By Shannon Walbran

HIV/AIDS is wreaking havoc on businesses as their workers become infected, particularly in much of Africa. But managers have been slow to respond because they do not yet fully comprehend the impact on their productivity and profits as workers fall ill, and the economy as a whole suffers.

"In view of globalization, high productivity is an essential ingredient for competitiveness. [Yet] a number of factors account for the loss of productivity, and one notable factor is the HIV/AIDS pandemic."

- Zambia President Levy Mwanawasa
  speech delivered on March 31, 2004

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Photo by Shannon Walbran

HIV educator Linzi Smith answers a technical question about the spread of the HIV/AIDS epidemic in the workplace. Her sometimes shocking presentations for managers lead to behavior-change techniques that reach thousands of workers.

How to Convince a Middle Manager to Help Prevent HIV Infections Examine the manager's motivation, which is to keep the department up and running. Managers will object to any time "wasted" by workers, even if it's for a plan like Smith's in which small groups spend 20 minutes together once a week to run through a simple, impactful lesson on wellness. Thus, managers need to see HIV education as an investment in productivity, or else they will object to "wasted time." Alert managers to how many of their employees are in the early, undiagnosed stages of infection by showing them slides of people with probable symptoms. Smith informs production line and factory managers that "the harder the labor, the heavier HIV will affect your labor force." Depending on what the nature of an industry, she works out an estimate of how long an infected person will be able to continue working without medication and how much healthier workers will be if they are tested and given treatment. Constantly remind managers how difficult it is to locate and train new workers. Facilitate small group role-plays in which a manager approaches a visibly ill worker and directs him toward HIV testing in a way that's legally appropriate, as well as humane. ETC coaches managers not to assume that a coughing person is HIV positive, and guides them through issues of confidentiality, while pushing the point that testing and disclosure of HIV status will help the infected and affected people more than any other piece of information.

How to Convince a Worker to Help Prevent HIV Infections Examine the worker's motivation, which is to protect his job and family. Unemployment is high in South Africa and most people who have work guard it fiercely. Thus, many workers refuse to get tested for HIV because they are sure they will be fired immediately. To ally their understandable fears, Smith tells them that getting tested for HIV will not force them lose to their job but rather help them keep it. Start at the top and ensure that the company has an appropriate policy of non-discrimination against HIV positive employees (and if it doesn't, help them write one). Each company's policy must align with the laws of their home country. Once this happens, one is then free to encourage workers to get tested and disclose their status so they can: obtain any existing health benefits, such as paid leave, partially-paid medication, or counseling; avoid being fired for missing work without an excuse; protect their loved ones from getting infected by learning from peer educator programs about how HIV is spread and how to take precautions that avoid exchange of bodily fluids. To further protect the workers' families, ETC's peer educator program provides instruction about the foundations of communication and wellness before offering any details about viruses. The classes use peer educators who speak the same vernacular as workers.

Staffing for HIV/AIDS Prevention Education If you're running an HIV/AIDS education organization for the business sector, you'll need proper staffing to take on tasks — from analyzing the company, to writing new policy, to costing out the search and selection of new replacement workers. Who are the people you could consider bringing on board? To address the industry's needs in HIV education and prevention, ETC partners with an array of staff, consultants, and other organizations, including: Project managers Researchers, economists, and statisticians Presentation specialists Psychologists and counselors Social workers Nurses Lawyers Trainers People living with AIDS Employee Assistance Program experts HIV testing kit suppliers Anti-retroviral drug suppliers and counselors Crisis management consultants

Dos and Don'ts for HIV Workplace Education DO have facts and evidence on hand to answer questions. The most common queries are, "How do I know if I'm HIV positive?", "How can I tell if my colleague is HIV positive?" and "How can I keep myself healthy?" DO acquaint everyone with the five elements necessary to spread HIV: an infected person an exit point for the virus (e.g., an open wound) infected body fluid (e.g., blood, semen, vaginal fluid) risky behavior (at the workplace or at home) entry point (e.g., mucous membranes or an open cut) DO explain to people how to protect themselves and others. Educate them on how unlikely HIV infection is through casual, everyday contact. DO "follow the money" in convincing businesspeople that HIV is a risk they can manage in their factories and shops. Show them the financial advantages of prevention. DO realize how an employed person supports a whole network of others at home. Keeping the workforce healthy buoys the nation's economy. Remember that unemployed people look up to and listen to their employed friends and neighbors. DO make sure the company has an effective HIV employee policy. Favoritism lets some ill workers off the hook while others get fired for missing a few days — following a consistent policy for all is the safest legal course of action. DO allow people to voice their fears and explore their misconceptions about AIDS because so much misinformation is floating around. DON'T let rumors about colleagues run amuck. Managers should speak directly to workers who are often absent or who appear ill. A frank, confidential conversation will lead to solutions rather than scandals. DON'T turn down the ideas that managers have for making the workplace safer for all employees. Use care and caution to protect your workforce, making sure not to assume infection or to discriminate.

