SOCIAL SCIENCE
RESEARCH ON HIV/AIDS
Solveig Freudenthal
November 2001
III. Research on protection of young people and future generations 5
Gender and sexual and reproductive health 6
Condom use 8
HIV/AIDS/Sex education 10
Peer education 11
IV. Health care research 13
Access to health care 14
Home-based care 15
Access to drugs 15
V. Research on and for policy 17
Stigma and discrimination 20
Violence against women and children 20
NGOs and CBOs 21
VI. Research on social and economic consequences 22
Orphans 23
Agriculture 23
Education 24
Business 24
Action research: participatory and interactive methods 25
HIV prevention and local contexts 26
Gender sensitive research 26
Mitigation and poverty reduction 27
Scaling up 27
Research on protection of young people and future generations 27
Health care research 28
Research on and for policy 28
Research on social and economic consequences 28
Challenges for the future 29
Acronyms and abbreviations
AIDS Acquired Immuno-Deficiency Syndrome
ARV Antiretroviral
CBO Community Based Organisation
CEDAW The Convention on the Elimination of all forms of Discrimination Against Women
GDP Gross Domestic Product
GNP Gross National Product
HBC Home-Based Care
HIV Human Immunodeficiency Virus
IEC Information, Education and Communication
IMF International Monetary Fund
KAP Knowledge, Attitude, Practice
NAPCP National AIDS Prevention and Control Programme
NGO Non-Governmental Organisation
SAP Structural
Adjustment Programme
SAREC Department for Research Cooperation at Sida
Sida Swedish International Development Cooperation Agency
SRH Sexual and Reproductive Health
STD Sexually Transmitted Disease
TB Tuberculosis
UNAIDS Joint United Nations Programme on HIV/AIDS
UNFPA United Nations Population Fund
UNICEF United Nations International Children’s Emergency Fund
WHO World Health Organisation
Executive
summary
Around 22 million people have died from AIDS since the beginning of the epidemic and there are approximately 36 million people infected with HIV in the world today, of which about 70 percent live in Sub-Saharan Africa. Rates of newly acquired HIV infection are highest in the 15-19 age group, and the majority of infections in this group are girls. Concerted national and international efforts are therefore needed to prevent the spread of HIV, mitigate the effects of the epidemic and to break the silence that still continues to surround HIV in many countries.
In the early years of the epidemic, preventing HIV was seen as an issue of changing individual behaviour, or changing the behaviour of individuals in specific high-risk groups. Educational campaigns were initially directed to individuals, who were informed which behaviours would put them to risk for HIV. But this focus neglected the social contexts within which particular actions become meaningful and interventions often failed to elicit behaviour change. Social scientists therefore began to investigate individual behaviour as guided by a shared culture. It became more and more apparent that an understanding of the social, political and economic context within which AIDS is occurring is critically important.
Social scientists have made significant research contributions by examining how individuals and groups perceive risk and how culture influences risk behaviours in a wide variety of settings. Unfortunately this knowledge has seldom been disseminated in fora directed to policy makers. To date, most prevention efforts are still focusing on increasing individual awareness about risks of transmission and promoting individual risk reduction. Few HIV prevention programmes have been designed where the socioeconomic and sociocultural contexts in which individuals live are taken into consideration.
In studying economic and political settings connected with high prevalence of HIV/AIDS, social scientists have come to the conclusion that there is a clear link between levels of HIV/AIDS and poverty throughout the world. Whilst an impressive amount of research has been undertaken to study the impact of the epidemic, less has been achieved in mitigating its effects of deepening poverty and the rolling back of development gains. Discussions on the implications of HIV/AIDS for national development and policy have often been limited and both national and global development targets and goals have been formulated without taking into account the added challenges resulting from sharp increases in AIDS-related mortality rates.
To comprehend the behavioural dynamics of STD/HIV transmission, it is necessary to understand cultural constructions of women and men’s sexuality as well as the socio-economic context. A number of studies have shown the importance that gender roles play in sexual and reproductive health. Particularly, how ideologies of male dominance result in power imbalances that influence sexual risk behaviour and create barriers to behaviour change. A major criticism of some early AIDS prevention initiatives was that they failed to give enough attention to women’s economic and social subordination and thus the implications for their ability to negotiate safe sex. There is an increasing interest in “male involvement” studies in development research, but there is also a risk that “masculinity” studies become as one-sided as the previous “women in development” approaches. Research should rather investigate both women and men and the interaction between them.
As this literature review shows, substantial social science research has been conducted on HIV/AIDS during the last 20 years. There are of course research gaps, but much is already known. We know what kinds of socio-economic contexts are driving the pandemic (in which poverty and gender inequality are the main forces) and that an interplay of factors are facilitating sexual transmission. Among these factors are: little or no condom use; a large proportion of an adult population with multiple partners; overlapping (as opposed to serial) sexual partnerships; wide sexual networks (often due to work migration); women’s economic dependence on marriage or poverty driven commercial sex work and their lack of power in negotiating sexual relationships; age differences between sexual partners - typically older men and young women or girls; high rates of sexually transmitted infections, especially genital ulcers. At the same time research shows that most people in Africa have a good knowledge about AIDS.
