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 WORLD HEALTH COMMUNICATION ASSOCIATES

"Engaging the Unengaged"

Russian Healthy Cities Network Planning Meeting

Moscow
6 December 2005

Meeting Report

Carinne Allinson
Franklin Apfel
World Health Communication Associates Ltd

I. Background

Coordinators from the Russian Healthy City Network were convened in this meeting to explore ways in which the Healthy City approach, infrastructure and values can be focused on critical HIV/AIDS challenges in their own "back yards" and beyond. The aim of the meeting was to help each city identify actions that will address key gaps in current initiatives, "engage the unengaged", overcome obstacles and strengthen current prevention and treatment options and initiatives.

The meeting builds on the HIV/AIDS Ask? & Act! – It's Your Health campaign concept and draws from its activities to date. This campaign is proposed as a globally-supported, locally-applied set of activities aimed at enhancing HIV/AIDS prevention and treatment information, education and public awareness (and supportive policies) by stimulating demand for information and engaging and strengthening the capacity of health leaders, people living with HIV/AIDS (PLWHA) and information mediators, eg health professionals, media, policy spokespeople, NGO advocates, and private sector advertisers, to respond effectively. It is not about starting new projects but enhancing the effectiveness of existing initiatives.

Media audits done in St Petersburg, Izhevsk and Kaliningrad (see Annex 1) earlier this year pointed to the need to focus on engaging young people, people living with HIV and AIDS, and health professionals in ongoing initiatives. Building on these findings, this meeting joined Healthy City coordinators together with representatives from youth associations, PLWHA advocacy groups, nursing, media and industry. Representatives from each stakeholder group were asked to focus on needs, opportunities and obstacles to "engaging the unengaged". They were further asked to share practical experience in identifying ways to reach the "hard to reach" and to reflect on successes and failures. This paper summarises their presentations and the city plans which the discussions stimulated.

The meeting additionally benefited from being held in parallel (same venue and dates) with a Regional Global Fund meeting. Key WHO, UNAIDS and Global Fund representatives, attending the parallel meeting, joined the HC coordinators and shared their perspectives on needs, opportunities and obstacles as well.

This meeting was organised by WHCA and the Russian Network of Healthy Cities, and with the support of the WHO Healthy City Baltic Centre and Johnson & Johnson.

II. Introduction

The Ground Rules

The meeting adopted Chatham House rules, a UK convention, which basically state that everything discussed can be made public but nothing can be attributed without permission. Because of the inclusion of additional presentations by key players from the Global Fund meeting, presentations would have to be kept to about 10-15 minutes, to allow plenty of time for the Healthy Cities groups to discuss their action plans.

Welcome

Nina Zagrebina welcomed participants on behalf of the Russian Healthy Cities Network and expressed appreciation for the work undertaken so far in the HIV/AIDS Ask? & Act! – It's your health! campaign. Everyone here was very concerned at the rapid spread of the HIV/AIDS epidemic in Russia. Analysis of the media audit undertaken in Izhevsk, and other reports, had highlighted that there was still insufficient information, no coordinated inter-agency awareness-raising activities, and lack of sufficient expertise and training for this work, including with young people. Media coverage continued to be largely superficial and confined mainly to the medical, rather than social, aspects of HIV/AIDS, which helped to maintain the gap between health professionals and the general public.

The Healthy Cities National Network, with its experience of intersectoral work, is ideally placed to bridge this medical/social divide. The Healthy Cities structures offer a good opportunity to combine use of specialist health care professionals, media, and work with PLWHA in prevention and treatment to find new ways to tackle the HIV/AIDS epidemic. It was hoped that one of the outcomes of the meeting would be a coordinated plan for the National Network which would enable the HC network to be used to support activities, receive guidance in effective HIV/AIDS communications, and be open to collaboration with other agencies.

Healthy Cities

The meeting was being held in partnership with the Russian Healthy Cities National Network and the WHO Healthy City Baltic Centre.

The Baltic Centre was set up to assist the Healthy Cities networks in all ten countries around the Baltic Sea, as required. Participants were reminded of the goals of the Healthy Cities network, especially health promotion, and a wide range of tools had already been developed for this work, which could be applied to the problem of HIV/AIDS. The Baltic Centre itself was available for collaboration and assistance with any action plans developed as a result of this meeting, and offers:

• Expert services
• Support
• Training
• Information
• Networking
• Coordination

The Russian Healthy Cities National Network started in 1996, in Izhevsk. The network had thus had nearly ten years to learn the Healthy Cities approach, and although it was hard in practice to implement the multisectoral approach, there were now seven more cities ready to apply to WHO for designation. This had required serious commitment from the cities to intersectoral cooperation, equal opportunities for all sectors of the population, work in cooperation with communities, etc. All these cities were keen to draw up a draft plan of what they could do, using their Healthy Cities approach, to address the problem of HIV/AIDS.

