Preventing and Mitigating AIDS in Sub-Saharan Africa Research and Data Priorities for the Social and Behavioral Sciences (1996) / Chapter Skim
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5 PRIMARY HIV-PREVENTION STRATEGIES
5 PRIMARY HIV-PREVENTION STRATEGIES
Pages 155-203
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From page 155... ...
How successful have these efforts been at preventing new cases of HIV infection? 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 ~ Social marketing is the application of commercial marketing techniques to achieve a social goal.
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From page 156... ...
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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From page 157... ...
In Africa, as elsewhere, HIV-prevention messages have included promotion of partner reduction, postponing of sexual debut, alternatives to risky sex, mutually faithful monogamy, consistent and proper use of condoms, better recognition of STD symptoms, and more effective health-seeking behav or. The purpose of the discussion in this chapter is to delineate opportunities for effecting beneficial behavior changes and to discuss how these opportunities might be realized.
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From page 160... ...
In addition, evidence that STDs may facilitate HIV transmission and the interconnectedness of STD and HIV transmission modalities and prevention (see Chapter 3) strongly suggest an important role for STD treatment, control, and prevention in AIDS prevention (Laga et al., 1991; Grosskurth et al., 19951.
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From page 161... ...
Although it would be highly desirable to design prevention programs that are based on a good understanding of the target population and the sociocultural, environmental, and structural context, few prevention programs are based on preliminary, or formative, research findings. As noted earlier, the groups most commonly targeted are those traditionally seen as at particularly high risk, such as truckers, uniformed service workers, commercial sex workers, or STD patients.
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From page 162... ...
Has that behavior change been sustained? And finally, has that behavior change succeeded in reducing the incidence of HIV?
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From page 163... ...
Insistence on pure scientific rigor may be counterproductive for HIV/AIDS-prevention interventions, where innovative methods and program designs are urgently needed, and prevention efforts must rely almost exclusively on behavior change (Coyle et al., 1991~. Examples of programs that have been implemented in sub-Saharan Africa and reported in studies are described briefly in Annex 5-1 and referred to in subsequent sections of this chapter.
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From page 164... ...
Several institution-based programs in Africa have demonstrated changes in risk behavior (Ngugi et al., 1988 t433; Loodts and Van de Perre, 1989; Kamenga et al., 1991; Allen et al., 1992b ~73; Mwizarubi et al., 1992 t123; Williams and Ray, 1993 [20-243; Wynendaele et al., 1995~. In Rwanda, for example, the initiation of an education, STD treatment, and condom distribution program for all military recruits led to a reduction in the incidence of urethritis (Loodts and Van de Perre, 1989; World Health Organization, 1992c t113~.
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From page 165... ...
In Uganda, an evaluation of a counseling and testing intervention found significant reported decreases in risk behaviors among both seronegative and seropositive individuals (Moore et al., 1993~.4 Community-based Programs Community-based programs use group interventions to reach communities. These interventions include the use of peer educators to reach sex workers or school-aged youth, use of traditional health providers to reach rural communities, or programs targeted to other community groups (see studies L1]
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From page 166... ...
Examples include media education programs, condom social marketing programs, and policy changes such as a regulation requiring condom use in brothels. Population-based programs may be targeted to such large segments of the population as adolescents, sexually active males, men and women with multiple partners, or all sexually active men and women (see studies [2]
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From page 167... ...
A person in a polygynous union in which all partners are supposed to have sexual relations only within that union is at somewhat higher risk of HIV infection than a person in a couple union, simply because there are more people who could potentially fail to stay faithful to that union. However, a person in such a polygynous union is at much lower risk than a person with multiple partners who themselves have multiple partners.
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From page 168... ...
HIV-prevention programs in such high-prevalence countries need to reach all sexually active men and women, but special attention still needs to be focused on particular groups of men who are high-risk transmitters. These population subsets include clients of sex workers, male STD patients, men in the uniformed services, truckers or other transport workers, men away from home, prisoners, and fishermen.
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From page 169... ...
The following case study from Zaire illustrates a population-based intervention targeted to African men in which behavior change was promoted, and condoms were made available, easily accessible, and affordable.5 Case Study The Zaire AIDS Media and Condom Social Marketing Project was initiated in 1988 (Population Services International, 1992 t171~. The program developed specific messages targeted to youth aged 12 to 19 and young adults aged 20 to 30.
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From page 170... ...
Although their estimate can be debated, the project investigators concluded that the program's 1991 condom sales prevented about 7,200 primary cases of HIV/AIDS (Population Services International, 1992 t173~. This estimate does not include a much larger number of secondary infections (infections acquired from the primary cases)
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From page 171... ...
