B-Change helps community groups strengthen online HIV prevention work in the Middle East and North Africa (MENA)

workshop participants in rabatdebate the final selection of user personas. These personas will be used as a reference in the design and implementation of a regional information communication technology-based approach to hiv prevention in Lebanon, morocco and Tunisia. [photo credit: b-change/garcia]

workshop participants in rabatdebate the final selection of user personas. These personas will be used as a reference in the design and implementation of a regional information communication technology-based approach to hiv prevention in Lebanon, morocco and Tunisia. [photo credit: b-change/garcia]

[Rabat, Morocco] Community organisations working at the frontline of health and human rights in the Middle East and North Africa (MENA) have received a big boost in the form of HIV prevention strategies which utilise information and communication technologies (ICT) to engage gay and bisexual men.

Work has already begun across Lebanon, Morocco and Tunisia to implement a new regional strategy, a product of a 12-month community-led, collaborative design process. The process began in 2014, when the International HIV/AIDS Alliance (the Alliance) approached B-Change Technology to share its expertise in using technology to support the well-being of young people in Southeast Asia; the budding partnership has since snowballed into numerous opportunities for knowledge exchange among peers in the developing world.

The dilemma of providing access to health for marginalised people

The HIV epidemic is on the rise globally among gay, bisexual men and other men-who-have-sex-with-men (MSM); MENA is one of the two regions with the fastest growing epidemic in the world. “Sadly, MENA is also a region with some of the worst treatment coverage in the world,” says Manuel Couffignal, Regional Programme Advisor for the Alliance in MENA.

The Alliance has been implementing HIV prevention programmes in North Africa and the Middle East for over 10 years. The Alliance focuses specifically on key populations in the HIV epidemic who are often left out of national health programmes in the region.

In the highly stigmatising context of the Middle East and North Africa (MENA) region, key populations in the HIV epidemic live clandestinely and many are not reached by the prevention or care and support programs, despite the efforts of the few community-based outreach interventions targeting them in the region.

Sexual minorities are still discriminated against by medical care providers while grappling with stigma and legal problems. Both these factors discourage these minorities from accessing services such as HIV testing. The educational system across MENA lacks sexual education and mention of male sexual health is largely taboo. Given this environment most gay, bisexual men, other MSM and transgender people are not able to “come out”.

“Under Article 534 of the Lebanese Penal Code ‘unnatural sexual intercourse’ is punishable by up to one year imprisonment,’ explains Rabih Maher, an advisor to a community-based organisation in Lebanon called Helem. “MSM and transgender people are also targeted by the police as a result of this law.”

New approaches to health in the ‘Arab Spring’ era

The rise of the internet, mobile communications and social media presents several opportunities for health advocates of marginalised communities in the developing world. Fast changing technologies mean that health practitioners need to build their capacities now to prepare for the health communications landscape of the future.

In 2015 the International Telecommunications Union reported that mobile-accessible broadband services expanded from 45-percent globally in 2011 to 60-percent in 2015 due to the cost to roll-out mobile internet services in the developing world is dropping faster that fixed-wire connections. The pace of mobile internet network improvements running parallel with ever-increasing choice and affordability of smartphones, means that connectivity is outpacing other infrastructure projects. Even rural communities who have traditionally bore the brunt of lagging technological advancements stand to benefit from ambitious high-profile projects such as Facebook’s ‘Internet.org’ and Google’s ‘Project Loon’ that are designed to bridge the gap for rural communities in Africa. Both these initiatives are already being piloted in other regions in the developing work.

The MENA region is no exception to this upward trend in connectivity, especially in the region’s urban centres. MENA was witness to the recent ‘Arab Spring’ where SMS, Twitter and other social media helped propel civil society movements, at scales never seen before, to challenge long-held political demonstrates how technology has helped catalyse social change in the MENA region.

People in MENA are generally able to use social media, instant messaging services and smartphone apps to connect with peers and to access information, although in some countries such as Turkey, Egypt and Iran freedom of online expression is curtailed and local activists report that the threat of state surveillance and censorship is high. Despite the prevailing social, cultural and political environment, many groups, including those directly affected by the HIV epidemic, thrive covertly thanks to peer-to-peer encryption, virtual private networks and other tools that provide lifelines to the world wide web.

