitals in the past month. This is a subjective measure of STI.

47%

All Respondents

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PEER EDUCATION
- Awareness & Participation - Satisfaction & Effectiveness - Qualitative analysis

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AWARENESS OF PEER EDUCATION

87% 79% 74% 72% 62%

81%

87% 61%
45% 30%

Posters in AIDS Leaflets Peer Drama in Songs or PSI factory events in and education factory music activity in factory booklets and club factory sessions

Video

72% of employees mentioned peer education and club sessions when asked for sources of HIV information in the workplace.

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ALAFA RUNS PEER EDUCATION SESSIONS

95% 90% 89% 77%

88%

All Respondents
Management Skilled employee Unskilled employee Admin / Other

It was widely known and recognised that ALAFA runs these peer education sessions in the workplace.

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ALAFA TRAINS PEER EDUCATORS

93% 89%

87%

87%

78%

All Respondents
Management Skilled employee Unskilled employee Admin / Other

As is the fact that ALAFA trains the peer educators.

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THE PEER EDUCATION EFFECT

95%
95% learned something new at the session

33%
33% of workers have attended peer education sessions

95%

95% changed their behavior after

85%

85% prompted to go for testing

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ATTENDEE SATISFACTION & FEEDBACK

94%
94% felt free to ask questions at the sessions

98%
98% of attendees enjoyed attending the sessions

86%

86% thought there were too many attendees

33%

33% thought the sessions were too long

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IMPACT OF ALAFA PARTICIPATION

84%
56%

76%

61%
50%

61%

50%

15% Confidence in Tested previously, revealing HIV Status most recent test at this factory

4%

5%
Use a condom Made changes to everytime / almost behavior in past year everytime

Two or more partners in past month

There were significant differences between those who accessed ALAFA services (clinic / peer education) and those that didnt. In particular around testing and changes to behavior in the past year.

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QUALITATIVE STUDY: PEER EDUCATION

Peer education sessions were valued and sessions were said to be creative and interesting and that the topics were sufficiently varied Peer educators were said to be knowledgeable and capable of conducting and controlling the discussion groups

[Before] I was not a caring person. But now I take things seriously and take interest. I even share the information with others

Peer educators need to be supported so they can continue with their work. They guide us a lot

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QUALITATIVE STUDY: PEER EDUCATION

Peer educators felt that they worked hard and did a good job and that PLHIV in ALAFA factories were much better off than in other factories Some peer educators mentioned that it was difficult to deal with traumatic stories that employees shared with them and debriefing would be useful

Before I had an active social life. My cellphone always ringing with calls from men. Now that has gone down. I have cut down on my male partners

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QUALITATIVE STUDY: PEER EDUCATION

It was felt that there should be some form of support for PEs for example, by receiving some form of recognition monthly e.g. cellphone airtime. It was suggested by one group of peer educators that there be more opportunities for creating dramas and poems as a means of communicating. Peer educators were satisfied with the training they received and were also motivated to make changes themselves including, for example, testing for HIV (including partner testing), being faithful to ones partner and changing lifestyles:

Maybe have a projector, people watch a movie, instead of listening to us all the time. Pictures can explain better to other people

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COMMUNICATIONS AWARENESS & EDUCATION Folder/Alafa/Alafa for - /Users/Simon/Documents/Clients

Austin/Other photos from 2012/factory HTC.jpg

COMMUNICATION AND CONTEXT

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25

Media access remains a great challenge

84%
Radio

43%
Television

9%
Print & Magazines

3%
Internet

Most workers (84%) have regular access (two days per week or more) to a radio; just under a half watched TV more than once per week. Internet access is rare 96% of workers have never used it.

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MOBILE / CELL PHONES ARE UBIQUITOUS.

Two or more times per week (97%)

Cell Phone

One time or less (1%) Never (3%)

97% of all workers have regular access to a mobile or cell phone. This potentially provides an important out of workplace communications channel for ALAFA.

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WHERE DO WORKERS GET THEIR INFORMATION?

81%

81%

69%

67%

64%

87%

62%

58% 43%

Factory / AIDS Education

Friends

Factory / Clinic

AIDS Organisation

Hospital

Parent / Family

Private Doctor

The workplace is a critical and leading source of HIV / AIDS information, over 80% of employees cited factory and AIDS education as sources of information in the past year; with over two-thirds citing the factory clinic.