"Tour de Table"

Expectations of the meeting were high. Some encompassed "concrete" outcomes, such as action plans to develop the role of Healthy Cities, guidelines or personal contacts. Some focused on less concrete outcomes – ideas for communicating with young people and patients, links and information. Some people were present at the meeting in order to listen and learn, and offer help as required – in other words, to facilitate the meeting of other participants' expectations.

III STAKEHOLDER PRESENTATIONS – UN Agencies

The three presentations were given by  Akram Eltom of WHO Euro Moscow Office, Bertil Lindblad of UNAIDS, and Henning Mikkelsen of UNAIDS.  All three presentations gave the very strong message that the epidemic in Russia is severe (it has the largest epidemic, and the second fastest rate of transmission, in the world) and although more money is now being pledged by both outside funders (eg Global Fund, World Bank) and the Russian government, money alone is not enough – much more needs to be done.

The burden of disease has tended to be amongst marginal groups (mainly IDUs, but also now prisoners, sex workers and homosexuals), but it is starting to spread to the general population. PWLHA tend to be mostly male, and in the under 30 age group, which could have severe economic repercussions if action is not taken very soon to prevent the situation getting out of hand.

Needs

Several pressing needs were highlighted by the presentations:

1. Improved access to HAART
   Russia's figures for access to HAART are very low, comparable only to those for Turkmenistan. Of approx. 340,000 registered PLWHA (which is less than half the estimated total figures for PLWHA of 840,000 to 1 million), only 90,000 were in treatment as of December 2005. No national target has been set for Russia as yet, but it is hoped this will be established in the next twelve months. The need for ARVs is projected to rise rapidly, and it has been shown that the mortality rate without access to ARV closely parallels the need for HAART.

2. Reduce the cost of HAART
   Although the price has now come down, more needs to be done, as the groups in most need tend to be unemployed or young people.

3. Equity of access to HAART
   Although IDUs comprise over 80% of PLWHA, their access to HAART is only 10% or less.

4. "Targeted" awareness-raising and prevention activities
   Addressed to those groups which are most at risk (prisoners, IDUs, commercial sex workers, homosexuals, young people). Promoting prevention and safe behaviour would also help to raise the demand for treatment amongst those groups.

5. Accurate information about HIV/AIDS
   There is still a large level of ignorance amongst the public about how it is transmitted, for example, and about "safe" behaviour. Ignorance and fear feed stigma and discrimination, which is one of the biggest barriers to curbing the epidemic.  Additionally, the message needs to be put across that HIV/AIDS does not mean death any more.[1] With access to treatment, a PLWHA can live a perfectly normal life, with everything that goes with that (family, job, social life, etc).

6. Awareness-raising in schools
   Young people, in the 18-25 age group, are particularly vulnerable. Therefore, it is important to include education in schools about healthy lifestyles and safe sex, and how to protect oneself.

7. Training in counselling and patient-management skills for professionals
   Health professionals in Russia are clinically well trained, but often lack patient communication skills. It does not matter how good the clinical skills are, if patients are not dealt with in a sensitive, respectful and dignified manner, you risk having a good health service with no patients.

8. "Vaccination against stigma"
   In a recent television programme (A Time to Live), people from all walks of life were brought together to discuss HIV/AIDS in a calm, rational manner, and people's questions about HIV/AIDS were answered (and misconceptions corrected). This brought HIV/AIDS into the public arena, without hysteria or drama, where it could be the subject of "normal" discussion. Such television programmes are needed all year round, in all the Russian regions, to act as a "vaccination" against stigma.

9. Include PLWHA in treatment and prevention initiatives
   Experience from elsewhere has shown that PLWHA (and others affected by the epidemic) have an important role to play and should not be treated as "victims" or "objects". The inclusion of PLWHA proved to be a decisive factor in the success of the UNAIDS Multi-City Action Plan, in the 1990s in Western Europe.

10. Make sure resources reach the Regions
    HIV/AIDS is not confined to big cities only. It affects everyone, everywhere – in every Region, Oblast, city, and small community.

11. Business input
    Businesses can have a powerful positive effect in two ways – by ensuring that PLWHA are not discriminated against, and by providing education in the workplace to combat stigma and provide information about "safe behaviour".

