HIV Prevention

Hello All,

Just a reminder that this debate will take place tomorrow morning from 9am-11am. For the videocast, click here: https://admin.na4.acrobat.com/_a833642795/wbusaid/

All the best,
Bobby

Dear Community Members,

As some of you are aware, the webcast of this debate experienced some technical difficulties this morning. The debate organizers will be posting the video of the debate on AIDSTAR-one.org when it becomes available.

While participants awaited the webcast this morning, an organic exchange on HIV prevention occurred. Quotes from this conversation were posted in this community earlier today. While the initial exchange occurred in a public space, we have removed the post from the community. We will try to connect with those who took part in this conversation and invite them to share their thoughts in this community. As soon as the video of the debate becomes available, we will link to it here and attempt to build a robust dialogue around 'Behavior Change for HIV Prevention.'

Thank you all for your participation,

Bobby

Behaviour change is key to controlling diseases like HIV which are
substantially driven by the behaviours and beliefs of people. So my
posistion is that behavior change activities must be maintained. What is
important is to review how programs or interventions to bring about behavior
change are implemented. Are they appropriate to the population? Are the
correct messages being sent out? Are we monitoring what we are doing for
effectiveness in terms of outcomes and use of resources. I think these
issues are important.
Chilunga

Behavior change is very important in reducing HIV prevelance. In Uganda behavior change is credited for the significant decline in HIV infection since the early 1990's. The reason we were able to do was the massive campaigns undertaken by the government to enlighten people and encourage people to change their behavior. In addition because the government was so open about AIDS the stigma was reduced and we were able to confront the problem head on.

Richard,
Thanks so much for sharing these thoughts. What are your thoughts on why recent HIV prevention efforts in Uganda have been less successful than those of the 1990s? Has stigma returned (i.e. have things slipped back into how they were before the campaigns), or has the nature of the problems evolved. And, is the answer simply government commitment?
I'm interested in how behavioral change efforts can be done so that the norm changes are sustained, and whether that continues constant vigilance/action to maintain, or it can be a permanent change.

Thanks!

Hello Maria,

Good question! As I'm quite busy at this time, I will only venture a rather brief answer, even though a much more complex/nuanced answer would be preferable. Thus to make a much longer story much shorter, I think the main (though not the only) reason is that the behavior change-focused approach (mainly focused on "zero grazing") that Uganda utilized over 20 years ago now, in the late 1980s, is really "long dead" for the most part. After the early to mid 1990s, the HIV-AIDS approach in Uganda became much more focused on a variety of other issues, such as expanding of VCT, condom and STI treatment services, and eventually of addressing PMTCT and then ARV access, along with a number of other issues. Of course, all of those are valid and important approaches, but this has had the effect of inadvertently minimizing the intense, early focus on sexual behavior change. In effect, the slogan and entire approach centered around "zero grazing" was nearly forgotten by the mid-1990s (after peaking in the late 1980s). Over five years ago, when I was still with USAID in Washington, we supported extensive research (employing focus groups, interviews and other methodologies ...

Hello Maria,

Good question! As I'm quite busy at this time, I will only venture a rather brief answer, even though a much more complex/nuanced answer would be preferable. Thus to make a much longer story much shorter, I think the main (though not the only) reason is that the behavior change-focused approach (mainly focused on "zero grazing") that Uganda utilized over 20 years ago now, in the late 1980s, is really "long dead" for the most part. After the early to mid 1990s, the HIV-AIDS approach in Uganda became much more focused on a variety of other issues, such as expanding of VCT, condom and STI treatment services, and eventually of addressing PMTCT and then ARV access, along with a number of other issues. Of course, all of those are valid and important approaches, but this has had the effect of inadvertently minimizing the intense, early focus on sexual behavior change. In effect, the slogan and entire approach centered around "zero grazing" was nearly forgotten by the mid-1990s (after peaking in the late 1980s). Over five years ago, when I was still with USAID in Washington, we supported extensive research (employing focus groups, interviews and other methodologies); FYI some of this research was included in Doug Kirby's overview 2008 article, at:

http://sti.bmj.com/cgi/content/full/84/Suppl_2/ii35

Also especially accessible to many readers would be the very interesting (front page) Washington Post piece, also from a few years ago, that in fact addressed your very question:

http://www.washingtonpost.com/wp-dyn/content/article/2007/03/28/AR20070328025...

I hope this helps answer your question...