Sida/SAREC has identified four main areas of focus for social science research on HIV/AIDS: (1) protection of young people and future generations; (2) health care research; (3) research on and for policy and (4) the social and economic consequences of the HIV/AIDS epidemic. Within these four areas, aspects that need further research are:
In terms of young people, specific socio-economic contexts, in particular an understanding of gender differences in the socialisation of young people into sexuality. Furthermore, problems of communication about sexuality and sexual negotiations need to be addressed. As condoms still provide the most useful means of preventing HIV transmission, more research is needed on encouraging consequent condom use. Sex/health education for schools needs support and further research on the impact of media health messages is necessary. There is also a need for more research on youth friendly sexual and reproductive health services. Turning to health care, research is needed on the relation between health sector reforms and the HIV/AIDS epidemic. What are the essential elements of public and private health systems that can successfully mitigate the rapidly expanding pandemic? What kinds of counselling and testing services need to be in place for AIDS drugs to benefit people. Moreover, there is a need for further research on how individuals’ compliance with anti-retroviral (ARV) therapy can best be achieved. A main factor in research on policy, is that of compiling and comparing lessons learned in approaches by countries/communities that have been relatively successful in containing the epidemic and/or mitigating its effects. In terms of socioeconomic consequences, how are local economies coping with changes in the labour force (on household, village and district level)? How are educational and health systems carrying out their mandates despite the human losses due to AIDS? There is also need for research on AIDS and the workplace.
These research gaps are however not the main obstacle to successful HIV/AIDS prevention and mitigation programmes in Africa. The knowledge of how to prevent HIV transmission exists, but research results are seldom being implemented in HIV prevention and care programmes. The key challenge for the future is therefore to establish strong links between research, policy and implementation. All research proposals should include plans for dissemination of research results to policy makers. And policy makers in turn must show commitment and willingness to listen to researchers and use research results in the design of projects and programmes. African regional research networks could play an important role in co-ordinating systematic research and develop fruitful dialogue and collaboration with governmental institutions, such as HIV/AIDS councils and policy makers.
I.
Introduction
The AIDS pandemic, now at the beginning of its third decade, is one of the most devastating diseases of our time. Concerted national and international efforts are needed to prevent the spread of HIV and to break the silence that still continues to surround the disease in many countries. The disaster caused by HIV/AIDS is unique because it deprives families, communities and entire nations of people at their most productive ages. The epidemic is deepening poverty, reversing human development achievements, worsening gender inequalities, eroding the ability of governments to maintain essential services, reducing labour productivity and supply and hampering economic growth in the countries worst affected for decades to come.
Around 22 million people have died from the disease since the beginning of the epidemic (UNAIDS Dec. 2000). The UNAIDS programme estimates that 5.3 million people became infected with HIV during year 2000, and that there are approximately 36 million people infected with HIV in the world today, of which about 70 percent live in Sub-Saharan Africa. UNAIDS further estimates that close to 15,000 people are infected with HIV every day. The proportion of female infected is becoming increasingly significant, with 55 per cent of the infections in Sub-Saharan Africa in 1999 occurring among women (UNAIDS, Dec. 2000). Rates of newly acquired HIV infection are highest in the 15-19 age group, and the majority of infections in this group are girls. The consequence of increased deaths of young people in some African countries has been to decrease life expectancy at birth by 15 to 20 years in southern Africa and 5 to 10 years in other parts of sub-Saharan Africa (WHO 2000).
As HIV/AIDS is an increasing health and development problem in the world, it will continue to occupy a significant place in Swedish development co-operation. The Swedish Government adopted in 1999 a strategic framework that should guide continued support to research on HIV/AIDS. The strategy document “Investing for future generations” (1999) describes the stance the Swedish Government has taken as part of international efforts to prevent and mitigate the impact of HIV/AIDS. The strategy focuses on activities and support that address both immediate and underlying causes of the HIV/AIDS epidemic as well as its immediate and long-term effects. Four strategic goals are established:
· To enable people to protect themselves against HIV infection (HIV Prevention)
· To encourage greater political commitment to HIV prevention programmes (Political Commitment)
· To allow people infected and affected by HIV/AIDS to pursue their lives with quality and dignity (Care and Support)
· To develop coping strategies to alleviate long-term effects (Coping Strategies)
Prevention in a broad sense and with future generations in mind is the mark of Swedish involvement. An emphasis has been placed on proactive involvement in order to reduce the spread of HIV and other related sexually transmitted diseases, and with a focus on youth. The framework stresses a multi-sectoral approach and views HIV/AIDS not only as a health problem, but also as a general development issue. Different kinds of research, in national and international cooperation, have a key role to play in the future control of the pandemic.
Sweden is but one contributor among many and it is therefore necessary to set priorities and choose areas of focus for future involvement in which inputs can achieve best results. In the light of earlier experiences and of developments during the past years’ preparatory work, a strategy for continued research cooperation was approved by Sida’s Research Board in1999. Highest priority is to be given to research that aims at:
High priority will also be given to:
The decisions on funding for biomedical research have been made already and are mainly continuations of previous support to different research groups. For the social sciences, further preparatory work was deemed necessary. In particular, the need was stressed for a programme of support to be firmly rooted in African research communities. It was thus decided that preparatory work towards a programme for the social sciences, should first and foremost investigate the possibilities of support to established African regional networks and associations.