12. Political commitment
    Although the Russian government has recently pledged more money to the fight against HIV/AIDS, money alone is not enough. Without the political will, nothing will come of it.

Obstacles

1. Stigma
   Although all infectious diseases have had to contend with the problem of stigma, that surrounding HIV/AIDS is particularly difficult to combat, as it challenges people's sense of social justice and moral values. HIV/AIDS is often equated with sin and immorality, but from a public health point of view it is not practical to discriminate on moral grounds. As a strategy to combat the epidemic, it is both negative and highly ineffective. By trying to forget or ignore these people, on the grounds that they are "corrupt", the epidemic will very quickly spread to the general population, as has been shown elsewhere. People's fear of stigma and discrimination is a powerful deterrent from seeking treatment.

2. Legal barriers
   As long as people's fear of the law is stronger than their fear of HIV/AIDS, they will not come in for treatment. Additionally, by not acting to protect PLWHA from discrimination, the law further deters people from seeking treatment.

Opportunities

1. Strong resource base
   Russia has an excellent health service, with a good record of disease treatment. It is a middle income, highly developed country, with a well educated population. The levels of awareness and coordination in the government are good, and all the UN agencies work closely together in the country. It already has a huge "scientific capital" upon which to draw.

2. Civil society
   Although the concept of civil society in Russia is fairly new, there is good media access to the general population in Russia. Media, educational institutions, NGOs and PLWHA can all play an important part in strengthening advocacy and communications to civil society generally.

3. Existing expertise
   There is a wealth of expertise which is available to inform future work. There are some 40 million PLWHA around the world, and many countries have experience of successful campaigns and strategies to share. For example, the UNAIDS AMICALL initiative (an initiative among local mayors) started in Africa but is also now running a pilot scheme in Ukraine. Within Russia itself, UNICEF has been working successfully with young people in Tomsk, setting up youth-friendly health care services and working with children and teachers in schools. This is a good example of successful collaboration between civil society and health professionals. The UNAIDS Multi-City Action Plan linked about ten cities across Europe, and many lessons were learnt (such as making sure that PLWHA are included in such initiatives) which can inform current initiatives in Russia. There are also lots of networks of cities in Europe with which the Healthy Cities can link up, to share experience and expertise.

4. PLWHA
   Previously, HIV/AIDS was mainly in Western Europe and there were few cases in Eastern Europe. Now the situation has changed and there is an emerging movement of PLWHA, who are beginning to organise themselves. Millions of PLWHA across the world are working and living normal lives, with positive experiences to share.

5. The Healthy Cities Network
   Now that money is less of a  problem, the question is, what projects? It is important that the projects should take place where the problem is actually happening, which is not just in the big cities and capitals. With their local focus, the Healthy Cities are ideally placed to ensure that the resources reach those areas where they are most needed. As we deal with such questions as how to protect our youngsters from harm, how to get the support of parents, and work with the local police, the local experiences can be shared through the Network – the results of information campaigns, advocacy, particular activities and positive experiences.

Although there are some obstacles to be overcome, and a range of pressing needs, the overall tone of this session was positive. The strong position of the Healthy Cities was emphasised, as well as the range of expertise available to assist in the work ahead.

IV STAKEHOLDER PRESENTATIONS – Media

The three presentations were given by Natalia Katsap, of the Russian Media Partnership to Combat HIV/AIDS (RMP), Julia Velichkina, who is the General Producer of the Time to Live telemarathon project, and Daria Alexseeva, of Focus-Media. All three presentations focused on successful media campaigning initiatives and stressed the great opportunities that were available.

Needs

The following list of needs includes those specifically mentioned in the presentations, as well as those issues that need to be addressed and/or included if a campaign is to be successful:

1. Information
   There is a need to "saturate" the marketplace with basic information, so that it is everywhere people look. Information is a simple, but highly effective, tool which is capable of changing the course of the HIV/AIDS epidemic in Russia. This will also help to correct misunderstandings and misinformation.

2. Single platform/comprehensive campaign
   By involving all forms of media (TV, radio, print) in one coordinated initiative, it is possible to achieve "saturation" coverage, so that whenever people turn on the television or radio, or open a magazine or newspaper, they are confronted with a consistent campaign message. The RMP has already brought together over 40 media companies to work collaboratively with other companies (eg Coca Cola) and celebrities to produce the Russian Stop AIDS campaign. By working together in this manner, it is possible to create "an echo chamber", where a consistent message is repeated over and over. This has a much greater impact than one-off and/or short-term campaigns which do not utilise all the platforms available. In addition, the RMP works for the integration of HIV/AIDS messages into long-term programming and publications, which coupled with short PSAs is the most effective approach to awareness-raising campaigns.