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WHAT COMMUNICATIONS HAVE IMPACT?

87% 79% 74% 72%

81%

87% 62%

61% 45% 30%

Posters in AIDS events Leaflets and Peer factory in factory booklets education and club sessions

Drama in factory

Songs or music

PSI activity in factory

Video

Within the workplace itself, the activities with the highest levels of recall were posters, AIDS events, leaflets & booklets and peer education and club sessions.

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OUT OF WORKPLACE COMMUNICATIONS ACTIVITIES WITH CUT THROUGH.

88% 67%

81%

61%

87%
40% 5%

Radio adverts or programmes

Posters / Leaflets or Stickers

TV adverts or programmes

Magazine information or magazines

Internet

Radio (88%) was by far the most mentioned source of information; followed by posters, TV and magazines. Internet is negligible (in line with earlier usage data).

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KNOWLEDGE OF HOW TO PREVENT INFECTION

95.00%

81%

87%

12.00% Always use condoms Abstaining

11.00% Limit or reduce partners

11.00% Have only one partner

0.03% Don't share utensils with PLHIV

When asked the main ways to avoid HIV infection, use of condoms was almost universal (95%); changing other sexual behaviors was lower.

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UNDRSTANDING HIV / AIDS

94% 90% 75%

81%

87%
48%

A person who looks healthy can be HIV+

HIV can be passed from Circumcised men are HIV / AIDS can be cured mother to baby less likely to get infected

There are now high levels of knowledge around some of the fundamental facts of HIV / AIDS, but further education around circumcision as a means of risk mitigation is still required.

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QUALITATIVE INSIGHT: COMMUNICATIONS

Communication about HIV through posters and other materials was said to be valuable and materials were noted to be appropriate in design and language: The language is clear and the format is perfect. Some participants felt materials could be updated more regularly Although knowledge was generally good, it was felt that education remained necessary and that interactive forums including support groups were useful approaches, and it was felt that there was potential to have additional education sessions on weekends. It was also noted that peer educators were able to address questions: Where we dont understand, PEs are there to assist Previously people who said they were HIV positive were laughed at, but that this no longer occurred. Disclosure was seen as beneficial

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QUALITATIVE INSIGHT: UNDERSTANDING HIV

Good overall understanding of HIV with main concerns being about transactional sex, with female employees relating their low income as a risk factor Alcohol consumption was recognised as a risk factor for exposure to casual sex Training in budgeting was mentioned as a way to reduce vulnerability There were some concerns about exposure to HIV infected blood, and concerns that universal precautions were not always followed e.g. always using gloves or keeping first aid items sterile

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DE-STIMATISING HIV AND THOSE INFECTED

97% 90%

81%

87%
81%

I would work next to someone who is HIV positive

People living with HIV in this factory are accepted by their fellow workers

If I was HIV+ I would feel comfortable disclosing at this factory

There are very low levels of stigma directed towards PLHIV and four out of five people would be happy to disclose their status at their workplace.

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Awareness of ALAFA and its work to bring healthcare to the workplace.

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AWARENESS OF ALAFA SERVICES

Services All (n=2,800) Manager/ Supervisor (n=153) 95% 77% 100% 91% 90% 93% 65% 80% 91% 52% 47% Skilled employee (n=1,141) 95% 66% 98% 90% 83% 81% 70% 69% 76% 45% 41% Unskilled employee (n=1,134) 95% 64% 99% 91% 84% 82% 69% 69% 72% 46% 46% Admin/ other (n=372) 98% 67% 98% 92% 84% 92% 64% 68% 78% 37% 33%

Know of Clinic or Nurse at factory Of yes, personally received treatment or advice Yes, one can get free male condoms in factory Of yes, personally obtained male condoms Of yes, male condoms are available most or all the time Yes, one can get free female condoms in factory Of yes, personally obtained female condoms Of yes, female condoms are available most or all the time Yes, I know of AIDS peer educators in this factory Of yes, attended sessions in past year Of those attending in past year, attended once a week or more

96% 66% 98% 90% 84% 84% 68% 72% 76% 45% 42%

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HAVE YOU HEARD OF ALAFA?

There are very high levels of awareness of ALAFA, given the migratory nature of the workforce this is a strong result. We then asked those who were aware of ALAFA if they were aware of the following services.

