Preventing and Mitigating AIDS in Sub-Saharan Africa

Research and Data Priorities for the Social and Behavioral Sciences

Barney Cohen and James Trussell, editors

Panel on Data and Research Priorities for Arresting AIDS in Sub-Saharan Africa

Committee on Population

Commission on Behavioral and Social Sciences and Education

National Research Council

NATIONAL ACADEMY PRESS
Washington, D.C.
1996



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page R1
Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences Preventing and Mitigating AIDS in Sub-Saharan Africa Research and Data Priorities for the Social and Behavioral Sciences Barney Cohen and James Trussell, editors Panel on Data and Research Priorities for Arresting AIDS in Sub-Saharan Africa Committee on Population Commission on Behavioral and Social Sciences and Education National Research Council NATIONAL ACADEMY PRESS Washington, D.C. 1996

OCR for page R1
Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, D.C. 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The project that is the subject of this report was funded principally by the Bureau for Africa of the U.S. Agency for International Development (USAID) through a cooperative agreement administered by USAID's Office of Health and Nutrition. The Andrew W. Mellon Foundation also provided funding to the Committee on Population for this project. Library of Congress Cataloging-in-Publication Data National Research Council (U.S.). Panel on Data and Research Priorities for Arresting AIDS in Sub-Saharan Africa. Preventing and mitigating AIDS in Sub-Saharan Africa : research and data priorities for the social and behavioral sciences / Barney Cohen and James Trussell, editors ; Panel on Data and Research Priorities for Arresting AIDS in Sub-Saharan Africa, Committee on Population, Commission on Behavioral and Social Sciences and Education, National Research Council. p. cm. Includes bibliographical refererences and index. ISBN 0-309-05480-X 1. AIDS (Disease)—Africa, Sub-Saharan. I. Cohen, Barney, 1959- . II. Trussell, James. III. Title RA644.A25N264 1996 614.5′993—dc20 96-11347 CIP Additional copies are available for sale from National Academy Press 2101 Constitution Avenue, N.W. Box 285 Washington, D.C. 20055. Call 800-624-6242 or 202-334-3313 (in the Washington Metropolitan Area). Copyright 1996 by the National Academy of Sciences. All rights reserved. Printed in the United States of America

OCR for page R1
Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences PANEL ON DATA AND RESEARCH PRIORITIES FOR ARRESTING AIDS IN SUB-SAHARAN AFRICA JANE MENKEN (Cochair), Population Studies Center, University of Pennsylvania JAMES TRUSSELL (Cochair), Office of Population Research, Princeton University KOFI AWUSABO-ASARE, University of Cape Coast, Cape Coast, Ghana JOHN G. CLELAND, Center for Population Studies, London School of Hygiene and Tropical Medicine CARL KENDALL, Department of International Health and Development, Tulane School of Public Health and Tropical Medicine PETER R. LAMPTEY, Family Health International, Arlington, Virginia EUSTACE P.Y. MUHONDWA, The Population Council, Dar es Salaam, Tanzania A. MEAD OVER, The World Bank, Washington, D.C. THOMAS C. QUINN, Infectious Disease Division, Johns Hopkins University DEBORAH L. RUGG, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, Atlanta, Georgia DANIEL TARANTOLA, François-Xavier Bagnoud Center for Health and Human Rights, Harvard School of Public Health JUDITH WASSERHEIT, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, Atlanta, Georgia MARIA J. WAWER, Center for Population and Family Health, Columbia University PETER O. WAY, International Programs Center, Bureau of the Census, U.S. Department of Commerce DEBREWORK ZEWDIE, The World Bank, Washington, D.C. National Research Council Staff BARNEY COHEN, Study Director TRISH DeFRISCO, Senior Project Assistant Liaison Representatives to the Panel BENOIT FERRY, World Health Organization, Global Programme on AIDS DEAN T. JAMISON, Board on International Health, Institute of Medicine

OCR for page R1
Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences Consultants to the Panel BETSY ARMSTRONG, Population Studies Center, University of Pennsylvania LORNA EDWARDS, Harare, Zimbabwe JENNIFER JOHNSON-KUHN, Department of Anthropology, Northwestern University SAHR KPUNDEH, National Research Council ALEXIS KUATE, Ministry of Health, Yaoundé, Cameroon ANNICK MADY, Association de Soutien à L'Autopromotion Sanitaire et Urbaine, Côte d'Ivoire DECLARE MUSHI, Tanzania AIDS Project, Dar es Salaam, Tanzania RICHARD ODINDO, Medical Education Department, Nairobi, Kenya ELIZABETH PISANI, Center for Population Studies, London School of Hygiene and Tropical Medicine CHRISTINE SOLOMON, Family Health International, Arlington, Virginia LAURA ZANINI, François-Xavier Bagnoud Center for Health and Human Rights, Harvard School of Public Health

OCR for page R1
Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences COMMITTEE ON POPULATION RONALD D. LEE (Chair), Departments of Demography and Economics, University of California, Berkeley CAROLINE H. BLEDSOE, Department of Anthropology, Northwestern University JOSE-LUIS BOBADILLA, World Bank, Washington, D.C. JOHN BONGAARTS, The Population Council, New York JOHN B. CASTERLINE, The Population Council, New York LINDA G. MARTIN, RAND, Santa Monica, California MARK R. MONTGOMERY, The Population Council, New York ROBERT A. MOFFITT, Department of Economics, Brown University ANNE R. PEBLEY, RAND, Santa Monica, California RONALD R. RINDFUSS, Carolina Population Center, University of North Carolina, Chapel Hill JAMES P. SMITH, RAND, Santa Monica, California BETH J. SOLDO, Department of Demography, Georgetown University MARTA TIENDA, Population Research Center, University of Chicago AMY O. TSUI, Carolina Population Center, University of North Carolina, Chapel Hill JOHN G. HAAGA, Director BARNEY COHEN, Program Officer TRISH DeFRISCO, Senior Project Assistant KAREN A. FOOTE, Program Officer JOEL A. ROSENQUIST, Project Assistant JOYCE E. WALZ, Administrative Associate

OCR for page R1
Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Harold Liebowitz is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Harold Liebowitz are chairman and vice chairman, respectively, of the National Research Council.