3. Easy access to further information
   Short PSAs cannot contain comprehensive information about HIV/AIDS prevention or treatment, and it is therefore essential to provide a link or reference to further information. This can be an internet site, or print, or toll-free telephone line.

4. Active demonstration of personal attitudes
   A simple thing like wearing a coloured bracelet, or high-profile celebrities/politicians expressing solidarity with PLWHA, can have a powerful persuasive effect on other "unengaged" people, especially when linked to a long-term, ongoing campaign with consistent (and recognisable) branding/logo, and strong presence in the media market (eg the Stop AIDS campaign).

5. Awareness of what other messages are being promoted
   Discussing some of the problems encountered in promoting the concept of "safe sex", it was obvious that there are competing messages (sometimes "misinformation") from other actors. Choose appropriate messages to "counterbalance" these other messages. Sometimes it is possible (and preferable) to work with the authorities promoting these other messages (for example, by inviting them to workshops), but unfortunately this is not always the case. In this case, try to avoid being confrontational. It is also very important to structure messages in a way that reinforces, and is reinforced by, similar messages by other campaigns with a strong media presence.

6. Appropriate format
   Focus-Media found that the most effective campaigns were those which used a format which was appropriate for the target audience. For younger children, cartoons were an effective format. For older children, campaigns using live actors, current youth "slang", or well-known celebrities (pop and sports stars, for example) were found to effective. For this reason, it is important to engage professionals in campaign development and production – ad agencies are best placed to provide high quality and effective cover.

7. Evaluation
   In order to assess the effectiveness of a campaign, evaluation is essential. For example, following one campaign to promote the use of condoms, evaluation showed that condom use amongst young people had increased twofold – a successful campaign outcome! It is important to present the results of campaigns in a professional manner and report the impact of the campaign, rather than behaviour change which is the result of many factors (your campaign being one of many). "Pre-testing" is also essential – campaign messages should be tested with representatives of stakeholder groups before being used in the marketplace.

8. Early and ongoing involvement of PLWHA
   It is important to engage PLWHA at the stage of concept development and the engagement needs to be ongoing (including "pre-testing" of messages) to ensure that the final product does not reinforce harmful stigma and stereotypes.

9. Adequate use of available tools
   Many good opportunities and tools were identified during the course of the three media presentations. RMP, for example, makes all of its materials available free and without copyright to organisations interested in placing the messages. However, these are no use unless adequate and professional use is made of them in the cities (and surrounding Regions).

10. Work with journalists
    It is important to work with journalists to promote understanding of the problems and show them how to present information in a sensitive way. This cannot be done in a one-day workshop, but will need to be carried out by involving journalists in ongoing interaction over several months. After being involved with PLWHA over a period of about 4 months, one journalist was quoted as saying, "Only now do I begin to understand what the problem is." This journalist felt she had "caught", rather than been "taught", the relevant understanding and was now thinking about the language she used when reporting HIV/AIDS issues. She now avoided using words like "infected", "carriers" and "plague".

11. Consider context and language
    It is important to consider the social and political environment in which campaigns are operating and have a comprehensive approach to prevention messages – for example, selecting a narrow message such as promoting condom use can attract criticism for not including being faithful to one's partner and being abstinent as effective HIV prevention measures. It is also important to give careful consideration to the choice of terminology: the use of "safe" in Russia generated criticism that the use of "protected" would not have, as the latter is more precise and less misleading.

Obstacles

1. Misunderstandings
   Until misunderstandings are corrected, the messages will not be taken on board. As an example, if people do not understand how HIV/AIDS is transmitted, they cannot see the point of using a condom if (as they believe) they can just contract HIV through kissing.

2. Society's attitudes
   Surveys show that less than 3% know someone who is a PLWHA, and many people still regard it as a problem that affects other people, but not them, or their loved ones, or their community. People still also see it as something that only affects certain sorts of people (promiscuous, homosexuals, drug users, for example). Until these attitudes change, other prevention and treatment information initiatives will not make much headway.

3. Opposition from other sectors
   The Focus-Media campaign had met with active opposition and resistance from certain municipal and state authorities to some of its work trying to educate young people about safe sex. Books mentioning sex were banned from schools, and some TV and radio companies refused to air advertisements promoting safe sex. This also lead to misleading messages, such as the idea that fidelity to one's spouse was effective protection against HIV/AIDS, and that "safe sex" does not exist.

