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“Sapa sang Kinabuhi”: How the River-of-Life Toolhelped in getting behavior change in motion among people affected with injecting drug use in Cebu City

“Sapa sang Kinabuhi”: How the River-of-Life Tool helped in getting behavior change in motion among people affected with injecting drug use in Cebu City

By: John Piermont Montilla (PHANSuP) and Dr. Ilya Tac-an (Cebu-CHD)


SALT facilitator: "I would like to ask the social hygiene clinic staff why is it that the leaders representing the community of people who inject drugs present in this dialogue are honest to share their real-life risk behaviors without hesitation"


Clinic staff: Sir, it is because they are already our regular clients… some of them are already more than 10 years as client. We already established a good working relationshipwith them as partners in HIV prevention.


SALT Facilitator: Okay, as we can see in their group river-of-life chart they just presented, 6 of them in the risk-behavior item on injecting use practice are in level 5, and two are in level 3. Why is it that despite being a regular client… some for more than 10 years, they still remain in level 5, which is the highest level?


Clinic staff: We believe the best answer will come from them…


SALT Facilitator: Okay, let me ask the “magnificent 7” leaders…. Why is it that despite being a regular client of the social hygiene clinic… almost all of your members are still in level 5?


 (PWID group looking at each other, a brief silence with all heads bowing down….)


PWID Leader: Sir, it is our fist time to see our behaviors reflected in that chart that we developed.  Now, we are ashamed to see that despite the help of Dr. Ilya and the social hygiene clinic staff for many years, our risk level is still at level 5. Seems that we never changed at all… But because of that chart, we will be helping each other to lower down our risk behavior one step at a time...


                                                   Excerpts from a SALT dialogue between “magnificent 7” emerging PWID leaders 

                                                   and their HIV service providers from the social hygiene clinic of Cebu City

                                                                                      December 27, 2011, Cebu City Health Department Training Room

Enabled by the generous support from the MAC AIDS Fund, eighteen (18) HIV care providers from PWID, PLHIV and clinic staff jointly participated in the first roll-out basic course on positive living counseling on dignity, health and sexuality – a positive prevention capacity development activity held at the Cebu City Health Department on December 26-27, 2011. The activity is enabled by the support from the MAC AIDS Fund.


The activity is an offshoot of the collaborative venture of the  Philippine NGO Support Program, Inc. (PHANSuP), Cebu Plus Association (CebuPlus), and the Cebu City Health Department (Cebu-CHD. entitled Community Engagement for Building a Unified Response to the HIV Epidemic in Cebu City Project or in short, the C. E. B. U. Response Project.


The project strives in shaping and pursuing a human rights-anchored and community-based framework of action that responds to the current HIV status of the Philippines, which is identified as one of 7 countries with more than 25% increase of HIV infection. Injecting drug use was identified as an emerging driver particularly in Cebu City, which hosts the greatest number of PWID in the country. 


Seven (7) emerging leaders from the PWID community in Cebu City assessed their risk-behaviors and developed their “Sapa sang Kinabuhi”, that allowed them to map their individual and community group risk to HIV and AIDS. Eight (8) clinic staff also developed their own self-assessments.


The term  "Sapa sang Kinabuhi" is the participants’ own terminology  to localize the “River of Life” Tool[1] and make it more easily understood by the community using the "Bisaya" language of the "Cebuano" people.  "Sapa meaning river and Kinabuhi meaning Life".

The "river-of-life" workshop is part of the positive sexuality module of the positive living course on dignity, health and sexuality. The module is inspired by the UNAIDS and GNP+ resource on Positive Health, Dignity and Prevention  ( The River-of-life is a behavior change tool of positive living counselors with their counselees that aims in promoting "responsible, satisfying and safer sex life and to contribute to the "zero infection" objective of the getting to zero campaign (positive dignity for zero discrimination and positive health for zero AIDS-related death). 

 Image 1: The Positive Living Sexuality Framework

The facilitator guided the PWID emergent leaders in developing their individual “River-of-Life” chart. To reinforce trust-building as an important component of a dialogue, the service providers (i.e., social hygiene clinic staff) also developed their own self assessment of risk behaviors and river of life charts and shared the results in plenary.


The steps were: 

  1. Perform the self assessment of risk behavior, interpret and share the results with other group members
  2. Transform self assessment results into an individual River-of-Life chart, interpret and share results with members
  3. Work with group members and integrate individual results in a group River-of-Life chart, interpret and share results in plenary. Identify members who have something to share (low risk) and those who have something to learn (high-risk) and together plan on how to bring all group members to the safer side of the river.
  4. Initiate dialogue using the results presented, facilitate learning and sharing as well as identify appropriate positive living counseling interventions on prevention, treatment and care that can be provided by the service provider in the group's journey to the safer side of the river.