OCR for page R1
Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences Acknowledgments This report is the product of the efforts of many people. The panel was established under the auspices of the Committee on Population. The committee, chaired by Ronald Lee, was responsible for establishing the panel and for reviewing the final report. We are most grateful to the organizations that provided financial support for the work of the panel: The Bureau for Africa of the U.S. Agency for International Development and the Andrew W. Mellon Foundation. Besides providing funding, the representatives of these organizations were a valuable source of information and advice in the development of the panel's overall work plan. Special thanks are due to Claude Cheta, Hortense Deffo, Jean-Pierre Edjoa, Zakariaou Njoumeni, and others on the staff of the Institut de Recherche et des Etudes de Comportements (IRESCO) in Cameroon, who prepared two very useful background papers for the panel. Thanks are also due to Lorna Edwards, Alexis Kuate, Annick Mady, Declare Mushi, and Richard Odindo for their help implementing a questionnaire to non-governmental organizations in various sub-Saharan African countries; to Jeff O'Malley and Ioanna Trilivas, who participated in the design of the survey; and to Sahr Kpundeh, who managed its implementation. We are very grateful to the numerous researchers and policy makers in Africa who made time in their busy work schedules to talk to members of the panel during their mission to Africa in January and February 1995. We are especially indebted to Betsy Armstrong for her many hours of thoughtful editing, to John Belanger and Joanna Sadowska for checking and rechecking of the references, and to Claire Del Medico and Amy Worlton for

OCR for page R1
Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences preparation of the manuscripts. We are also grateful to Elizabeth Pisani and Christine Solomon for their substantial contributions to Chapters 4 and 5, respectively. Special thanks are due as well to Trish DeFrisco for her superb administrative and logistical support to the panel, to Jennifer Johnson-Kuhn for her valuable research assistance on Chapter 6, to Rona Briere for her skillful editing of the report, and to André Lux for his excellent translation of the Summary into French. We owe the greatest debt to Barney Cohen, who managed the entire process and ensured that we met our deadlines and whose intellectual contributions can be found in every chapter of the report, especially Chapters 1, 2, 6, and 7. We close by expressing our heartfelt appreciation to the members of the panel who contributed long hours and their special expertise to the crafting of this report. Kofi Awusabo-Asare and Daniel Tarantola prepared the initial draft of sections of Chapter 2; Thomas Quinn, Maria Wawer, and Peter Way prepared the initial draft of Chapter 3; John Cleland prepared the initial draft of Chapter 4; Peter Lamptey, Deborah Rugg, and Carl Kendall prepared the initial draft of Chapter 5; and Mead Over prepared the initial draft of Chapter 6. James Trussell and Jane Menken, Cochairs Panel on Research and Data Priorities for Arresting AIDS in Sub-Saharan Africa

OCR for page R1
Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences Contents     SUMMARY   1     RESUME   21 1   INTRODUCTION   45     Purpose of the Report,   45     Background,   46     The Panel's Task,   52     Organization of the Report,   53 2   SOCIETAL CONTEXT   57     Social Structure and Family Organization,   58     Sexual Behavior and HIV/AIDS,   61     Mobility,   64     Medical and Program Factors,   66     Economic Factors,   67 3   EPIDEMIOLOGY OF THE HIV/AIDS EPIDEMIC   69     Status of the Epidemic,   70     Modes of Transmission,   83     Remaining Gaps in Knowledge,   98     Recommendations,   103

OCR for page R1
Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences 4   SEXUAL BEHAVIOR AND HIV/AIDS   105     Sources of Information,   106     Questions of Methodology,   106     Patterns of Sexual Activity,   112     Sex-Related Risk Factors,   125     Sexual Practices and Beliefs,   131     AIDS Awareness,   136     The Role of Condoms,   141     Behavior Change,   148     Conclusions,   151     Recommendations,   152 5   PRIMARY HIV-PREVENTION STRATEGIES   155     Behavior-Change Intervention Program Design and Evaluation,   157     Intervention Evaluation,   162     A Typology of Intervention Programs,   163     Interventions Targeting Sexually Active Men,   166     Interventions Targeting Sexually Active Women,   173     Interventions Targeting Youth,   182     Perinatal Transmission,   190     Recommendations,   193     Annex 5-1: Selected AIDS Intervention Programs in Africa,   198 6   MITIGATING THE IMPACT OF THE EPIDEMIC   204     Introduction,   204     Impact on Persons with HIV,   207     Impact on Extended Family Members and Friends,   211     Indirect Impact of AIDS on the Rest of Society,   216     Attempts to Mitigate the Impact of HIV/AIDS,   240     Recommendations,   243     Annex 6-1: A Brief Survey of Nongovernmental Organizations Implementing Mitigation Programs in Sub-Saharan Africa,   245 7   BUILDING CAPACITY FOR AIDS-RELATED RESEARCH   251     Introduction,   251     Constraints on Research in Sub-Saharan Africa,   253     Recommendations,   267

OCR for page R1
Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences     REFERENCES   271 APPENDIX A:   PANEL VISITS TO THREE AFRICAN COUNTRIES, JANUARY 20-FEBRUARY 12, 1995   315 APPENDIX B:   BIOGRAPHICAL SKETCHES   340     INDEX   347