Opportunities

1. HIV/AIDS is a "burning issue"
   Surveys have shown that the majority of Russians consider the issue is important, and also that they believe the State should do its best to disseminate information. This means people will be receptive to information, and supportive of campaigns.

2. Existing expertise and materials
   Many successful initiatives exist to serve as models for further campaigns, and work in the Regions/cities. Some of these initiatives have produced materials which are copyright-free and available for use and adaptation by other initiatives. For example, the TPAA is happy to offer all the Stop AIDS campaign materials (for TV, radio, print and outdoor) free of charge, and they can be rebranded with local AIDS Centres or hotline numbers for use in the Healthy Cities. Other campaign initiatives/formats (eg A Time to Live) can be easily adapted. The Russian Media Partnership already exists as a single platform uniting many companies.

3. Open discussion of "taboo" issues
   Programmes such as the Time to Live telemarathons provide a platform for the open discussion, in a calm, rational manner, of issues which have hitherto been "taboo", allowing people from all different perspectives (including PLWHA) to contribute to the debate. Open dialogue is one of the most effective ways to change the course of the epidemic.

4. Regional relevance
   Formats such as the Time to Live telemarathons can be adapted to reflect the particular issues and situations in the different Regions (and cities).

5. Proven efficacy
   The materials showcased during the presentations had already been demonstrated to be effective. As a result of the Focus-Media campaigns aimed at getting over the message about safe sex to young people, more young people considered safe sex to be relevant. Other successes cited included a reduction in the number of people who felt that PLWHA should be isolated, increased use of condoms, greater understanding of the issues, etc.

6. Immediacy
   Some of the campaign initiatives can have immediate results – especially where the format is emotive, or where children are involved. As an example, during one of the Time to Live programmes which highlighted a successful project in an orphanage, before the programme had finished a local businessman had telephoned and offered financial support to the project.

7. Existing Training Programmes
   TPAA has an ongoing journalism programme, which conducts regular training and briefings for journalists and NGO representatives, targeted at improving the information exchange and coverage of HIV/AIDS and related issues. It is happy to include the Healthy Cities Network in this programme.

The overall tone of these presentations was very positive and highlighted the great opportunities provided by the possibilities for adaptation and use of the formats, platforms and materials showcased during the presentations.

V STAKEHOLDER PRESENTATIONS – Young People and PLWHA

The presentations were given by Anna Andreasian, representing the Standing Committee on Reproductive Health including AIDS (SCORA), of the International Federation of Medical Students' Associations (IFMSA), and by Lital Hollander of the European AIDS Treatment Group (EATG).

Needs

1. Peer education
   Both IFMSA and EATG were involved in projects involving peer education – young people talking to young people, sex workers teaching sex workers, IDUs talking to IDUs, etc – and had found such methods very effective in spreading the message about prevention and treatment. Young people found it easier to both ask for and receive information from their peers, who used games, performances, and other fun activities to put the message over. Drug users did not fear stigma from their peers.

2. Prevention Education
   The only way to beat the epidemic is prevention, and the only effective method of prevention is education. Working with 12-17 year olds in schools, to teach them how to protect themselves, is the most effective method. The point was made in one of the media presentations, and reiterated here: "We cannot keep them abstinent, let's at least keep them safe."

3. Don't forget IDUs
   Although there was excellent work going on to promote prevention of sexual transmission of HIV, little had been mentioned about IDUs. Most transmission (about 80%) is currently from drug use and unpalatable as people might find it, this has to be taken on board. Ignoring the needs and special circumstances of IDUs will only fuel the epidemic, and spread it to the general population more quickly.

4. Drug use harm reduction
   This is absolutely essential if any progress is to be made in combating the epidemic. In Italy, where initially the situation had been similar to that in Russia with about 80% of transmission being the result of drug use, a very energetic harm reduction programme had succeeded in reducing IDU transmission to about 15%.

5. Clear political commitment
   Without clear political commitment, there was no hope of bring the epidemic under control. The example of the Moscow Duma campaign promoting sexual abstinence and denying that there was such a thing as "safe sex", was a clear example of the damage that could be done in the absence of such commitment.

6. Budget and infrastructure
   Both of these had to be devoted to fighting the epidemic. The Global Fund has confirmed that money earmarked for this in Russia is not being used. However, without the commitment of adequate resources and infrastructure, no real headway will be made.

7. Confidentiality
   People will not come in for testing while they fear that their HIV status would be disclosed to other people (eg employers). The consequences of such disclosure could be very severe – they could lose their job, suffer from discrimination, and even violence.

