Part 4: Procedures

Core Phases

The social networks strategy includes four core elements or phases: a Recruiter Enlistment phase, an Engagement phase, a Recruitment of Network Associates phase, and a CTR phase.

1. Recruiter Enlistment

Potential recruiters are identified, screened for eligibility, contacted, and invited to participate in the program.

Note: The term “recruiter” is used exclusively in this manual to refer to individuals who recruit from their networks. However, each agency should use a term that will be accepted by its target population (e.g., peer advocate, health promoter, community advocate), and culturally appropriate.

Any agency planning to use the social networks strategy should:

• Define the population or pool from which potential recruiters will initially be identified. For example, this population might be defined as African American women who are injection drug users and currently enrolled in care services within the agency.

Lessons Learned

“Beyond identifying specific target groups, consider structuring it based on risks and behaviors. Networks succeeded in identifying positives when they hit on groups that had behavioral connections related to high-risk activities, such as homelessness, IDU, etc.”

• Develop procedures by which potential recruiters will be identified from this population or pool. For example, potential recruiters could be identified by reviewing client records, or by asking case managers or care providers to nominate specific clients.

		“Know your gatekeeper in the agencies and have continual contact.”
Lessons Learned		“Go back to being outreach workers and building relationships with providers and remembering those folks with follow-up phone calls. An effective way to identify with recruiters in building relationships with providers is to show how the program is being affected by their work.”

• Develop procedures and criteria (inclusion and exclusion) for screening potential recruiters to determine eligibility for the program. For example, exclusion criteria could include persons who might pose a risk for violence or persons with significant mental illness who might interfere with appropriate participation. These criteria may be modified on the basis of ongoing experience. Input on appropriate criteria should be sought from the program advisory group.
• Develop procedures for identifying additional potential recruiters. HIV-positive and high risk HIV-negative network associates may be invited to enlist as recruiters.

Lessons Learned

“The high-risk negatives who were prior associates brought in 75% of all the positives, versus the positive recruiters who were prior associates, so I think they have a lot of value in identifying target populations. The high-risk negative people seem to have a larger network than the positives.”

• Develop procedures for contacting potential recruiters (e.g., by telephone, or during a routine visit to the agency
• Develop procedures for explaining the program to potential recruiters and inviting them to participate. For example, explanations may be given individually or in groups. Explanations should include certain standard information, such as a brief description of the program’s purpose; what participation involves; the role of the recruiter; potential benefits the program might have for recruiters, network associates they recruit for CTR, and the community; and what risks might be involved in participation. Explanations of the program can be provided using a checklist list of key points (e.g., role of recruiters, role of provider, who should be referred for CTR, incentives).
• Develop supporting written or visual materials that will be used to help explain the program to potential recruiters and how these materials will be developed.
• Determine the specific staff members who will perform each of these functions (e.g., HIV counselors, case managers, service providers).

2. Engagement (Orientation, Interview, and Coaching)

Orientation

Persons who accept the invitation to become recruiters will receive a more thorough orientation to the program. Orientation should take place, even when recruiters only participate in the program for a short period of time (which is typical). Due to different circumstances, there may be some variation in how orientation is accomplished. Protocols should clearly describe the following:

• Procedures for how and when new recruiters will be oriented to the program. For example, this may be done individually or in groups.
• The content to be used in the orientations. For example, the content should include an in-depth discussion of the program and its purpose; what constitutes participation; the role of the recruiter; the meaning of the term “network associate;” options for recruiting network associates; and a detailed discussion of potential benefits and risks of the program. The orientation can be conducted using a checklist of key points.

Lessons Learned

"You don’t want to overwhelm the person with information. The initial orientation should be no longer than 30 minutes. But after that, orientation should be ongoing."

• Supporting written or visual materials that will accompany the orientation and how these materials will be developed.
• Procedures for documenting persons who receive the orientation, understand the program, understand that participation in the program is voluntary, and still elect to participate in the program. Documentation could be accomplished by maintaining a log of persons attending the orientation session or, more formally, by asking each person to sign a consent form indicating her or his desire to participate in the program.
• Specific staff who will conduct the orientation (e.g., HIV counselors, case managers).

Interview

Obtaining network information
Persons who still elect to participate in the program as recruiters after orientation should meet with agency staff for in-depth interviews and discussions about recruiting their network associates for HIV CTR.

