The most important concern in the HIV & AIDS field is the task of prevention. The epidemiological measures of prevalence and incidence illustrate the imperative to invest in this area.
Prevalence refers to the total number of infected people within a population at a certain point in time. HIV prevalence can be affected by variation in incidence levels (the number of new infections), the deaths of infected people (which lowers overall prevalence), and by treatment adherence (which, even at low levels of incidence, contributes to an increase in prevalence over time). HIV incidence varies according to the measurement period and methods used (whether household or antenatal clinic surveys, for example). Both prevalence and incidence differ across regions and age groups, and across gender cohorts as well. The control of both depends mostly on the adoption of preventive interventions that reduce new infections. Therefore, decreases in incidence and thereby in prevalence depend on effective preventative interventions. This CAI discussion paper delves into the issues that characterise the imperative of prevention, weighing the benefits and challenges associated with each.
Treatment as prevention
One preventative intervention involves treatment employed as part of prevention. In this case, prevention and treatment cannot be considered separately. Effective treatment can prevent some new infections - as in the case of vertical transmission from mother to child, where it significantly reduces the risk of transmission to the baby due to the decrease in the viral load of the mother. However, treatment intervention does not carry the same kind of preventative effect with regard to transmission via sexual intercourse or drug injection. In these later cases, HIV incidence and prevalence can be lowered more effectively through the adoption of measures that empower people to access and control their health care.
There are two key issues to consider regarding prevention:
1. The first aspect to consider to carry out effective prevention is related to the accessibility to preventive tools such as educational campaigns run via radio and TV; to places where the prevention can take place, for instance in schools, health centres or urban environments; to products such as free male and female condoms or eventually the recently unveiled tenofovir microbicide gel (not yet on the market); and to diagnostics such as the HIV antibody test accompanied by counselling, for instance. However, usually not everyone within a targeted population has access to them. Moreover, some populations have not been even targeted or face the consequences of a late response to the HIV&AIDS reality.
The situation in Lesotho serves as an example illustrating the lack of access to prevention and treatment. Although the first AIDS cases there were reported in the late 1980s, leading to the instigation of a National Prevention Programme, it was only after the year 2000 that a structured Governmental strategy was put in place with the aim of increasing condom use alongside provision of care for the infected population. The late response was influenced by poor finances and infrastructure combined with extreme social discrimination against women in a male-dominated society. Traditionally, women lacked political, financial and social rights. Statistics indicate that, in 2008, women made up 56% of the infected adult population.
HIV prevalence did not rise significantly between 2000 and 2003; however, the goal of reducing HIV prevalence by 5% by 2003 was not achieved. Then in 2003 HIV & AIDS was declared a national disaster. Only in 2006 did Lesotho pass the Legal Capacity of Married Persons Act, which grants equal status to married women.
Lesotho's AIDS effort is now guided by the National AIDS Policy and Strategic Plan for 2006-2011. The Government is focusing on HIV prevention through condom promotion, prevention of mother-to-child transmission, and providing anti-retroviral treatment for the infected population.
2. The second prevention issue involves developing appropriate models for corresponding prevention interventions:
Some models aim to instigate behaviour change by adopting a strong informative approach. These models have proven to be effective to some extent, especially in educating people about the risks of infection, means of transmission, the nature of the HIV virus and its relation to AIDS, as well as warning them about the consequences of living with HIV & AIDS. However, this approach is weak in answering the question: why is it that well-informed people expose themselves to HIV? Sometimes, people seem to ignore information that had been learnt, tune it out. Why do we act in ways that also endanger health?
Alternative models focus on a relational approach, aiming to achieve structural attitude changes towards the way people deal not just with HIV & AIDS, but also with relationships, care for oneself and others, sexuality, losses, choices and death. All these challenges are to some extent feared by human beings, though not necessarily at a conscious level. One of the key focuses of this approach is the issue of acceptance of one's natural fears and vulnerability to danger, which experience and studies have shown to be greatly denied. Where denial occurs, adoption of a distant attitude towards the reality of HIV & AIDS is observed.