Participation by external donors, the commercial sector, private voluntary organizations, nongovernmental organizations, and other community-based organizations is vital to any country's AIDS control program. Comparable levels of condom sales using mass media and social marketing have been achieved in several African countries, including Ethiopia, Cameroon, Cote d'Ivoire, Burkina Faso, and Zambia (Population Services International, 1994a)
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From page 172... ...
Condom social marketing programs in Africa have been very successful in reaching men at home, at work, in bars and hotels, and at truck stops (Mwizarubi et al., 1992 [121; Population Services International, 1994a)
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From page 173... ...
INTERVENTIONS TARGETING SEXUALLY ACTIVE WOMEN More than half of the estimated 11 million adults infected with HIV in subSaharan Africa are women (World Health Organization, 1994a, 1995J. This section addresses HIV-prevention programs targeting sexually active adult women; the following section addresses programs targeting adolescents, includ ing adolescent girls.
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From page 174... ...
. Rigid male-dominated sexual relations remove much of female sexual behavior, directly and indirectly, from women's own control, so that it is not subject to rational decision making.
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From page 175... ...
There are several reasons why such programs have had very little effect on HIV risk for most sexually active women. First, in some circumstances, a woman's exposure to HIV and STDs depends less on her own risk behavior than on the behavior of her sexual partner, over whom she has little control.
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From page 176... ...
Even these programs are neither as extensive nor as intensive as those in Thailand, for example, that target commercial sex workers (see, e.g., Hanenberg et al., 1994, and, Visrutaratna et al., 1995~. The largest and most difficult group to work with are women in marital unions, whose desire for pregnancy and lack of control over their spouse's sexual behavior pose a challenge to the design of effective interventions.
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From page 177... ...
As mentioned earlier, current efforts to reduce HIV transmission among women in Africa have focused on interventions targeted to commercial sex workers. The first case study below describes such an intervention; it is followed by discussion of an innovative empowerment program targeting women in Botswana.
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From page 178... ...
That this gradient remains after controlling for the effects of reported condom use and number of clients implies that STD treatment was a key factor in the decline in STD incidence. This program demonstrates that a comprehensive prevention program of behavior-change intervention, STD treatment, and condom provision can lead to a reduction in the incidence of both STDs and HIV.
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From page 179... ...
This omission may be one of the reasons why average condom use with clients did not exceed 60 percent. Case Study: A Community-based Intervention A two-stage study of the effectiveness of nurse-managed peer education and support groups for AIDS prevention among women was initiated in Botswana in 1990 (Norr et al., 1992; Tlou, 1995~.
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From page 180... ...
There are several commendable elements of this intervention. First, it is a community-based intervention targeted to women in both urban and rural areas, rather than solely to groups traditionally seen as high risk (such as commercial sex workers)
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From page 181... ...
Monogamous African women frequently report being exposed to HIV through their husbands' other sexual partnerships. · Interventions based on individual decision-making models do not take into account women's low power.
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From page 182... ...
Moreover, new technologies need to be developed for STD diagnosis and new programs implemented to reach infected women. · Women need to participate in the research and development of HIV intervention programs targeted to them.
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From page 183... ...
Further, even where delay in sexual debut is considered possible or desirable, there is a paucity of information available to adolescents about responsible, safe expressions of sexuality once sexual relations have been initiated. African adolescents, like adolescents elsewhere in the world, are often unable to discuss openly with their parents their questions, fears, and concerns about sex, marriage, and other adult topics.
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From page 184... ...
Policy-based intervention strategies are also needed to influence social norms and change sexual practices that facilitate the spread of HIV in this group, such as the sugar daddy syndrome, child marriage, incest, and rape. Principally because of limited resources, however, virtually no prevention programs in Africa have linked advocacy for protective laws and policies for adolescent girls with program design and implementation.
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From page 185... ...
Target Population Adolescents, like other age groups, are a heterogeneous group for which numerous multifaceted intervention strategies are required to achieve behavior change. Youth intervention strategies can target by access point (e.g., schools, clinics, media, street corners)
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From page 186... ...
be an additional component of prevention programs targeted to youth, particularly in view of the large numbers of AIDS orphans projected in many African countries. Innovative responses to the burgeoning burden on families of AIDS patients and AIDS orphans are being developed (Delehanty, 19931.
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From page 187... ...
The following case study highlights some of the issues and limitations discussed above and is representative of typical interventions targeted to African youth to date. Case Study In 1989, results from serosurveys in Addis Ababa, Ethiopia showed that 24 percent of female commercial sex workers between the ages of 12 and 16 were HIV-seropositive (Gebru et al., 1990~.