Lessons Learned

“The easier I rolled it out, the better. But when I tried to over-explain about the social networks process, it was too much information.”

Interviewers should work with the recruiter to elicit names of network associates the recruiter thinks would benefit from HIV CTR (i.e., persons who the recruiter knows and believes may be at high risk for HIV infection). (This program was not designed for anonymous testing since it would be difficult to link recruiters to their network associates without names.) Interviewers may also attempt to elicit information about the nature of the recruiter’s relationship with each network associate (e.g., sex partner, injection drug partner, other social contact). This information would help prioritize which network associates to contact first, as well as allow a better understanding of the dynamics of the network.

Lessons Learned

“Sometimes recruiters would just give first names. But once they saw how we dealt with the first wave of folks, they gave us more information as they became more comfortable.”

Lessons Learned

“If you’re too client-centered, you don’t get what you need. Ask for what you want; be direct. Don’t beat around the bush to try to get to a question.”

If the recruiter is not comfortable providing names, the interviewer will, at a minimum, ask for the first name, or initials, of the network associates she or he intends to attempt to recruit. Interviewers might also ask recruiters to identify perceived “leaders” in the network, who might themselves be enlisted as recruiters.

		“There is a big difference between educating people and eliciting information from them. People need interviewing skills. There should be training around motivational interviewing techniques..”
Lessons Learned
		“While it’s good to target populations, we must be fluid in following the networks and going where those trends lead us.”

Developing plans for recruitment
After identifying individual network associates, the interviewer should help the recruiter understand how to recruit these network associates for HIV CTR. The basic strategy for contacting individual network associates is for the recruiter to approach the individual alone, make personal contact with the network associate, and then refer or accompany them to HIV CTR.

Any agency planning to use the social networks strategy should be able to describe:

• Approaches and strategies that will be offered to recruiters for recruiting network associates.
• The interview format to be used for interviewing recruiters about their network associates.
• How interviewers will work with recruiters to develop plans for attempting to recruit network associates for HIV CTR.
• Supporting written or visual materials that will be used for interviewing.
• Procedures for documenting information obtained during interviews.
• Specific staff who will conduct the interviews (e.g., HIV prevention counselors, case managers).

Coaching

The interviewer should coach the recruiter on how best to approach network associates to recruit for HIV CTR. Coaching should include: 1) personal safety, 2) approaches for raising the topic of HIV CTR with network associates, 3) issues to consider with regard to disclosing their serostatus, 4) approaches for disclosing their own HIV serostatus to network associates, should they choose to do so, 5) approaches to raising the topic of CTR to network associates without revealing their own serostatus, should they prefer not to disclose, 6) how to respond to network associates’ questions about HIV transmission risks, available support services, confidentiality protections, or other issues, 7) how to respond to network associates’ reactions, including the possibility of an angry or violent response, and 8) how and where each network associate can receive HIV CTR. Coaching should include role-plays.

Lessons Learned

"Engage in role playing or show videos of an appropriate coaching session. Having examples of seeing someone do it effectively would be helpful"

The intent of coaching is for recruiters to get comfortable with recommending HIV CTR to persons they know or are acquainted with well enough to believe they are at high risk for HIV. Recruiters may know or be acquainted with some network associates through shared network venues (e.g., if they hang out in the same locations). However, the emphasis of this activity is on social connections. It is not the intent of this activity for recruiters to approach venues that are not part of their own social networks and conduct “outreach” to persons with whom they have no social connection.

		“Focus on the importance of being client-centered. Give a sense of ownership so recruiters feel they are a part of something. Look at the volunteer as an expert resource and a guide.”
Lessons Learned
		“Reiterate that this is not a job and we are not their employer.”

Once the recruiter has been satisfactorily coached, he/she should be provided CTR referral cards that can be given to network associates when they are contacted. Referral cards should contain information such as CTR site location and recruiter ID #. Color coded cards may be used to distinguish network associates from other clients (e.g., if the associate loses the card, they may still remember the color of the card, allowing the associate to be linked to the recruiter).