8. Work with patient NGOs
   There are many cogent reasons why NGOs are important as partners in this work. Not only do PLWHA know their own needs, and are better placed in many cases to undertake prevention work amongst their peers, but when patients are empowered, they can be a very effective force. Good NGO advocacy gets results – as demonstrated in England and Italy for the Enhanced Access programme. England, with strong NGOs, received 2,000 doses whereas Italy, with about half the number of PLWHA but weak NGOs, received only 100 doses. Patient NGOs are already being included in management by organisations such as DGSanco.

9. Work with ALL stakeholders
   EATG is involved with both advocacy and scientific aspects of the HIV/AIDS issue and works with every sector, including patients, health professionals, and pharmaceutical companies. This approach needs to be adopted in Russia, and Healthy Cities are ideally placed, and have the infrastructure, to do this.

10. NGOs need more power
    Although there are very good NGOs in Russia, they do not have enough power. They are hampered by insufficient access and visibility, people who do not return their calls, bad relations with the law enforcement authorities, and sometimes bad press. They need to be taken seriously and included in the process.

11. Vigilance for possible abuse
    Unfortunately, there have been instances of unethical experiments and clinical trials involving PLWHA. If only one person dies unnecessarily during such trials, it is one too many.

12. Involvement and leadership of PLWHA
    This underlines previous points about peer education and including NGOs. It is their health, and their needs, and they are best placed to know what is required.

Obstacles

1. Absence of effective prevention methods, and care and treatment
   This is reflected in the fact that the epidemic in Russia is rampant and the death rate is TEN TIMES that in Western Europe.

2. Methadone is illegal
   Despite the fact that Methadone is listed as an "essential" drug by WHO, it is illegal in Russia. The experience of other countries is that harm reduction measures for IDUs, such as needle exchange programmes, are significantly more effective if accompanied by the use of Methadone.

3. Absence of effective harm reduction
   Harm reduction is not working in Russia because it is not seriously applied. The absence of an energetic harm reduction programme is actually fuelling the epidemic.

4. Penalisation of IDUs
   IDUs are afraid to come in for testing and treatment, because they fear they will end up in prison, where they will not receive treatment. This is a major obstacle to effective prevention and treatment work amongst IDUs.

5. Human Rights abuses
   This includes both lack of confidentiality during testing and unethical practices surrounding some clinical trials.

6. Barriers to access to treatment
   These were listed as including geographical (Russia is a big country and people may have to travel a long way to their nearest treatment centre); active drug use; stigma; and lack of support and counselling.

7. Limitations on NGO work in Russia
   These were listed as including language (few people know English); sense of helplessness (the authorities do not listen and some health professionals regard Russian activists as "criminals", who do not have the intelligence of Western European activists!); isolation (PLWHA are afraid to confess their HIV+ status for fear of the consequences – they may lose their job, or suffer violence); and budget constraints (eg tax restrictions).

Opportunities

1. Bring SCORA to Russia
   Although IFMSA has a presence in Russia, the SCORA does not. It is, however, looking for an opportunity to set up in Russia. This would give Russian medical students opportunities to exchange ideas, projects, experience, and to experience how other countries' health systems approach the HIV/AIDS issue through student exchange programmes. It would bring a wealth of international and national expertise through to the local level.

2. Existing activities
   Both SCORA and EATG have ongoing projects which could help the current initiative. SCORA has a full programme of activities for World AIDS Day, which follows roughly the same format in most countries, as well as ongoing projects working with school students and other youth groups in different countries. It also produces training materials, awareness-raising activities, leaflets, questionnaires, etc. EATG is involved in many projects with different stakeholders, including advocacy and policy work, education, training and networking. One of its existing initiatives is COPE, which is engaged in translating existing materials from English into Russian. All these initiatives and activities represent a large store of knowledge, experience and ideas which could inform the work of the Healthy Cities in HIV/AIDS prevention and treatment initiatives.

3. NGO capabilities
   NGOs make very good partners as they have access to local populations, can engage in peer education, have access to information, are effective at educating the general population. They are the best disseminators of information, because they have high credibility with people. They are more committed than many other people, because most of their members are PLWHA or friends or relatives of PLWHA, and they are motivated by the fact that they are seeing their friends and loved ones die, or face death themselves. They are also fast learners – PLWHA use the internet a lot to communicate, obtain information, network, and to learn about the science involved in HIV/AIDS and its treatment/prevention.

4. Existing NGO structure
   EATG already undertakes a lot of training in Eastern Europe, has ongoing networks, advocacy and policy work, and experience of working with the media and in awareness-raising. It also has earned a high credible profile with the UN agencies, WHO, and DGSanco, etc.