It is no surprise that community groups in MENA have increasingly turned to online spaces to conduct peer outreach for raising awareness on HIV and sexual health. Outreach work in recent years has been implemented within social networking platforms (e.g. Facebook, Twitter and YouTube) and other online spaces where gay and bisexual men meet to negotiate friendships, sex or relationships (e.g. Grindr, Hornet, Planet Romeo, etc).

In contrast, the service providers and other actors in the HIV response are not fully utilising ICT for distribution of HIV prevention, care or support purposes. Given the proliferation of social media and dating apps, the potential impact of ICT-based approaches is high. “New innovative methods are critically needed,” Couffignal adds, “to identify, reach, test and provide care and support to key populations in this region.”

The resulting ICT strategy from community groups in the Alliance’s MENA programme focuses on improving the quality and scale of HIV prevention outreach activities conducted by peer educators in online spaces.

The objective of the strategy is to improve online referral of men to offline, community-friendly sexual health and support services. The strategy is already underway and includes activities designed to raise the awareness of health and human rights with the use of online engagement techniques using interactive content (e.g. videos, infographics and other digital resources).

While early results of formative online work have been encouraging, community groups in MENA have struggled to increase the scale and consistency of their online outreach activities. “Helem, like the other organisations in the MENA program need technical support,” admits Maher. “We need human resource training to do this work and to achieve our goal”

Security protocols have tended to be weak. Evaluation and quality assurance of these formative ICT-based prevention programmes have also been areas in need of improvement. Some informal online outreach activities have risked being shut-down as peer educators were unaware that their activities may have violated the terms of use of app or websites.

A model of collaborative, community-based design

A recent workshop held in Rabat, Morocco’s capital, was the second of two workshops where B-Change Technology (BCT) partnered with the Alliance to help community groups transform their ideas into a concrete reality. Over the past 12 months community groups from Algeria, Lebanon, Morocco and Tunisia gathered market data and psychographic insights using surveys and interviews; conceptualised and tested potential ICT-based approaches; then articulated the various processes required to implement the approaches that showed the most potential for success.

“We used the Open Space technique combined with various user-oriented design methods to create an interactive workshop experience,” explains Laurindo Garcia, BCT director and founder of the B-Change Group.  “We did our best to empower the participants to lead and exercise full creativity throughout the process.”

BCT used its diagnostics methodology to assess the institutional capacity of each participating community organisation on various issues related to information communication technology. The assessments produced recommendations for short-term actions that could lead each organisation towards improved capacity and sustainability.

A participant at the 2014 oran workshop takes a break during the intense prototyping phase.  ideas for tech-basedHIV prevention intervention were brought to life as minimum-viable products and tested by volunteers from the local community [photo credit: b-change/garcia]

A participant at the 2014 oran workshop takes a break during the intense prototyping phase.  ideas for tech-basedHIV prevention intervention were brought to life as minimum-viable products and tested by volunteers from the local community [photo credit: b-change/garcia]

The meeting in Rabat was preceded by a workshop held in Oran, Algeria in November 2014. The Oran workshop was a testing ground where community participants worked together to review market data, create their ideas from scratch and test rudimentary prototypes in simulated environments. Having completed a prototyping process, each concept was assessed for feasibility. The concept that was considered most feasible in the short-term was taken forward and made the focus for the workshop in Rabat.

While in Rabat, community participants reflected on the current environment for the LGBT community in MENA and proceeded to produce: personas of target users; the first iteration of standard operating procedures for online peer educators; workflows for content creation; frameworks for monitoring and evaluating activities; and, a six-month workplan for each participating community organisation, including online security training. A key outcome for the participants was strengthened commitment to work collaboratively on a regional, tech-based approach that maximised limited available resources.

At the completion of the workshop, each community organisation started implementing a three-month beta-test of the frameworks that they created in Lebanon, Morocco and Tunisia. At the end of the beta-testing period, the groups will reconvene to assess data gathered, adapt and iterate the frameworks in preparation for a second phase that could be scaled-up pending available resources.

“We are confident that field data from the beta-testing phase will lay solid foundation,” Couffignal said when explaining preparations for the next iteration of an ICT-based HIV prevention strategy for gay and bisexual men in the region. “Once the field data has been analysed, partnerships will be sought from public and private sector in hopes that support can be secured to scale-up tech-based HIV prevention in the Middle East and North Africa.”