Any agency planning to use the social networks strategy should develop:

• Methods that will be used, including topics to be covered
• Supporting written or visual materials that will be used
• Staff who will perform different tasks in the program (e.g., HIV prevention counselors, case managers)

Follow-up with recruiters

The interviewer should arrange a follow-up plan with the recruiter. Follow-up may be accomplished in person or by telephone. This will allow the interviewer to assess how the recruiter’s efforts are progressing. If the recruiter has not been successful in recruiting network associates for testing, the interviewer should work with the recruiter to develop strategies to overcome obstacles to successful recruitment. This will also provide an opportunity to elicit additional network associates.

Lessons Learned

“In follow-up, it’s important to go back to whom they identified previously. Did they encounter the person and he refused? Or was it that the network associate is too caught up in his lifestyle? We had recruiters who were told off by a network associate. It’s important to encourage them for the job they did, even if referrals weren’t successful.”

Any agency planning to use the social networks strategy should clearly describe procedures for following up with recruiters after the interview.

3. Recruitment of Network Associates

After they have been interviewed and a recruitment plan has been developed, recruiters should begin contacting their network associates to recommend HIV CTR. The recruiter will attempt to locate her or his network associates to recommend HIV CTR. The recruiter will then either offer to accompany the associate to testing (CTR agency or mobile van testing site) or provide, to his associates, a CTR referral card that includes information on how to access the program’s CTR services.

Follow-up of network associates
Some network associates who are referred to the program’s CTR services may not report for CTR. The program may include provisions for coaching recruiters to follow up with any network associates who are referred, but do not report for, CTR.

4. Counseling, Testing, and Referral Phase

Network associates who accept recommendations for HIV CTR may receive CTR in the field (e.g., in mobile van) or be accompanied by the recruiter or referred to the program CTR site. Agencies should comply with all health department requirements regarding HIV counseling, testing, and referral services.

Newly diagnosed HIV-positive persons, previously diagnosed HIV-positive persons, and persons at high risk for acquiring HIV are useful for referring other high-risk persons from the network. Therefore, providers should consider these individuals as potential recruiters and assess whether they meet the criteria for a recruiter. If criteria are met, providers should invite them to participate in the program. Enlisting such individuals will facilitate additional testing within the network. Newly diagnosed individuals may not initially be interested in serving as a recruiter but, given some time, they may become interested once they have adjusted to their serostatus.

Including high-risk HIV-negative persons as recruiters may make it less likely that other recruiters’ serostatus will be assumed, which may lead to a decreased likelihood of stigmatizing. There may be some variation in how CTR should be conducted, depending on local requirements.

Any agency planning to use the social networks strategy should determine:

• Whether CTR will be offered in the field and, if so, how and under what circumstances
• Specific staff that will conduct the CTR
• Whether anonymous testing will be offered and, if so, how and under what circumstances
• Procedures for CTR using routine or rapid testing
• Other services that will be available to clients, either directly from the agency or through referral (e.g., medical evaluation; additional HIV risk reduction interventions; STD screening, diagnosis, and treatment; substance abuse treatment; mental health treatment; and social services)
• Procedures for making referrals, assisting clients with getting to referrals, and confirming that referred clients acted on the referrals and received, or are receiving, services as a result of the referral

Lessons Learned

“If we’re going to encourage people to find out what their status is, we have the responsibility to link them to follow-up care.”

For network associates who test positive, the agency should:

• Provide post-test counseling
• Provide, or refer for, medical evaluation and management
• Assess HIV behavioral risks and provide, or refer for, appropriate HIV risk reduction interventions
• Provide, or refer for, other appropriate services (e.g., STD screening, diagnosis, and treatment; hepatitis screening and vaccination; substance abuse treatment; mental health services; and social services, such as assistance with food, housing, employment, or finances)
• Provide, or refer for, PCRS (following all applicable health department guidelines, protocols, procedures, and performance standards)
• Conduct follow-up with clients to determine if they acted on referrals and received relevant services
• Consider enlisting them as recruiters

For network associates who test negative, the agency should:

• Assess the need for follow-up testing
• Assess HIV behavioral risks and refer for appropriate HIV prevention interventions and follow-up testing
• Refer for other relevant services and access potential candidates to be enlisted as recruiters
• Consider enlisting them as recruiters (if high-risk)

Lessons Learned

“Social Networks is aimed at getting high-risk people. So if you’re targeting someone who’s at high-risk, you need to have a risk reduction plan.”

Go to Section One; Part 5