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From page 188... ...
Statistical significance, however, was not reported. A "considerable effect" on attitudes toward risky sexual behavior was noted among the experimental students.
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From page 189... ...
Although some parents fear that an early discussion of sexual behavior may make adolescents prone to earlier sexual debut, a review of the HIV/AIDS-education literature shows that sex/AIDS-education programs do not increase sexual experimentation or promiscuity (Ford et al., 1992; Grunseit and Kippax, 1993; Kirby et al., 1994~. In fact, some program planners in sub-Saharan Africa have been surprised to find that the majority of parents in their areas support AIDS education in schools (World Health Organization, 1994b)
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From page 190... ...
provide education for both adolescent males and females regarding their responsibilities in human reproduction and HIV transmission; (5) include child-to-child (peer educations teaching methods, whereby older children share knowledge with younger children and those not attending school; (6)
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From page 191... ...
, no definite conclusions can be drawn on the basis of available data concerning its potential protective effect with regard to perinatal HIV transmission. Furthermore, even if the efficacy data were to point to caesarean section as an effective prevention strategy, the increased risk and high cost associated with the procedure render it an infeasible alternative in all but a handful of teaching hospitals in the region.
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From page 192... ...
to the mother during pregnancy, labor, and delivery and then to the newborn during the first weeks of life. Data from a clinical trial involving 364 births to HIV-positive women showed a 67.5 percent reduction in the risk of HIV transmission attributable to AZT therapy (Centers for Disease Control, 1994~.
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From page 193... ...
KEY RECOMMENDATION 3. More evaluation research is needed to correlate process and outcome indicators- such as reported condom sales and behavior change with reductions in HIV incidence or prevalence.
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From page 194... ...
A microbicide is not a quick-fix substitute for the fundamental structural reforms necessary to achieve gender equality, but rather a temporary and partial response to this problem as it influences HIV transmission (Elias and Heise,
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From page 195... ...
Research is needed to determine the extent to which STDs help cause HIV infection, to examine the importance of the behavioral synergy of STD and HIV transmission, and to design more effective intervention programs. There is a need for assessment of the relative efficacy and feasibility of various interventions for STD treatment and sexual behavior change in reducing HIV transmission.
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From page 196... ...
Few intervention evaluations have adequately assessed effectiveness in terms of behavior change or seroincidence declines, much less cost-effectiveness. Results of evaluation studies currently in progress in several countries in sub-Saharan Africa (Family Health International/AIDSCAP, 1994)
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From page 197... ...
Given the rapid spread of HIV among women in sub-Saharan Africa, perinatal transmission continues to have a major impact on infant and child morbidity and mortality among populations with a high HIV seroprevalence. Studies using modified treatment regimens with Zidovudine (AZT)
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From page 198... ...
Malawi Institution-based (hospital) Commercial sex · Behavior-change interventions workers · Condom provision Ghanaian youth · Behavior-change interventions 500,000 couples in · Behavior-change interventions Guinea Female prostitutes · Condom provision · Family planning · Behavior-change interventions and women · HIV testing and counseling attending clinics · Free condom provision General population · HIV/STD counseling (mostly married males)
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From page 199... ...
· The proportion of sexually active 15-year-olds fell from 44 to 27%. · Men reported an 18% decrease in sexual partners over 3 months.
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From page 200... ...
1 9. Zambia · Behavior-change interventions · Condom provision · Free HIV testing and counseling Military recruits · Behavior-change interventions · Condom provision Truck drivers and · Behavior-change interventions their partners · Condom provision Young adults aged · Condom promotion and 13-39 in rural provision by trained peers and communities community health workers The general population; 400,000 workers · Behavior-change interventions · Condom provision 149 HIV- · HIV testing and counseling discordant couples · Free condom provision Commercial sex workers in Kinshasa 13 million urban youth and their parents 2 million people Population-based · Behavior-change interventions · STD treatment · Condom provisions · Counseling and testing · Behavior-change interventions · Condom provision · Behavior-change interventions · STD treatment · Policy component · Survival skills workshop General · Behavior-change interventions population · Condom provision
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From page 201... ...
Population Services International, 1994d · Three STDs treated at four clinics declined by Mouli, 1992 54, 53, and 42%, respectively.
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From page 202... ...
(workplace) youth · Condom provision · Income generation for commercial sex workers 22.Zimbabwe Institution-based 15,000 male and · Behavior-change interventions (Eastern (workplace)
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From page 203... ...
· The program was expanded to 10 additional workplaces. · There were 2.5 million condoms distributed in 2 years · Consistent condom use in commercial sex workers rose from 5% in 1989 to nearly 50% in 1992.
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