86%

All Respondents

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AWARENESS OF ALAFA : EDUCATION

100%

80%

86%
60% 40%

87%

88%

85%

All Respondents

20%

0%

Trains Peer Educators

Runs Peer Sessions

Provides HIV / AIDS materials

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AWARENESS OF ALAFA : PREVENTION

100%

80%

90%

86%
60% 40%

88%

91%

All Respondents

20%

0%

Distributes free male condoms

Distributes Free female HIV testing for employees condoms

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AWARENESS OF ALAFA : TREATMENT

100%

80%

90%

86%
60% 40%

88%

All Respondents

20%

0%

Supports clinic in factory

Supports HIV treatment

0%

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AWARENESS OF ALAFA : FACTORY POLICY

100%

80%

86%
60% 40%

82%

All Respondents

20%

0%

Helps develop factory policy

0%

0%

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Building prole. - /Users/Simon/Documents/Clients Awareness of ALAFA and Folder/Alafa/Alafa for Austin/Other photos from 2012/factory HTC.jpg its work to bring healthcare to the workplace.

COMMUNICATION AND CONTEXT

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ALAFA PARTICIPANTS OUTCOMES

100%

84%
80% 60% 40% 20% 0%

76% 50% 56% 61% 50% 61%

15% 4%
Confidence in revealing HIV Status Tested previously, most recent test at this factory

5%
Use a condom Made changes to everytime / almost behavior in past everytime year

Two or more partners in past month

There were significant differences between those who accessed ALAFA services (clinic / peer education) and those that didnt. More likely to be tested, more likely to use a condom and more likely to have changed behavior in the past year.

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PEER EDUCATOR OUTCOMES

100% 80% 60% 40% 20%

81%

87% 68% 54% 40% 59% 57% 71%

4%
0% Confidence in revealing HIV Status Tested previously, most recent test at this factory

6%
Use a condom Made changes to everytime / almost behavior in past everytime year

Two or more partners in past month

There were significant differences between those who are peer educators and those who arent. In particular in terms of testing and behavioral changes.

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SEXUAL PARTNERS IN THE PAST YEAR.

100% 80% 60% 40% 20% 0%

72%

7%
None One

16%
Two

6%
Three or more

Most of those who had ever had sex, only had one partner in the past year (72%), and one in 15 (7%) had no partner. Around one fifth (22%) had two or more partners in the past year, and a minority of this group had two or more partners in the past month (5% or 1% of the total population)

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QUALITATIVE INSIGHT: CLINIC SERVICES

The clinical services provided to support PLHIV were valued by employees, although there were concerns that general medication was not available to those who were HIV negative Attending the clinic might create an association with being HIV positive: There is not confidentiality protected, as people know that when a person goes to the clinic they are positive Some concerns with ART - side effects such as changes in body shape. Need for adequate food was highlighted Support groups were noted to be useful, especially when it was highlighted that one did not necessarily have to be HIV positive to attend. However, it was not always well known that support groups included positive and negative participants, and this reduced interest

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KEY CONCLUSIONS

KEY CONCLUSIONS

HIV prevalence is stable, and has reached saturation levels among female employees in their 30s, with higher rates of new infections more likely to be occurring in the younger age range where HIV prevalence is lower The main risk for HIV infection among employees is sexual partner turnover and for females, exposure to higher risk men. There is a good general knowledge and a good proportion of employees acknowledge they take prevention measures and have changed their behaviour to prevent HIV There are strong and significant impacts on employees who have participated in the peer education sessions or accessed clinic services especially in relation to HIV testing, condom use and saying they had changed behavior. Risk related to partner reduction remains a key gap

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KEY CONCLUSIONS

Overall, there are good levels of knowledge and low levels of stigma with a good openness towards disclosure. The survey data shows that ALAFA programmes were also the main source of HIV and AIDS information, and there was good awareness of various elements of the programme. These findings, along with the qualitative data, provide strong evidence that the ALAFA programme is achieving its broad objectives The clinical services and resources such as condoms are well understood and valued. There is a good uptake of VCT Peer education sessions are well valued and the approach and format is well appreciated. The main concern is that the groups could be smaller There are strong and significant impacts on employees who have participated in the peer education sessions or accessed clinic services especially in relation to HIV testing, condom use and saying they had changed behavior. Risk related to partner reduction remains a key gap

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