Sida/SARECs strategy document for research on HIV/AIDS
(1999:19) has delineated four main areas for social science research:
1.
Research
aiming at protection of young people and future generations
2.
Health
care research
3.
Research
on and for policy
4.
Research
on social and economic consequences
Within all four of these areas there are aspects that have been quite well researched and aspects that need more work. This review paper has been commissioned by Sida/SAREC, as a first step to identify what has been done, what needs to be done and how research can support communities, service providers, policy formation and decision-making with an emphasis on Africa. The review is based on almost 200 published and unpublished documents, but it is not meant to be exhaustive. It tries to highlight key trends, themes and issues that have emerged from recent literature within the four areas. The review begins with an overview of social science research on HIV/AIDS in Africa with a focus on poverty and gender inequality as factors driving the pandemic. Main trends in social science research within each of the four areas, along with lessons learnt, are then described. A number of the issues are crosscutting, thus the choice of heading is at times arbitrary. Thereafter, the issue of methodological approaches to HIV prevention is examined. In the last chapter, further social science research needs are outlined and challenges that need to be met for HIV/AIDS prevention and mitigation programmes to be successful are highlighted.
In the early years of the epidemic, preventing HIV was seen as an issue of changing the behaviour of individuals, particularly in high-risk groups. Survey research was initiated to locate individual risk behaviours in knowledge, attitudes and practices (KAP) studies. Epidemiological models identified routes of transmission and patterns of transmission. Groups or categories of persons at highest risk were identified and interventions were specifically targeted towards those groups; e.g. groups of prostitutes, truck drivers, or injection drug users (Norr et al. 1992, Glick-Schiller et al. 1994). )
Psychological and social psychological theories such as the Health Belief Model (Becker and Joseph 1974, 1988), Social Learning Theory (Bandura 1977) and the Theory of Reasoned Action (Ajzen I and Fishbein M 1980, Fishbein and Middlestadt 1987) were applied in efforts to improve the educational campaigns (Friedman and O'Reilly 1997). These approaches posit that appropriate information, about risk behaviour and the risks involved in unprotected sex, to an individual will result in behaviour change. Such models and theories were developed in North America and Europe and have been criticised, even when applied in Northern industrialised societies, for neglecting the social contexts in which particular actions become meaningful (Singer and Weeks 1996) as well as for the assumptions they make about rationality (Aggleton 1996). Applying these models and theories to an African context poses even greater difficulties. For example, social norms, duties and obligations may be different in strength and kind to those encountered in Northern societies. Furthermore, these models may be inadequate in explaining sexual risk-taking in contexts where decision-making may be rooted in group processes of understandings and norms (Aggleton 1996).
Many social scientists therefore turned away from individual risk behaviour approaches and began to investigate behaviour as guided by cultural contexts (Schoepf 1991, Treichler 1992, McGrath et al. 1993, Streefland 1995, Connors and McGrath 1997). For example, notions of what it means to be a ‘real man’ in a particular social context can powerfully influence sexual risk behaviour. “Real men take risks”, as one man pointed out in a study from Nigeria (Orubuloye et al 1993). Furthermore, what may seem to an outsider to constitute sexual risk-taking, may be viewed differently from the perspective of the people involved. Such behaviour may be seen as quite normal and rational showing that one is "respecting or trusting one’s partner" (Aggleton 1996).
Social scientists have made significant research contributions by examining how individuals and groups perceive risk and how culture influences risk behaviours in a wide variety of settings (Ingstad 1990, Ford and Koetsawang 1991, McGrath et al. 1993, Frankenberg 1995, Schoepf 1995, Preston-Whyte 1995a). Unfortunately this knowledge is seldom disseminated with the goal of reaching and informing policy makers. To date, most HIV prevention efforts still focus on the individual’s perceptions and behaviour change. Few programmes have been designed where the social and economic context in which individuals live are taken into consideration (Collins and Rau 2000).
Substantial research has been undertaken to study the impact of the epidemic, but less has been achieved in mitigating its effects. Discussions on the implications of HIV/AIDS among development experts and policy makers have been limited and both national and global development targets and goals have often been formulated without taking into account the added challenges resulting from sharp increases in AIDS-related mortality rates (Loewenson and Whiteside 2001).
AIDS is often called a disease of poverty. (Ankrah 1991, Schoepf 1991, Farmer et al. 1996, Aggleton 1996, Connors and McGrath 1997, UNAIDS/99.16E, Collins and Rau 2000). Poverty causes work migration and urban drift, and it causes women to engage in risky sexual practices, just to name a few examples. Many rural impoverished households have household members who work in urban or industrial areas or on large-scale, commercial farms. Being separated from their families for long periods of time, these people often find new sexual partners, or form new families. But employment opportunities in towns and industrial areas are usually very limited and this leads to the creation of an urban class of very poor men and women whose way of life may involve many sexual partners. For women, this can be a survival strategy, and as long as there are no realistic alternatives in terms of other income generating activities, women will continue engaging in risky sexual activities (Packard and Epstein 1991; Schoepf 1995; McGrath et al. 1993, Preston-Whyte 1995b, Aggleton 1996, UNAIDS 2000, Loewenson and Whiteside 2001, Collins and Rau 2000).
