As suggested earlier, despite the many limitations inherent in attempting to evaluate the effectiveness of interventions aimed at HIV prevention, clear evidence is emerging that such efforts can be successful, particularly among higher-risk groups. 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 subcontinent or even the country level. Despite the fact that levels of AIDS awareness are extremely high in sub-Saharan Africa, getting people to change their behavior is difficult. Denial, fear, external pressures, social and sexual norms, other priorities, or simple economics can keep people from adopting healthier life-styles.
Yet getting people to change their behavior is not impossible. Indeed, health educators in sub-Saharan Africa have had a fair amount of success in recent years. For example, broad-based education campaigns have persuaded large numbers of people to have their children immunized against various childhood diseases and have 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. 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. At the same time, it is important to have realistic expectations about what can be achieved. Behavior change will never be 100 percent: some individuals will never choose to protect themselves, while others will lapse into old patterns of behavior after a short period of time.
To increase the likelihood of success, interventions need to be culturally appropriate and locally relevant, reflecting the social context within which they are embedded. They should be designed with a clear idea of the target population and the types of behaviors to be changed. In turn, recognized impediments in the social environment to behavior change probably need to be specifically addressed. Behavior-change interventions should include promotion of lower-risk behavior, assistance in development of risk-reduction skills, and promotion of changes in societal norms. It must be noted that in sub-Saharan Africa, there is an urgent need to design ways of targeting women and adolescents for prevention messages.
Basic principles of successful intervention programs include the following:
learning about and adapting to local conditions,
ensuring community participation,
carefully targeting the audience,
identifying effective strategies and messages,