SHARP's strategic approach involves focusing prevention interventions for results. The "High 5" focus includes: 1) high prevalence/most-at-risk groups; 2) high-risk behaviours; 3) high transmission areas; 4) high-risk places; and 5) high-risk events. These emphases are reflected in the types of outgoing messages sent as part of Text Me! Flash Me!: 1) promotion "blasts" (e.g., free airtime, free lubricants); 2) education "blasts" (example: "Friends, it's your turn to show true love this Valentine Day by being faithful to 1 partner n using condoms n lubes each time u have sex"); 3) automatic short messaging service (SMS) response to a coded text inquiry; and 4) personalised follow-up response.

Specifically, Text Me! relies on a database of cell phone numbers collected by peer educators and social networks. Outgoing SMS texts are sent with educational and promotional messages, either through a "phased communication" strategy or in response to trends noticed through ongoing quality assurance and monitoring and evaluation (M&E). Automatic SMS text responses are sent to clients' SMS text inquiries that refer clients who text "HELP" to live Helpline counselors, who call back within 24 hours.

The Helpline is advertised through peer educators, social networks, and discrete Text Me! posters, which read: "To get more info about friendly services in your area, use your phone to send a short text and the name of your town to XXXX. Worried that you may have gotten an infection from sex? Text STI. Need to know where to go for friendly HIV testing? Text VCT. Want to know about medicines and therapies for HIV-positive people? Text ART. Want to know where to buy condoms or lubricants? Text PROTECT. Need to talk to someone in private about your HIV and AIDS questions? Text PROTECT."

The Flash Me! component of the project refers to the fact that, in order to encourage clients to call and use a Helpline, it is important that the call is free to the client. However, in Ghana, there is currently no way to procure a phone number that will be free for all callers from all networks. The solution was that potential clients may "flash" the cell phone number of a Helpline counselor on duty, who returns the client's call within 24 hours. Helpline counselors' cell phone numbers and duty hours are disseminated both through social networks, discrete fliers, and by peer educators.

As part of this project, MARP-friendly training was provided for health workers. This involved a toolkit featuring: key tasks for a Helpline counselor; Helpline scripts for intro and airtime promotion; frequently asked questions (FAQs); 8 key behaviours; referral sheet; updated inventory of STI and HIV-related services in Accra; knowledge and behaviour information sheet; roster of Text Me! SMS messages already sent to MSM; key reminders leaflet; Helpline service hours fliers; airtime for counselors and clients; reminder brochure of key messages; condoms and lubricants; Helpline M&E forms and bi-monthly reporting forms; and letter to supervisor.

These job aides are based on an evidence-based approach, focusing on promoting key behaviours through peer education, referrals, and condom/lube sales. SHARP maintains that this strategy improves consistency of messages and information as part of a harmonised behaviour communication change (BCC) strategy for each intended audience. At the core is an effort to strengthen peer educators' knowledge, skills, and impact on adoption of key behaviours, as well as to increases quality of outreach interventions. Consistent with this approach, the existing training curricula and job aides for peer educators were strengthened to be harmonised, evidence-based, behaviour-focused, more user-friendly with an attractive layout, and integrated into a more participatory training methodology with skills-based games, role plays, and group work. Also, innovative job aids such as Watch Me! video clips have been identified on YouTube and other websites, and packaged into downloadable formats for cell phones. Accompanied by newly developed discussion cue cards, Watch Me! is meant to diversify the source of information and provide an entertaining, educational, and discrete means of communicating HIV/AIDS messages and facilitating quick transfer among peer networks (from cell phone to cell phone).

HIV/AIDS.

As in many countries, MSM are a most-at-risk population in Ghana.

In the first month of the Helpline (September 2008), 5 Helpline Counselors counseled 439 MSM clients. This amounts to an average of 88 MSM clients per Helpline counselor per month - compared to 50 MSM clients per peer educator or health worker per month in facilities and communities. The average call lasted 20 minutes.

Information from the telephone survey and the M&E forms indicate the main reasons for contacting the Helpline are to access information and advice about HIV and STI. Although FGD and M&E data clearly indicate that promotions of free airtime increased the number of clients accessing services, only 3% of survey respondents indicated their primary reason for accessing the Helpline was to "get free units". Forty-four percent of respondents said the thing that they liked the most about the Helpline was the education they received, compared to 12.1% who said it was the incentives.

Here are some selected reflections from Helpline counselors and peer educators taking part in this programme:

• "Sometimes MSM deny their (sexual orientation) face to face....Whereas on the phone they can say 'if I tell you I am MSM, will it worry you?'"
• "The text and flash has worked very well....By (clients?) texting or flashing, counselors can give information about the various friendly centers available where they can go an access a CT."
• "[O]ne day the 'It's Your Turn' Friday text message sent out as part of the Helpline program stopped a couple who were about to have sex without protection. They had come to visit me and went into my room. Later he told me that just when they were going to have an affair the Text message came through and it pricked his conscience, so they stopped."
• "Society frowns on it - but because of the Helpline they are coming out more and talking about their problems. They now walk in freely and willingly into friendly drop in centers. And in a way they are curbing HIV and AIDS infection."

In addition to the initiative described above, the 5-year SHARP programme has developed a number of tools and interventions for HIV and AIDS prevention. For instance, the "My Life!" Positive Living Tool Kit is designed especially for low-literate people living with HIV (PLHIV) and tailored for use during support group meetings. The goal of the Kit is to empower PLHIV with the knowledge, skills, and attitudes necessary to adopt 8 key behaviours promoting effective prevention, treatment, care and support. It includes: user-friendly instructions for support groups and their facilitators, audio-recorded technical content, games, motivational testimonials from real PLHIV, visuals (print materials, videos, and DVDs), wooden dildos for condom demonstrations, and videos on specific positive living topics. The Kit, whose self-empowerment theme is "Hope is in my hands", has 10 modules.

SHARP also facilitates monthly PLHIV support group meetings with technical support/mentoring by its NGO Implementing Partners. These groups are designed to move PLHIV from passive recipients of food, medications, money, gospel music, and prayer meetings organised for them to empowered women and men with increased self-efficacy and self-esteem, capable of running their own meetings and adopting key prevention, care-seeking, and treatment adherence behaviours.