Kane et al (1993) gives an example from a study in some villages northern Senegal of the epidemiological relationship between migration and HIV status. The study found that 27 per cent of male work-migrants and 11 per cent their spouses were infected with HIV. In a control group of men and their wives who had not travelled outside Senegal in the last 10 years, only one man and one woman was infected with HIV.
Gender refers to the socially constructed relationship between women and men. Gender determinants are deeply rooted in social norms that ascribe to women and men a distinct set of productive and reproductive roles and responsibilities. Thus to comprehend the behavioural dynamics of STD/HIV transmission, it is necessary to understand cultural constructions of women’s and men’s sexuality as well as their socio-economic context (Kippax et al. 1995; Lear 1995; Orobaton and Guyer 1994; Santow 1995; Taylor 1995). A number of studies have shown the importance that gender roles play in sexual and reproductive health. Particularly, how ideologies of male dominance result in power imbalances that influence sexual risk behaviour and create barriers to behaviour change (Catania et al. 1992; Haram 1995; Obbo 1995; Lear 1995; Paivia 1995; Pleck et al. 1993; Silberschmidt 1991; Talle 1994; Wood and Jewkes 1997, UNAIDS 1999).
A major criticism of some early AIDS prevention initiatives was that they failed to give enough attention to women’s economic and social subordination and the implications of this for their ability to negotiate where, when and how sex took place (UNAIDS 1999). McGrath et al. (1993) gives an example from Uganda, where they found that women were well aware of the risk reduction messages given by AIDS control programs, but because these messages failed to provide them with realistic alternatives, they continued to be at risk. People were told to use condoms, but since these women’s partners refused to have sex, if the women insisted that they use condoms, this risk reduction message offered no real option for reducing risk of infection. Similar findings have been reported from other studies in many other countries such as Uganda, Zambia and Zaire (Wallman 1998, Bond and Dover 1997, Schoepf 1995).
The exchange of gifts has considerable significance in the creation and maintenance of social relationships, especially sexual relationships among many groups of people in Africa. Haram (1995) reports from a study amongst the Meru people in northern Tanzania, that for most young Meru women, sexual relationships are their only means to gain access to items like soap, body lotion, shoes, nice dresses and money. Before marriage, both women and men tend to have many sexual partners. According to Haram, there is high level of AIDS awareness among the Meru, but many women are still tempted to enter sexual relationships because of the gifts men can offer them. From a Western point of view gifts in return for sex may appear close to sex working, but it is not. People make a sharp delineation between gifts and the purchasing of sex. Gifts occur within a relationship, however short, rather than as a commercial transaction (Dover 1995).
Approaching sexual and reproductive health through interventions that target on changing negative aspects of gender roles is part of current international policy. Female empowerment was a major issue in the Cairo International Conference on Population and Development’s Programme of Action (UNFPA 1995). Women’s rights were linked in the document to promoting attitudes of male responsibility through greater participation of men in sexual and reproductive health, as well as in family welfare. This latter goal, reflects an increasing interest in “masculinity” and “male involvement” studies in development research (Hawkins 1992; Kippax et al. 1994; Orobaton and Guyer 1994; Ray et al. 1998; Setel 1996; Sweetman 1997; Silberschmidt 1991; Talle 1995). However, there is a danger that “masculinity” studies become as one-sided as the previous “women in development” approaches. Research should rather investigate both women and men and the interaction between them.
Promoting safer sexual behaviour and gender equality among young people is an important goal in the Swedish strategy document “Investing in future generations”(1999:34). Most young children in Africa are still not infected with the HIV virus and youth have a better potential for sexual behaviour change than older people. What then is already known about these issues and in which areas is research still needed?
A number of studies have been carried out in East and Southern Africa to determine trends in sexual and reproductive health knowledge, attitudes, practices and behaviour among young people. These studies show major gaps in many young people's knowledge of sexuality and reproduction (Baggaley 1996; Kasule et al. 1997; Lema and Hassan 1994; Macwang’i 1993; Mbizvo et al. 1995; Ndubani 1998, Muvandi et al 2000). Major obstacles to improving young people’s knowledge of sexual and reproductive health are social attitudes, particularly the prohibitive silence around sexuality and the censure of pre-marital sexual relations.
Studies show that contemporary age of sexual
debut has decreased in many African countries. For example, in Zambia sexual
debut can be as early as 10 years for girls and 12 years for boys and by their
mid-teens most Zambian adolescents are sexually active (Feldman 1993; Webb
1997; Zambia DHS 1996; Muvandi et al 2000). Other studies from East and
Southern Africa show similar data on early sexual activity (Illinigumugabo et
al. 1994;Helitzer-Allen 1994; Matasha et al. 1998; Mbizvo et al. 1995; Tawuo et
al. 1998). Given the age differences found between young girls and some of
their sexual partners, early sexual debut obviously exposes the young sexually
active population to STDs and HIV. Early sexual debut also has implications for
knowledge about sex and reproductive health and for sexual negotiation.
