(World Health Organization, 1992c; Coates, 1993; Lamptey et al., 1993; Choi and Coates, 1994; Stryker et al., 1995). At the same time, however, data from various surveillance systems indicate that current interventions are probably not yet having a significant impact on the epidemic at the continent or even the country level (Lamptey et al., 1993; see also Chapter 3). Despite the fact that levels of AIDS awareness are extremely high across the continent (see Chapter 4), getting people to change their behavior is difficult. Denial, fear, external pressures, other priorities, or simple economics can sometimes keep people from adopting healthier life-styles.

There are many reasons why prevention efforts in Africa have not had as large an impact on the spread of the epidemic as desired. AIDS has struck the continent at a time when it is undergoing its worst financial crisis since independence. In some countries, other catastrophes—such as wars, droughts, or famines—have been more immediate and taken precedence over AIDS-prevention efforts. Throughout the continent, the overall magnitude of the response has been inadequate, and expectations about what could be achieved quickly have been unrealistic. A lack of indigenous management capacity and chronic weaknesses in the public health system have hindered the development and implementation of AIDS control programs. Individuals and organizations working against the spread of AIDS have had to face discrimination, complacency, and even persistent denial in the community. Many AIDS workers have become exhausted after struggling for so long against impossible odds; many others have died (Mann et al., 1992). Myths surrounding modes of transmission hinder the dissemination of correct knowledge and sustained behavior change (see, for example, Krynen, 1994; Nature, 1993; Ndyetabura and Paalman, 1994; Ankomah, 1994).

But getting people to change their behavior is not impossible. Indeed, health educators in Africa have had a fair amount of success in the recent past. For example, broad-based education campaigns have persuaded large numbers of people to have their children immunized against various childhood diseases and educated mothers to give their children oral rehydration formula during episodes of diarrhea. Of course, attempting to modify more personal behavior, such as sexual practices, is more challenging. Yet, family planning programs have been successful even in some of the most disadvantaged countries of the world (see, for example, Cleland et al., 1994). Even the most cautious reviews of behavioral interventions aimed at slowing the spread of HIV conclude that although most have not been rigorously evaluated, some approaches do seem to work (e.g., Oakley et al., 1995). It is important to have realistic expectations about what can and cannot be achieved. Behavior change will never be 100 percent effective: some individuals will never choose to protect themselves, while others will relapse into old patterns of behavior after just a short period of time (Cates and Hinman, 1992; Lamptey et al., 1993).

To increase the likelihood of success, interventions need to be culturally

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