How to Turn Ordinary People Into Change Agents: Training Peer Educators Select leaders Management is asked to make a grid that divides their entire company into sections of 20 people or fewer. In each of these sections, supervisors select two or three people who show enthusiasm and have an ability to read at a high school level. An introductory session is then held by ETC, as well as interviews of the candidates to determine if they can make the commitment to teaching. Asking for volunteers from the factory floor usually does not work, because often the people who volunteer will be very extraverted but not careful teachers. Or, people who just want to take a break from their ordinary job. Train the leaders ETC schedules a seven-day training course: First week: Monday, Tuesday, Wednesday Second week: Monday, Tuesday, Wednesday Third week: Test on Thursday Those who pass the test can continue as peer educators. The course is spread out so that people can absorb the complex information. The first week is all about decision-making and communication, so it is important that the participants apply the lessons at home (such as "reflective listening" in which you don't give advice but rather re-phrase the problem to the person who is complaining) to see if they work, before moving on to implementing the information in the workplace. Hold courses at the factory The weekly peer education sessions occur onsite at the workplace because Smith discovered that people would not travel to a seminar about health, even if it was free and food was provided. Making the course a required part of the job gives it status and importance, and to the peer educator, a certain respect. The lessons are short — just 20 minutes per class — but they take place over 48 weeks for long-lasting impact. Circumvent prejudices In South Africa, the "man-to-man" nature of the classes eliminates the stigma of nursing, illness, or health, all perceived in Zulu culture as the exclusive domain of women. Find out what prevents the population of workers from seeking health treatment, and make sure the courses do not reinforce those stereotypes.

Hitting Home — to Change a Culture

In Durban, South Africa, nine managers sit around a boardroom table, reacting to a particularly graphic presentation by Smith and her

Photo by Shannon Walbran Buy-in must happen from the boardroom to the factory floor for HIV prevention programs to be effective in the workplace

organization. They are seeing slide after slide of close-ups of mouth ulcers, skin rashes, and muscles wasting away. Then Smith shows a photo of a fit, smiling laborer.

"You might never guess," she says, "but this person is HIV positive. Just like roughly a third of your workers." This statistic hits the managers where it hurts most — productivity and profits.

But getting CEOs' buy-in to have their managers begin working to change their workers' behavior requires unlinking a complicated chain of human relations — not to mention unpacking deeply ingrained myths and taboos. ETC tackles this head-on by targeting each group of people along the behavior-change chain. It enlists them in preventing the spread of HIV by appealing to their primary motivations.

A Devastating Blow to the Economy

Approximately 42 million people have been infected with HIV worldwide. ¹ In South Africa, 6.5 million people were infected by the end of 2002. In Durban, South Africa's second-largest city (located in the province of KwaZulu-Natal where Smith is based), 38 percent of the population is infected. The majority are between 15 and 49 years old, the prime working years.

Photo by Shannon Walbran

Durban school children: In South Africa, HIV/AIDS is the number one cause of premature mortality for both genders, although females succumb more quickly than males and die younger, according to the National Burden of Disease Study 2000.

Linda Mbonambi, an urban renewal program manager based

Photo by Shannon Walbran "AIDS is costing this city!" says urban renewal specialist Linda Mbonambi

in Durban, offers a chilling warning: "HIV is costing this city," he says. "AIDS not only takes away people's lives, it undermines the human resource investment we're making. We spend this money in developing people, and then HIV just washes it away. Businesses tell us they're feeling the knock, especially in high levels of absenteeism and in lessening productivity. As the tax base of the city shrinks, it means the city is less able to deal with its pressing social and economic needs."

Asking Hard-Hitting Questions

HIV education is a first step in tackling this problem, but something else is needed. Smith's strategy is unique because it identifies male leaders in factories and trains them to be peer educators and counselors, not only in the workplace but also in their communities.