Men’s and women’s knowledge, attitudes and related sexual behaviour are highly influenced by gender norms and expectations, which can contribute to an individual’s risk of HIV infection. Many HIV prevention programmes continue to work solely with women in an attempt to empower them in sexual relationships. But since women’s ability to control and sustain their sexual health is often limited, it is important to involve men as well in prevention efforts. As argued by Long and Ankrah (1996): “Women’s empowerment cannot be achieved by women alone, but requires the support of men for its successful realisation”. Research suggests that men usually control sexual decision-making. In many cultures, coercive sex and sexual violence are not unusual (Wood and Jewkes 1997, Muvandi et al 2000). Sexual responsibility among men is therefore central to the health of both men and women.
According to
many researchers there is a need to generate knowledge on young men and women’s
perceptions of sexuality and gender relations (Bledsoe and Cohen 1993; Kippax
et al 1994; Lear 1995; Obbo 1995; Paiva 1995; Webb 1996 et al.; Ray et al.
1998). This type of research is not easy to conduct and Orubuloye et al (1997)
argue that there has been a constant failure to enquire into men’s belief
systems in relation to sex and sexuality. Research is needed on what messages
appeal to men and what the key factors are in motivating men to engage in safer
sexual practices. There is also a need for
research focuses to go beyond the ways in which dominant norms and youth
culture place young peoples’ sexual health at risk, and to also investigate the
ways that particular young people resist those norms (Aggleton and Campbell
2000).
In many
African societies speaking about sex is traditionally taboo between parents and
children. Previously, sexual education was given through initiation rites and/or
by the grandparental generation. These practices are dwindling, though there
are some ongoing experiments in utilising tradition for sexual education
(Ahlberg 1997; Fuglesang 1997). In Zimbabwe information about puberty and
growing up was traditionally the responsibility of the paternal aunts for girls
and the maternal uncle for boys. Two studies (Basset and Sherman 1994; Wilson
et al. 1995) suggest that this system is no longer functioning because of the
mobility and divisions in education and wealth in modern society. These days
young people often find out about sexuality and reproductive health from varied
and sometimes unreliable sources such as the media, friends and older peers
(Ahlberg 1994; Mudenda 1992). This results
in a combination of some knowledge along with misconceptions about sexual and
reproductive health problems including STD/HIV (Baggaley 1996; Kasule et al.
1997; Ndubani 1998). A further problem is
that formal information given to young people does not always meet their
expectations and concerns (Ahlberg 1994, 1997; Baggaley 1996; Fuglesang 1997;
Mudenda 1992; Williams et al. 1997). Religious organisations tend to be
particularly unrealistic in their teachings about sexuality, forbidding
pre-marital sex and contraception despite the fact that most adolescents are
sexually active (Ahlberg 1994; Baggaley 1996).
The impact of gender roles on communication in relation to sexuality has been recognised, but little research has hitherto been made. Yet it is one of the most important variables in predicting, for example, condom use (Amaro 1995). Practising safe sex involves a process of sexual negotiation, which in turn requires open communication about sexual issues between men and women (and boys and girls). Discussing sexuality is difficult in many cultures and is especially difficult for young people who are often unsure of themselves, lack experience and whose actions can be guided by peer attitudes or pressure. One study also raised questions about the usefulness of concepts such as 'sexual negotiation' for an understanding of how women may reduce their vulnerability to HIV infection (Mane, Gupta, Weiss 1994). In many circumstances women lack not only the skills but also the resources and the power to be able to negotiate safer sex with men. It is therefore utmost important that interventions to strengthen women’s sexual negotiation skills be conducted concurrently with educational programs designed for boys and men. Such programmes must promote men’s participation as equal partners in safer sex planning.
Furthermore, frankness about sexuality is not considered appropriate female behaviour in many cultures (Bassett and Mhloyi 1991; de Bruyn 1992; Hillier et al. 1998; Lear 1995; Taylor 1995; Weiss et al 1996). It implies a lack of sexual innocence and divergence from a “passive” role that is often expected in women. Men, despite their “active” role, may experience difficulty in talking about sexuality, be reluctant to admit their lack of knowledge, or may not be prepared to take responsibility for their sexual behaviour.
A dialogue approach to communication between women and men has been tried in some projects and the results are promising. In some cases it was found to be necessary to first build sexual communication skills in single-sex groups and then let women and men enter the dialogue with each other (AIDSCAP). Programmes to address partner communication have also emerged. One study found that training women and men in partner communication via role-plays and interactive methods lead to women feeling more comfortable with discussing their partner’s sexual history and men were more comfortable requesting condom use (Franzini 1990).
Many of these communication programmes have not been properly evaluated. It is important to understand the factors and processes that constrain and/or enhance communication and dialogue among young people, in order to design appropriate intervention methods. Furthermore, a better understanding of how to enhance both female assertion and male attitudes of sexual responsibility is needed.