Africa offers numerous examples of planned mass-media interventions that have been successful for over a decade as preventive tools. These interventions are part of a model that combines entertainment with education, known as ‘edutainment.' The soap opera, Soul City, launched in 1994, which initially targeted disadvantaged South Africans, now airs on prime time TV and attracts a huge and diverse audience. The show strongly emphasises the HIV & AIDS issue bringing to life through the characters' experiences situations in which people are faced with the challenging demand of making choices that would prevent them or not from infection and would also determine the course of their relationships. In 2002 a TV programme for young children, Takalani Sesame, introduced an HIV-positive character whose mother had died of AIDS. In different ways, these shows aim at addressing social issues like exclusion, HIV & AIDS and violence, and are based on the reality and demands of their own region. Takalani Sesame is an adaptation to the African reality of the original North American puppet animation, Sesame Street.
These programmes are good examples of interventions that consider personal background and local culture as important aspects in the implementation of prevention strategies. Models strongly based on behaviour change rather than on aspects related to subjective instances, like the history of peoples' relationships, have shown limited reach in more structural changes. An example of this is the approach to the African ABC strategy also launched in the 1990s, based on the premises of ‘abstinence,' ‘be faithful' and ‘condomise.' There is no doubt that the informative dimension should always be presented when talking about HIV & AIDS, but would it not be more effective to broaden the scenario in which the information is given?
Brazil offers an alternative to what seems to be a more traditional approach to preventive interventions of HIV & AIDS. The South American country was one of the first in the world to stop associating AIDS with death in its mass media campaigns, emphasising aspects like human rights and the incentive of self-esteem. Moreover, a variety of groups, like men who have sex with men or women that have sex with women, as well as taboo subjects, like women that are ashamed of buying condoms, have been targeted in mass campaigns. These broader approaches illustrate ways through which HIV & AIDS can be dealt with as an issue related to life experiences, choices and relationships.
Preventative measures are not limited to mass-media programmes. Group works within institutions like schools, churches, health services, and test centres, amongst others, are also part of the wide range of possible interventions. Furthermore, HIV&AIDS-related concerns do not necessarily have to be dealt with as an issue in itself. They can be included in regular school courses or in workshops related to sexuality, relationships and life planning, for example. Playful and informal (personal) approaches combined with clear information creates an understanding and intimate atmosphere that make the service users more confident in sharing information and confronting their own fear of taking the serological test. This approach can transform the socio-political demand of engaging people in taking the HIV test into a personal demand. Regarding implemented strategies, interventions based on the training of multiplication agents for the prevention of HIV that pass on their knowledge and experience to other member of the community have been successful in Brazil, for example.
The most efficient way of achieving the target of prevention is through the adoption of a relational approach. Information is not enough and can be easily forgotten or denied. In order to think about personal sexual behaviour, people need to be touched: touched by a sense of vulnerability, and by the need of caring for others. Furthermore, it can be useless to insist on a pure informative approach towards well-informed people.
Trained personnel are needed to deal with such an approach. Financial investment, social and political engagement and appropriate strategic planning need to continue taking place in order for people to respond effectively to the HIV & AIDS pandemic. Participation of community leaders or other community members in the development of prevention programmes is crucial in order to help health and business professionals to see and listen to community demands form a closer angle and define strategies realistically. In addition, it is generally acknowledged that prevention is more cost-effective than treatment and the development of new medications and technology to deal with HIV & AIDS itself. Finally, it is crucial to consider, design and implement interventions that target local communities within African countries, since continental interventions have been successful to some extent but have not seemed to be able to cover regional specificities.
Written by: Joana Finkelstein Veras (1)
(1) Contact Joana Finkelstein Veras through Consultancy Africa Intelligence's HIV & AIDS Unit (email@example.com).