Unemployment in South Africa is rampant, so that men who have jobs enjoy elevated status in their society. They become role models for unemployed men who emulate their behavior. Smith uses this cultural dynamic to change thinking about unhealthy sexual behaviors that abound in this polygamous, patriarchal society, where sexual responsibility — if any — has been the male prerogative.

In separate, carefully designed meetings, Smith sweeps through a business and blows the dust out of everyone's heads. She will ask a company president: "By how much has absenteeism over the past five years reduced your profit margin?" and "Do you monitor the risk of staff fallout as closely as you watch the currency exchange rate?"

Photo by Shannon Walbran

A manager listens to Smith: "Until I saw this slide show, I would never have guessed that a third of the workforce here is HIV positive." Managers learn how to approach workers and convince them to get tested, because testing saves jobs and lives.

Unusual Teachers Inspire Radical Techniques

Smith served in the HIV/AIDS and Life Skills Health Promotion Sector of Kwa-Zulu-Natal province's Health Department for 14 years. She treated her first AIDS patient in the early 1980s and realized immediately that the health services had limited mechanisms for helping people with the disease.

Photo by Shannon Walbran

Durban is located in South Africa's province of KwaZulu-Natal, which has the highest rates of HIV infection in the country: 1.8 million people or approximately 37 percent of the provincial population.

Testing: A Stunning Impact

Business managers who are subjected to Smith's gruesome photos are students in ETC's two-day intensive course on identifying and dealing with HIV in the workplace. They memorize the five elements necessary to transmit HIV. They learn the progression of stages from HIV to AIDS and how rapidly people decline without medication.

Managers are stunned to discover the impact of testing: a person who knows his status is likely to infect one to two others during the rest of his life, whereas somebody who has not been tested is likely to infect between six and ten other people. The refrain for managers is,

Photo by Shannon Walbran This South African worker (whose identity has been obscured to preserve anonymity) believes he is infected with HIV, but he is too scared to get tested. Management must assure him that he will not lose his job.

"Know your HIV status! Get tested!" because one must have that knowledge to take the next steps to making informed, healthy life choices.

Nevertheless, workers can be reluctant to get tested. A worker who prefers to remain anonymous gives a typically fearful response: "I don't know my HIV status, and I don't want to know, although I believe I'm HIV positive. I don't trust the clinic because the lady who runs it is very talkative, and she'll tell everybody."

Smith teaches managers to get past this reluctance by — for example — building an atmosphere of trust and support backed with a legally binding company policy that promises workers they will keep their jobs.

Education Doesn't Do It: Modify Behavior

Smith warns fellow HIV/AIDS educators at home and around the world that ordinary efforts are not sufficient. A simple seminar will not stop HIV infection. "You've got to get into people's value systems, their beliefs," she says.

"An 'awareness' lecture is useless or worse than useless. Managers think that once workers have attended a seminar, the job of preventing HIV is finished. Totally untrue."

Smith's courses unpack the profound prejudices, myths, and fears of her target audiences. For example, it's a well-known "fact" among South African laborers that the government is purposefully propagating HIV through infected spermicide in free condoms. "In order to fight myths, we must first let them be aired and discussed, and then we must counter them with facts and evidence," she says.

Smith listens respectfully to the panic-driven myths and then defuses the "infected condom conspiracy theory" with the question, "But isn't

Photo by Shannon Walbran This "Condomise!" poster is an example of a campaign that informs but is unlikely to change people's behavior unless it reaches into people's value systems, Smith says

the current government the ANC, Nelson Mandela's democratic party?" Workers see the point and move on to admitting they are reluctant to use condoms for other reasons.

She has strong words for both sides: "HIV/AIDS organizations should not let themselves get tricked into giving information and awareness lectures, which only lull management into complacency. It is absolutely not a case of 'a little education is better than nothing' — it's implementing behavior-change strategies, or don't even bother!"

She shows managers, and later workers, a diagram of a human figure with three arrows. One points to the head, one to the heart, and the last toward the hand. "Information and awareness are aimed at the head," she notes. "Do they change behavior? No! Think about anti-smoking campaigns. People know smoking is bad for them, but they don't stop. It's the same with HIV."

She points to the heart. "This is where change happens. Attitudes, values, beliefs. Only when somebody believes he needs to change will we move here," pointing to the hand, "to action."