Research shows that mass media based programmes have been developed with increasing success to promote sexual and reproductive health in different countries (Austin 1995, Israel and Nagano 1997, Johns Hopkins 1997). Many of these draw on social marketing techniques and use the persuasive power of the media to support health-enhancing objectives. In East Africa a few such initiatives using mass media and social marketing techniques have been initiated. One is a newspaper insert in Uganda supported by UNICEF called Straight Talk. This newspaper promotes safe sex practices and HIV/AIDS awareness among adolescents in the form of features and advice to personal questions. It is distributed widely in schools across the country. In Kenya, a radio programme, the Youth Variety Show is offering a combination of popular music and information on young peoples concern (Kiragu et al 1998). The radio programme is run by the Family Planning Association and young people are encouraged to call in and talk about their questions and concerns. In Tanzania The Femina magazine health information project has been set up with support from Sida. It builds on experiences made in the field of programming that AIDS prevention and SRH information can be conveyed to young people in entertaining ways that capture their attention. Combining education and entertainment (edutainment), has proven to be highly effective in motivating young people to seek information and services in order to change health related behaviours. It captures the audience attention, evokes strong emotional responses and provides role models for identification and for behaviour change (Johns Hopkins University 1997, 1998, Jarlbro 1998).
Research suggests that mass media help raise awareness and improve knowledge of the epidemic. It can make people understand that there is an alternative to the situation within which they find themselves (Pietrow et al 1997). Mass media and social marketing can play an important role in modifying concepts of masculinity and femininity and their relation to sexuality and HIV risk. Furthermore, mass media makes HIV/AIDS visible and puts it on the public agenda, which is a prerequisite for breaking the silence surrounding it.
Using condoms requires male agreement. Communication and negotiations about sex are particularly difficult in cultural contexts where women should not be knowledgeable about sex and lack decision-making power (Mane, Gupta and Weiss 1994). Condoms often carry negative associations (Dover 1995). They are seen as suitable for ‘casual sex’ but inappropriate in the context of a long-term relationship. Condoms are often associated with sex-workers and with mistrust, which also complicates their use. There are numerous rumours, as well as conspiracy stories, about the adverse affects of using condoms. Moreover, traditionally there is an accentuation on fertility in many sub-Saharan African societies, which also leads to a dislike of using condoms.
Wilton (1997) suggests that masculinity becomes threatened by condom use. There are several reasons for this: first, if condom use is requested by a woman this allows women to define the terms of sexual engagement; second, condom use may involve men having to deprioritise their own sexual pleasure; third, for men to demonstrate a degree of control over sexual behaviour may be feminising since male sexuality is most usually understood as uncontrollable, and finally, risk-taking itself is considered to be typically masculine.
In a recent study on youth in a Southern African township it was reported that the groups’ level of knowledge about HIV/AIDS was high, but perceived vulnerability and condom use were low. Six factors were identified that hindered condom use. They were: lack of perceived risk, peer norms, condom availability, adult attitudes to condoms and sex, gendered power relations and the economic context of adolescent sexuality. Informants did not constitute a homogenous group in terms of their understandings of sexuality. While there was a clear evidence of the existence of dominant social norms which place young people’s health at risk, there was also evidence that many young people are critical of the norms that govern their sexual behaviour and that they are aware of the ways in which peer and gender pressures place their health at risk. There was also evidence that a minority of youth actively challenge dominant norms and behave in health enhancing ways. This provides a good starting point for peer education programmes that seek to provide the context for the collective negotiation of alternative sexual norms (MacPhail and Campbell 2001).
There are also other signs of change. An analysis of studies focusing on 15-19 year olds found that teenagers with more education are now far more likely to use condoms than their peers with lower education, as well as less likely, particularly in countries with severe epidemics, to engage in casual sex. This was not the case early on in the African epidemic. At that stage, education tended to go hand in hand with more disposable income and higher mobility, both of which increased casual sex and the risk of contracting HIV. Thus education appears to have switched from being a liability to being a shield (UNAIDS 2000).
Some innovative condom social marketing programmes have addressed the barriers women face in accessing male condoms and insisting on their use. For example, women in Cameroon and Côte d’Ivoire can purchase condoms in self-service shops, where anonymity is preferred over direct interaction with sales people. In Burkina Faso, organised groups of women are involved in HIV prevention information and condom distribution to other women. Peer education programmes in Burkina Faso also provide women with effective responses to common male objections to condom use (PSI 1997). But more research is still needed in order to understand how to effectively reach men.
Some studies have explored the impact and effectiveness of condom social marketing programmes in reaching poor and vulnerable people (Price 2001, Agha et al 2001). Findings from a study in Mozambique (Agha et al 2001) indicate that condom social marketing programmes are effective in encouraging safer sex practices among persons engaged in sex with non-regular partners. However, it is important that the price on condoms is low so that poor people can afford to pay. Social marketing programmes that have a cost-recovery focus seem to exclude the poorest people.
Because of male resistance to condom use and the difficulties women have in negotiating the use of condoms, some researchers have suggested that female controlled protection is central to HIV prevention (Rivers and Aggleton 1999). The female condom, although more expensive and less widely available, provides women with an extended choice of protection and recent research suggests that male resistance to the female condom may be less than the male condom (Aggleton, Rivers and Scott 1998). While a number of studies have focused on the acceptability of the female condom, little research has been conducted into the ways in which its introduction might affect sexual communication and negotiation between men and women.