After the workshop, the facilitator initiated a SALT dialogue[2] using the results of the group “River-of-Life” chart. The SALT dialogue is a way of facilitating learning that is based on drawing out community strength rather than analysis of weaknesses. Strengths are those things that communities already have, already know and are dreaming about on how they individually and communally grow together. 


In the spirit of Community Engagement, the community’s strengths are expanded with their social spheres of influence that inspire them in their daily undertakings such as their sexual partners, their families, their Barangays, their service providers. During the dialogue, the PWID community vocally expresses that it’s only the City Health Department through the Social Hygiene Clinic who does not give up in serving them despite how society despises their plight. Clinic staff in their Action Plan asserted their commitment to build trust and a climate of respect.


Dr. Tac-an articulated that one of the most important learning she acquired in the basic courses is about “human dignity” and its role in HIV prevention, treatment and care. 

"There are PWID who are not bothered when they found themselves to be infected… they do not care… I wondered so much.. yet this course has helped me appreciate the value of human worth - which is human dignity … that we as service providers are duty-bearers and should treat every client especially the PWID community with respect in order for them to reclaim dignity that was lost or robbed from them due to their despised condition... human dignity should be the core essence of our service"

In engaging communities in the response, mutual trust and deep faith is a requirement, a mutual growing understanding between the claim-holders and the duty-bearers toward a common goal which both continually journey through sustained dialogue and action within a human rights-anchored and community-based framework of action.

The newly-formed “We Are One (WAO)” community group is the first community-based group of people who inject drugs in the Philippines and has a battle cry: "we are one for a drug- and HIV- free Cebu City". The group wants to  use of the tools in their peer outreach program in conjunction with the prevention, treatment and care interventions provided by the Cebu City Social Hygiene Clinic. One of their frustrations in the HIV response is the label "people who inject drugs" that gives the impression that they do not have the aspirations to have a life being drug-free. As Juno (one of the WAO leader) laments: 

"We are now creating our logo and we do not want the 'syringe' to be part of it or to be labeled as injecting drug user or anything that associates us with drug abuse"... We want people to believe that we also have aspirations for ourselves, for our community and for our City to be drug-free". 


The group believes that the tool will help them  build their momentum in reaching their aspirations as Charles (another WAO leader) says: 

“To journey from the danger side of life to the safer side of life and celebrate life that is worry-free, free from the fear of being detained by the police, free from the feeling of being dependent on drugs, free from guilt of harming our own body and our own future ”.


Dr. Ilya Tac-an who heads the social hygiene clinic said that the self-assessment tool is needed in her work with the PWID group as well as other groups whose behaviors are linked to crime and violence. She expressed that:


"The river-of-life tool is new and innovative and is one of the practical, easy and comprehensible community-driven tools that help most-at-risk communities drive their own behavior change program, which goes along with the prevention, treatment and care interventions that we provide for them".


After the exchange of insights and strategic ideas, Dr. Tac-an proposed the enrichment of the tool to tailor it to the needs of the PWID community.  This can be done by integrating the harm reduction hierarchy to measure safer injecting practices of PWID. (Please see Self Assessment of Risk Behavior tailored for the PWID community at the bottom of this blog)



[1] The River-of-Life Tool is adapted from the self-measurement of change tools of the Kabataang Gabay sa Positibong Pamumuhay – a community group of male sex workers based in Iloilo City developed under the UNCEF CPC-6 HIV Prevention Programme for most-at-risk children and youth in 2006 and the ADB-NGO Capacity-building for AIDS Competence 2007 under the technical expertise of the Constellation for Life Competence (formerly Constellation for AIDS Competence) based in Chaingmai Thailand. The Tool has been integrated in the positive prevention package rolled-out by the Philippine NGO Support Program (PHANSuP), Inc. in 5 HIV Priority areas in the Philippines (Manila, Iloilo, Cebu, Zamboanga and Davao) under its Community Engagement Strengthening for the Philippine HIV Response (CES4PHR) Program supported by the International HIV/AIDS Alliance.

[2] SALT means, S = Sharing, A = Appreciating, L = Learning, T = Transfer. SALT Dialogue is a process of facilitating learning and sharing through dialogue among and between members of a community or among and between communities and with their service providers and other support agencies to look inwardly for their individual and collective strengths and use these  as sustainable solution to their ever-changing needs, vulnerabilities an risks. See SALT here:


About the Community Engagement Strengthening for the Philippine HIV Response (CESPHR)


Out of the 20 areas, six (6) HIV epicenters were selected as knowledge hubs namely; the cities of Manila, Cebu, Iloilo, Bacolod, Zamboanga and Davao and identified local facilitation teams chaired by local social hygiene clinics with members from local community-based groups and NGOs. Currently, 7 CBGs, 2 NGOs and 6 social hygiene clinics strove to integrate the self assessments in their service delivery practice. Cebu city was identified as the Positive Prevention Hub.