Although there were a lot of needs and obstacles highlighted in these presentations, it is obvious that there is a lot of good and effective work going on and lots of opportunities to bring some of these existing activities and projects to bear in our Healthy Cities. There is also a lot of expertise and experience available to draw on.

VI STAKEHOLDER PRESENTATIONS – Nurses

The presentation was given by Valentina Sarkisova, the President of the Russian Nursing Association.

Needs

1. Change of mentality
   In the 1990s there was a lack of knowledge and understanding about HIV/AIDS prevention, treatment and care, which was compounded by a lack of modern disinfection, insufficient disposables, etc. Many health professionals, including nurses, were unwilling to work with AIDS patients, and that situation still persists to some extent. However, an education project run in 2004-05 for nurses which looked at aspects such as protocol for care, how to prevent infection, counselling, safety issues, etc, achieved positive results. A change of mentality amongst health professionals can be brought about through basic understanding and knowledge.

2. Information and healthy lifestyle programmes
   Until such a time as a vaccine for HIV is discovered, the best tool for nurses is information and healthy lifestyle programmes. Nurses are already active in disseminating health information in their daily work with members of the public, and they are therefore well placed to bring information about HIV/AIDS and how to live healthy lives and protect from HIV to those at risk.

3. Joint action
   Strategies on stigma and discrimination will only be successful if they involve joint action between the government, health professionals, PLWHA (and their relatives), and civil society.

4. Wider involvement of nurses
   Lots of existing programmes focus on physicians only, but nurses are the foundation of the Russian health system and are already a major force in health promotion. The existing AIDS Centres would benefit from involving nurses, as their small staff is over-stretched and cannot disseminate information as effectively as nurses can. Nurses are already involved in health promotion work with young people (at discos, in school, at family centres, etc).

5. Regional nursing associations need to work with central RNA programmes
   At the moment, the RNA programmes do not work in unison with the regional associations. There are a large number of nurses who are very active in the regions and if they were to work with the RNA programmes, it would improve the effectiveness of such programmes.

6. Training
   Nurses need training in HIV/AIDS "skills". Nurses need training in all the issues mentioned at 1. above, as well as being given the knowledge and information to engage in awareness-raising work, and deliver appropriate prevention and treatment advice.

7. Healthy Cities as "intersectoral convenor"
   We need to look at the different roles of different agencies in dealing with this problem, but common strategies are required to address what is a very complex problem. By convening the various sectors and agencies, Healthy Cities can "add value" to existing initiatives and ensure that such common strategies are possible.

Obstacles

1. Prevailing culture
   In a culture of shame, secretiveness and stigma, most people prefer not to know their HIV status. Issues such as lack of confidentiality, economic consequences, and even violence, act as strong deterrents.

2. Inadequate information and tools
   Although this has changed in places, lack of knowledge and understanding around issues of patient care, safety measures, etc, and lack of resources (disposables, modern disinfecting methods, etc), mean that some health professionals are still unwilling to work with HIV/AIDS patients.

3. Health workforce issues
   Health workers who are HIV+ or at risk face the same problems as the rest of the PLWHA population. In addition, in Africa, where the level of HIV/AIDS amongst nurses is roughly equal to that amongst the general population, the entire health care system is endangered. Health workers must be protected and supported, and the health workforce strengthened. It was noted that the theme for World Health Day 2006 is Human Resources for Health, as it was recognised that the issue of a strong health workforce was key to HIV/AIDS and without it, the attainment of the MDGs was threatened.

4. Excessive focus on physicians
   Existing programmes tended to focus on physicians, but it is the nurses who form the backbone of the health system. By excluding nurses, these programmes exclude the major force in prevention work.

5. AIDS Centres will not be able to cope with increasing demand
   The existing AIDS Centres are doing their best, but they only have a small staff and are probably already working at full capacity.

Opportunities

1. Nurses are a huge potential resource
   Nurses are the foundation of the Russian health system – there are over 1.3 million nurses, and the Russian Nursing Association is one of the largest organisations in the Russian Federation, with over 130,000 members.

2. Nurses are already engaged in health promotion
   Nurses are already engaged in lifelong health work, including with young people in discos, schools, family centres, as well as health care facilities. They already have a lot of experience at disseminating information, and getting over messages about healthy lifestyles, etc.

3. Nurses are already engaged in HIV/AIDS issues
   Because of their special position, nurses have already had to do a lot of work in HIV/AIDS prevention and treatment. They have also had to undertake training, review safety measures, learn new skills (such as counselling and supporting PLWHA), and take on board basic knowledge and understanding about HIV/AIDS.