HIV/AIDS/sex education
Many researchers consider education as one of the most important tools in the prevention of HIV transmission (Bolton and Singer 1992, Susser and Gonzales 1992, Leap and O’Connor 1993, Rivers and Aggleton 1993, Laver 1993, Awusabo-Asare 1995, Mogensen 1995). However, this view is not shared by all. Caldwell, in a recent paper argues, that “Africans have been educated by AIDS programs to know that AIDS is deadly and largely spread among them by high-risk sexual activities. The epidemic cannot be defeated by more education” (Caldwell 2000). But, at the end of the paper Caldwell states that “Finally, there must still be strong informational programs pointing out the reduction in the risk of AIDS from changed sexual behaviour”. More important than discussing semantics i.e. whether to call inputs “education” or “information”, is to discuss what works in AIDS education. There is a wealth of evidence that educational campaigns can be effective and arrest or reverse HIV trends by encouraging people to change or avoid risky behaviour and lifestyles. But sexual and reproductive health education is not an easy task and many factors have to work together for effective AIDS education.
Studies show that many young people in Africa have adequate knowledge of STDs and HIV/AIDS but that does not necessarily translate into behaviour change. For example, studies conducted in Zimbabwe and Malawi showed that adolescents were generally knowledgeable about AIDS, they know how the disease was transmitted and that it was fatal, but they did not think that they were at risk of HIV (Bassett and Sherman 1994, Helitzer-Allen 1994). Risk perceptions were instead projected upon “outsiders” – such as bar girls, prostitutes, homosexuals and truck drivers (Uwakwe et al 1994). Sexually active girls in rural Malawi did not feel that they were vulnerable to HIV infection because they know the boys with whom they developed relationships. As formulated by one girl “my mother knows his mother, so he cannot be infected” (Helitzer-Allen 1994).
Educational initiatives around HIV and AIDS have tended to concentrate on providing the facts about HIV transmission in the belief that this will change behaviour. But, there is little evidence that behaviour change has occurred among people on whom these educational campaigns have been targeted (Schoepf 1991, Laver 1993, Rivers and Aggleton 1993). Moreover, as mentioned earlier, public health campaigns about AIDS have often been directed towards individuals or to specifically targeted risk-groups, such as prostitutes and truck drivers. A group of truck drivers might, apart from driving trucks, not have very much in common and can belong to quite different social, economic and cultural groups. Hence, giving the same health message to a risk group may not be an effective way to halt the spread of HIV (Singer and Weeks 1996). Findings from research suggest that for AIDS education to be effective it has to be culturally appropriate and refer to a specific social and cultural context (Bolton and Singer 1992, Schoepf 1991, Mogensen 1995, O'Donnell et al. 1994b, Solomon and DeJong 1988). People have to be able to identify with the messages given, which should be delivered in colloquial language using whatever metaphors and idioms that are culturally appropriate.
The present challenge is to convince policy and decision-makers of the need for sex education and to involve the ministries of education and health in the planning and implementation of sexual education for schools and youth friendly services.
Peer education is regarded by many researchers and programme planners to be especially suitable and effective in HIV prevention (Norr et al. 1992, Singer and Weeks 1996, Feldman et al. 1997, Gregson et al. 1998,UNAIDS/99.46E). In peer education, members of a given group are selected and trained to promote change within that group by acting as role models and acceptable informants (Fuglesang 1995, Feldman et al. 1997; Bond and Faxelid 1998; UNAIDS/99.46E). Thus, peer education is by definition adapted to the specific cultural context and can be culturally appropriate. Peer educators use the local language including, local idioms and metaphors, as well as non-verbal gestures to allow their peers to feel comfortable when talking about issues of sexuality and HIV/AIDS. Peer education is also a cost-effective intervention strategy, because its use of volunteers makes it inexpensive to implement (UNAIDS/99.46E).
A literature review commissioned by UNAIDS (UNAIDS/99.46E) suggests that peer education is a widely used component of HIV prevention programmes among many groups of people and in many geographical areas. There have been projects to train members of almost every conceivable group as peer educators: primary and secondary school students, truck drivers, sex workers, hair dressers, taxi drivers, sports team members, farm workers to name but a few. Responses to these projects are often positive. People appreciate and generally accept as credible the information they receive from colleagues and peers (Collins and Rau 2000). Studies have shown that female peer educators can talk about sex without the risk of being stigmatised as promiscuous. Equipped with communication skills, educational materials and a certificate that recognised their role, peer educators can be successful in facilitating group discussions about sex and educating their peers about their bodies (Weiss et al 1996).
The literature review also indicates that peer education is seldom implemented alone. Rather it is often part of a larger, more comprehensive approach to HIV prevention that includes condom distribution, STD management, counselling, drama and/or advocacy.
