In-depth: Beyond ABC: The challenge of Prevention
LESOTHO-NAMIBIA: A new look at tailoring prevention messages
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In urban Zambia there have been increases in risk-avoiding behaviour
JOHANNESBURG, 14 November 2005 (IRIN In-Depth) - Conspicuous success has not accompanied the many southern African campaigns to prevent the spread of HIV. In Botswana and Swaziland the United Nations estimates that around 30 percent of adults are infected with HIV, while in four other countries - South Africa, Lesotho, Namibia and South Africa - more than one in five adults are thought to have the virus.
Access to antiretroviral treatment is slowly improving across the region, with the numbers of people on the life-saving drugs roughly tripling in the last few years. But this relatively successful focus on treatment has highlighted the need for a similar regional drive to also prevent new infections.
Although technological interventions offer hope of restricting the expansion of the epidemic, many are still in tentative stages and may take years to come to fruition. The downside is that using bio-medical tools, unless they are totally protective, has a risk that people will believe they are safe and revert to risky behaviour patterns.
PREVENTION CAMPAIGNS UNDER SCRUTINY
Behavioural change communication, one of the buzzwords in the prevention world, is crucial to stopping new HIV infections.
One of the criticisms of prevention campaigns is that too often they are externally designed, driven, funded and implemented. Many initiatives have shown signs of success, but UNAIDS regional co-ordinator Mark Stirling, for one, argues that the massive increase in urgency and impact that is needed can only be achieved with the weight of government behind them.
According to Stirling, the state, which has the authority and control of government structures, can drive effective campaigns.
Regional governments recently agreed on a joint plan for pushing prevention strategies, in which one of the first steps is a critical review of preventative strategies to single out the successful ones.
International donor agencies have also come under fire for encouraging disparate strategies that sometimes duplicate each other. For the first time in the over two decades that HIV/AIDS has been ravaging Africa, UN agencies signed a ten-point Declaration to support African governments in their efforts to accelerate HIV prevention. Crucially, the seven agencies agreed to mechanisms for monitoring the joint plan, and on key indicators for measuring success or failure.
Like any other public health exercise, prevention campaigns must have achievable targets to ensure that they are effective and to correct any deficiencies.
While the success or failure of treatment programmes can be readily assessed, the outcomes of prevention campaigns are harder to evaluate. One of the criticisms of the proliferation of behavioural modification, education and prevention campaigns has been the lack of assessment to determine whether or not they really work. A lack of proper assessment can not only lead to inefficient use of resources but also create confusion when conflicting and sometimes inappropriate messages are delivered.
Governments and NGOs point to large amounts of money spent on education campaigns, and cite studies showing that AIDS education campaigns are reaching increasing numbers of people.
But behavioural change communication experts say that although many people have information and knowledge about HIV/AIDS, this does not translate into behavioural change. Rather than saying "don't have sex, you'll get AIDS", the message must be grounded in a wider context that acknowledges the social and economic realities of people's lives.
Rosemary Romano, from the Academy of Education Development, noted that there was now a move away from posters and pamphlets as means of prevention to more effective behavioural interventions such as peer education.
GLIMMERS OF HOPE
Some intervention programmes have worked. In urban Zambia there have been increases in risk-avoiding behaviour, with consequent declines in infection levels.
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| The outcomes of prevention campaigns are harder to evaluate |
One country that appears to have achieved a decline in HIV is Zimbabwe. Mark Stirling told PlusNews that ongoing sustained prevention and behavioural modification programmes dating from the 1980s seemed finally to be bearing fruit between 2002 and 2004. Both men and women reported very high levels of condom use during casual sexual relationships, and it appeared that prevalence among pregnant women had dropped from 26 percent in 2003 to 21 percent in 2004. Whether this apparent trend will continue in the current turmoil in Zimbabwe is debatable.
One education and prevention campaign being watched with interest is Soul City, the acclaimed South African-based edutainment group, which has started expanding into neighbouring countries.
Soul City has been highly successful in using drama to reach its target audience. Heavy investment in preparatory work, defining what the messages for each programme in the series are and ongoing research into the impact on audiences provide the basis for its success. Although much work is done with experts in relevant fields, for example, in sexual abuse, Soul City works hard to ensure that the messages are understandable and relevant.
There is also a strong emphasis on monitoring and evaluation, and reports on each project are publicly available.
The question is now whether Soul City can successfully extend its messages to wider, more diverse audiences with different cultural backgrounds. The Soul City Regional Programme is a five-year project targeting Botswana, Lesotho, Malawi, Mozambique, Namibia, Swaziland, Zambia, and Zimbabwe, where it aims to create multimedia health education and train local partners in each country to set up an ongoing education campaign.
Even when strategies are known to work, they are often not being implemented adequately. For example, Malawi has a population of over 11 million people, yet less than 87,000 people access voluntary counselling and testing services.
One particularly notable failure is that of preventing huge numbers of children from contracting the virus from their mothers. In its latest AIDS Epidemic Update, UNAIDS and the World Health Organisation estimate that in 2005 there were 520,000 children in sub-Saharan Africa infected with HIV, while another 630,000 will become infected.
Without any intervention an estimated 35 percent of children born to HIV-positive mothers will be infected, which can be dramatically reduced by the use of antiretroviral treatment. Drug interventions, combined with formula feeding and caesarean sections, have lowered mother-to-child transmission rates to below two percent in developed in countries.
Given the advent of the antiretroviral treatment age in southern Africa, the links between treatment and prevention also need to be exploited. Research in various parts of the region has found that people appear more willing to volunteer for testing if they know that antiretroviral therapy is available. Research in South Africa found higher condom use and readiness to be tested among people at the one site offering anti-HIV drugs, compared to seven others that did not.
Key Prevention Campaigns in the region:
Soul City
www.soulcity.org.za
The HEART Campaign in Zambia
www.jhuccp.org
Corridors of Hope - Southern Africa
www.psi.org