The overall tone of the presentation was very positive and highlighted the huge potential resources that nurses represent, which is currently underused. However, their commitment and desire to become more "engaged" was very clear.

VII STAKEHOLDER PRESENTATIONS – Business & Industry

The two presentations were given by Scott Ratzan, representing Johnson & Johnson, and Evgeniy Yankov of TPAA, who talked about his work with businesses and the benefits of involving business in the fight against HIV/AIDS.

Needs

1. Partnership with the pharmaceutical industry
   More will be achieved by working in partnership with the pharmaceutical industry, rather than by putting them in a box marked "against". This includes working together on things such as practice management, innovative treatment, care and communication, in addition to the science and research aspects of HIV/AIDS.

2. Workplace policy
   Stigma begins where people live and work. Very few companies have workplace policies in place, to ensure that no one suffers discrimination at work, or loses their job, or is refused a job, on account of their HIV+ status.

3. Involve the business community
   Working people spend up to one third of their lives at work, and this includes PLWHA. Businesses are likely to feel the impact of the epidemic in two significant ways – firstly, over 60% of PLWHA are living in economically successful regions, where the businesses are likely to be based; and secondly, almost 80% of PLWHA are under 30 years of age, which represents a significant proportion of the existing and future workforce. Not only does the epidemic affect their staff, but also clients, others who work with the company, their relatives, and the communities in which they are situated. In a small town, one business may be directly and indirectly employing as much as half the town's population. In such circumstances, a little prevention work carried out in the workplace can go a long way.

4. Gain the support of top management
   It is important to have the support of the decision-makers within the company, those people who have the power to make and/or influence company policy.

5. Awareness-raising amongst the business community
   Surveys carried out by TPAA amongst businesses showed that whilst the business authorities themselves believed they were familiar with HIV/AIDS issues, the responses to the questions indicated a low level of awareness across all areas (eg transmission, legal, discrimination, etc).

6. "Sales pitch"
   In order to get the message over to business, it was necessary to "pitch" the message in terms which were familiar and understandable to businesses. By explaining to businesses what they stood to gain by engaging in HIV/AIDS prevention work, and the negative effects on their business (now and in the future) if they did not take action, the message was more likely to be effective.

Obstacles

The overall tone of both presentations was very positive, and both highlighted many advantages of, and opportunities for, working with the pharmaceutical industry and other companies. The only potential obstacle is the fact that most companies are not (yet) fully aware of the future implications for themselves if the HIV/AIDS epidemic is not brought under control – the potential impact is enormous, with loss of workforce and clients, and loss of profits.

Opportunities

Editorial Note: This has been "expanded" to include the Advantages of working with businesses as well.

1. Healthy Cities infrastructure
   This offers great opportunities for those companies who wish to engage in structured work on HIV/AIDS prevention.

2. Businesses are also "victims"
   As already pointed out, businesses stand to lose out heavily, in terms of loss of workforce and profits, if the situation is allowed to continue unchecked. It is therefore in their best interests to become involved. The potential costs to business can be easily described in financial terms, and the case for their involvement is not hard to make.

3. Low cost
   Many companies already engage in health care work as part of their general staff care programme, and the additional costs of including HIV/AIDS awareness-raising and prevention work in their existing health care provisions are therefore minimal.

4. Significant influence
   Most people spend a lot of time in the workplace and their employers have a big influence in their lives. Education in the workplace, therefore, can be very effective and will also benefit the workers' families and the communities within which the businesses operate. Additionally, many businesses have a great deal of influence in the municipalities where they operate. As leading employers, with large budgets, they can influence municipal policies and can advocate for policy change, or provision of services, regarding HIV/AIDS.

5. Existing materials
   TPAA is already involved in this work and has produced education materials for use with businesses, including the Health at Your Workplace programme materials. These materials cover all the relevant areas of concern (including strategic counselling on policy development, awareness-raising, prevention, etc). Materials are available for various levels of management, general staff, "training for trainers", etc.

6. Existing initiatives
   The Business Against AIDS Coalition was formed at the annual summit of business leaders on HIV/AIDS issues held in March 2005. The coalition includes international companies and provides a forum to exchange ideas, develop international standards on workplace policy, share experience on prevention work, etc. The summit is held annually, and will take place again in March 2006.

7. TPAA collaboration
   TPAA is very open for collaboration with the Healthy Cities initiative. Indeed, it is already active in several of the regions represented at this meeting. In addition to the educational materials already mentioned, TPAA also has a great deal of expertise to offer.

These presentations underlined the considerable advantages to working in partnership with industry and business, and both were extremely positive.