The NFT from Visayas and Mindanao who collaborated in developing the supposed roll-out proposal has further developed into the "Philippine HIV/AIDS Alliance" to scale-up the reach of the self assessment tools to the most unheard voices in the Philippine HIV response. For the communities of people who inject drugs, three sites who host the greatest number of injecting drug use behaviors were cities of Cebu in Central Visayas and Zamboanga and General Santos City in Mindanao.

The alliance is composed of three major stakeholders, (1) community-based groups as claim-holders, (2) local HIV service providers as duty-bearers and (3) PHANSuP among other technical support providers as partnership-builder. The successful roll-outs is part of the commitment of PHANSuP to the global community in promoting community competence through the MePA framework or the Meaningful Engagement of People living with and At risk of HIV and AIDS. Please see MePA framework here: 


The Self-assessment tool PWID version

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Comment by John Piermont Montilla on February 12, 2012 at 9:40pm

Hello Phil,


Thanks for this insight Phil, so true...

I just remembered my discussion (that i missed to include in my blog post) about where to put the aspirations of the community in the River-of-Life.

We noticed that the goal level "zero" or the least "1" is a goal for "behavior" which is analogous to what you say about "Pain" and not for their their Aspirations which I think is analogous to your concept of "Happiness".

So when I pondered a lot on this River-of-Life, i remembered an email from Caca about the "Journey" by Richard Bach. Please see copy of it below my response.

Then I realized upon too much pondering that the River-of-Life is not just a piece of paper template making maps of individual risks. Its actually a River of Life in the real sense. Wherein the Aspirations of the communities is where the river flows to a place only the Crystal River goes.

So happiness not just changing their behavior from the danger side to the safer side but the reaching of aspirations they dreamed of.

Hmmmm... interesting....

So an individual river-of-life only pictures the behavior from risk to risk free and when we put all the river of life side by side starting from the initial output and the subsequent outputs, we see how the blue shades becomes wider, and wider and wider until one's river of life allows him/her to finally paved the way for his dreams and aspirations to be achieved.

Yes! I think the title is appropriate.

Thank you Phil


The journey

"Once there lived a village of creatures along the bottom of a great, crystal river. The current of the river swept silently over them all – young and old, rich and poor, good and evil, the current going its own way, knowing only its own crystal self.

Each creature in its own manner clung tightly to the twigs and rocks of the river bottom, for clinging was their way of life, and resisting the current what each had learned from birth. But one creature said at last, “I am tired of clinging. Though I cannot see it with my eyes, I trust that the current knows where it is going. I shall let go and let it take me where it will. Clinging, I shall die of boredom.”
The other creatures laughed and said, “Fool! Let go, and that current you worship will throw you tumbled and smashed across the rocks, and you will die quicker than boredom!”. But the one heeded them not, and taking a breath did let go, and at once was tumbled and smashed by the current across the rocks. Yet in time, as the creature refused to cling again, the current lifted him free from the bottom, and he was bruised and hurt no more. And the creatures downstream to whom he was a stranger cried, “See a miracle! A creature like ourselves, yet he flies! See the Messiah, come to save us all!”
And the one carried in the current said, “I am no more Messiah than you. The river delights to lift us free, if only we dare let go. Our true work is this voyage, this adventure.”
But they cried the more, “Saviour!” all the while clinging to the rocks, and when they looked again he was gone, and they were left alone making legends of a Saviour."

– Richard Bach, Illusion


Comment by Phil on February 12, 2012 at 9:10pm

Hello Johnpierre, 

This is a thought. It is not an assertion. 

The title 'self assessment of risk-behaviour has the great virtues of clarity and directness. 

Sometimes I find that this idea helps me to think about an issue. There is a difference between 'the things that make me unhappy' and 'the things that make me happy'. So if I have a pain, I am likely to be unhappy. If that pain stops, it is likely that I will cease to be unhappy. But, that is not the same as being happy. There are a different set of things that I need to consider to give myself the chance to be happy. 

So, your method is indeed about the removal of risk. In a way, it is similar to the removal of the pain. It stops something that is not good, but it does not, by itself, lead to something that is good? 

At the moment, your title does make this distinction. I would be very careful to give a title to your method that does not make the distinction. 

I have one more practical suggestion. Write down a case study of the use of your approach. Take the most successful case that you know about. And look at the outcomes in that particular case. And use that reality to  create a title for your method. I would like to read the case study. 


Comment by John Piermont Montilla on February 10, 2012 at 8:01pm

Dear Friends.

I wish to stimulate a discussion with regards the title of the "self-assessment of risk-behavior".

Although we have succeeded in developing this tool that promotes self-inquiry and recognition of one's risk, the next step would be making terminologies more positive.

I wish to modify the title of the tool into "self-assessment of responsible, safer and satisfying sex life". The title will guide the person assessing his/her behavior towards it.

What are you insights?



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