Most evaluations of HIV/AIDS peer education programmes mentioned in the literature review had used experimental or quasi-experimental designs with outcome indicators such as reduction of HIV related risk behaviour and/or STD/HIV incidence. These evaluations showed that peer education, in combination with other prevention strategies, was very effective in several populations and geographical areas. However, there is still need for further research to determine what the critical elements of peer education are within the context of a comprehensive HIV prevention strategy. There is a need to know how to best influence policy-makers/stakeholders; how best to select, train and supervise peer-educators; how to address gender and cultural factors; how to scale up programmes and how to sustain peer education activities.
Public health services tend to be under utilised by young people due to factors such as shyness, judgmental attitudes by staff, lack of privacy and problems of costs (Atuyambe 1999; Chikotola 1996; Fuglesang 1997; Kim et al 1997; Rutgers and Verkuyl 1998; UMATI 1998). In order to address these problems there are a number of on-going interventions in Africa for youth friendly reproductive health services. Below are some examples.
In
Kenya, the Centre for the Study of Adolescence (CSA) has done extensive
research and advocacy work, in collaboration with Kenya Association for the
Promotion of Adolescent Health (KAPAH), to promote adolescent reproductive
health (CSA and KAPAH 1995). Youth friendly services for STDs have been
established by the Family Planning Association of Kenya (FPAK) in Nairobi,
Mombassa and Nakuru. In addition, the Ministry of Health has established two
youth clinics at Siaya and Machakos, funded by Sida. Other initiatives have
included: sports clubs, such as the Mathare Youth Sports Association (MYSA);
The Kenyan Society for people with AIDS (KESPA), working mainly with anti-AIDS
groups in schools; Teenage Mothers and Girl’s Association of Kenya (TEMAK)
which promotes female empowerment.
In Uganda, youth-friendly comprehensive reproductive health services through youth reproductive health centres are now being advocated. At least five donor funded youth reproductive health centres are now operational. These centres provide recreation, information education and counselling (IEC) services, treatment of STDs, and provision of family planning that includes supply of condoms. Other initiatives in Uganda include the “Youth Alive” network of youth clubs, as well as numerous sports clubs, locally based peer education schemes and anti-AIDS clubs in schools.
In
Zambia, Youth Friendly Services have been piloted in Lusaka since 1994 by
UNICEF. There has been training of peer educators by CARE in Lusaka, the
Copperbelt and Southern provinces and work with young people and HIV/AIDS by
Christian Children’s Fund, Planned Parenthood Association of Zambia (PPAZ) and
Family Life Movement Zambia (FLMZ) in Kafue. FLMZ is also providing family life
education for young people in Southern, the Copperbelt and Lusaka provinces.
Nationally, PPAZ has run skills training for youths and Family Health Trust
(FHT) has created Anti-AIDS Clubs in many schools.
Many of these initiatives and their intervention methods and processes have not been adequately researched, documented or evaluated for their acceptability to youth and community or their effectiveness. Furthermore, most sustained initiatives have taken place in urban areas. The utilisation of both public and private sector health services by young people needs to be understood in order to improve service and attendance, especially in view of women’s tendency to later treatment seeking than men.
The Swedish strategy document (1999) states that HIV/AIDS prevention will not be successful without close links to health care interventions. The HIV/AIDS epidemic has caused enormous strains on health systems, whilst home-care of the sick, as well as the increasing number of orphans has also put a strain on families and local communities. Swedish development cooperation has therefore decided to incorporate efforts within these areas, which also constitute a challenge to research.
HIV/AIDS:
the increased burden on health care services
Health care systems in Africa were already insufficient and under-financed before the advent of AIDS. These deficiencies have worsened which has increased the demand for health care and simultaneously reduced the health system’s capacity to respond. In the mid 1990s, it was estimated that treatment for people with HIV consumed 66% of public health spending in Rwanda and over a quarter of health expenditures in Zimbabwe.
Data from six hospitals in low-income countries with large epidemics show that the percentage of hospital beds occupied by HIV positive patients ranged between 39 and 70 per cent (World Bank 1997). In Malawi and Zimbabwe, the share of hospital beds occupied by HIV/AIDS patients is even higher. A study from South Africa projects that direct costs of HIV/AIDS as a proportion of total health expenditure might rise to well over fifty per cent by the year 2005 (de Vylder 1999). A related impact of the epidemic is the lack of facilities for patients suffering from other conditions.
HIV/AIDS related illness and premature death among health care workers themselves will continue to create further costs for the health sector, but few countries have as yet fully understood the epidemic’s impact on human resources in their health sector, according to UNAIDS (2000). In Malawi and Zambia, for example, five to six fold increases in health worker illness and death rates have reduced personnel and increased stress, overwork and fear for personal safety in remaining staff (Loewenson and Whiteside 2001).
The growing demand on health care systems is underscored by the tuberculosis epidemic in the countries most heavily affected by HIV. Tuberculosis (TB) has become the leading cause of death among people with HIV infections, accounting for about a third of AIDS deaths worldwide. But hospitals and health centres in Africa repeatedly run out of supplies of essential drugs. In Zambia, for example, where the tuberculosis caseload increased six fold between 1992 and 1998, proper treatment became increasingly problematic due to the lack of TB drugs (UNAIDS 2000).