Cheers,

Daniel

Daniel Halperin, PhD
Lecturer on Global Health
Harvard University School of Public Health

Hello Daniel, Maria

Maria you have asked about one of the great frustrations that people
working in behavior change in Uganda, and other places, face and for
which there is a multipronged answer. Daniel, you are right about the
diluted focus, but also remember that by the time PEPFAR made funds
increasingly available, message fatigue had already set in in Uganda.
Additionally the one main message focused on partner reduction became
diluted by other behavioral messages, and the communication effort was
very fragmented, with very little coordination and leadership (not just
political, but also on the communication front) So while I think that
clearly there were several new issues being introduced or expanded in
Uganda, we should not underestimate the contribution that dysfunctional
communication programming/ efforts might have had. This is a very quick
answer, obviously. Sereen

Sereen Thaddeus, MA MPH
Health Development Advisor
HIV Prevention Technical Lead
USAID Mozambique

Dear Sareen thaddeus,

Thank you for the up dates on HIV prevention. i think there has been no enough HIV communication especially in the rural areas in Uganda. My suggestion is donors/ funders should communicate HIV issues through the grass root organizations like ours and not only NGOs because they some times leave  gaps and do not reach every where as it is expected by CDC, GHD and others.

Please do consider the CBOs in order to archieve the MDGs .


Kagiri Sulaiman
Chairman/ founder
KCDP youth project
PO box 34727
Kampala
Uganda

Hi Maria,Daniel
The Washington Post article was spot on. In the early and late 90's everyone was terrified cause so many people were dying. There were also so many public awareness campaigns, t.v ads,plays, with that much fear going around many people changed their behavior. Unfortunately since the next generation did not see the effects of AIDS first hand they have become more reckless. Also in the urban areas because of the use of ARV's many people live long with HIV so it is no longer seen as death sentence

Hello Everyone,

Very interesting points all around. How then, do you all think a balance can be struck between providing treatment for those infected while ensuring that individuals fully comprehend the consequences of HIV acquisition? How do you think the recent stagnation in funding for treatment will impact the way in which individuals perceive risk? To extend the conversation even further, what does Uganda’s experience tell us about balancing prevention and treatment when crafting an HIV/AIDS response?

Thanks,
Bobby

Building on what I said before about ARV's, in the urban areas some people now regard AIDS as a chronic disease like diabetes not a terminal illness, so clearly the fear factor is gone

Perceived problem versus actual problem
Taking Uganda as an example, the celebrated ABC strategy for the prevention of HIV infections has since gone to the dogs thereby calling for more action and preferably a more applicable and sustainable measure/policy to save the human race from the dreadful epidemic.

It is well known that the variance in cultural diversity has a lot to do with community’s beliefs and behavior towards a particular situation. Imposition of policies onto communities is likely to contribute to failure of the strategies to control the spread of HIV among communities. It’s important to realize that what is applicable in one community may not necessarily apply in the other. For example, there are social norms and taboos, where it may be abominable to discus ‘sex’ among the family members especially the young. Cultural specific strategies is the answer.

The strategy should begin with research based policies and with input of the family and clan leaders. As long as policies are imposed on a particular community, it can never last long and will not be sustained.
Consequently, it should be noted that not everybody can collect dependable, and generalizable data to use in policy formulation ...

Perceived problem versus actual problem
Taking Uganda as an example, the celebrated ABC strategy for the prevention of HIV infections has since gone to the dogs thereby calling for more action and preferably a more applicable and sustainable measure/policy to save the human race from the dreadful epidemic.

It is well known that the variance in cultural diversity has a lot to do with community’s beliefs and behavior towards a particular situation. Imposition of policies onto communities is likely to contribute to failure of the strategies to control the spread of HIV among communities. It’s important to realize that what is applicable in one community may not necessarily apply in the other. For example, there are social norms and taboos, where it may be abominable to discus ‘sex’ among the family members especially the young. Cultural specific strategies is the answer.

The strategy should begin with research based policies and with input of the family and clan leaders. As long as policies are imposed on a particular community, it can never last long and will not be sustained.
Consequently, it should be noted that not everybody can collect dependable, and generalizable data to use in policy formulation. Particular credible researchers and research organizations need to be consulted in carrying out such surveys and research

Byaruhanga B Emmanuel
Mbarara-Uganda
+256-775428710

All,

We sincerely apologize for participants who tried to join the debate via the webcast on Tuesday, June 29. As many of you know, the World Cup is happening. In order to preserve bandwidth, additional filters were in place inside the World Bank to prevent too many people from watching the games. The filter unfortunately couldn't tell the difference between the football match and our debate. The good news is that the event was recorded and can be viewed on the link below.

http://www1.worldbank.org/hdnetwork/external/Aids/wbusaid.wmv

The meeting summary will be posted at www.aidstar-one.com in mid-August. The summary report from the first debate which discussed the 'test and treat' approach can also be found at http://www.aidstar-one.com/resources/calendar/emerging_issues_todays_hiv_resp...

I agree that ABC is not relevant in some circles and that particular credible researchers and research organizations need to be consulted in carrying out surveys, research and dissemination of findings.
However on the issue of trying to cater for all the cultural diversity, it makes all sense but with increasing globalisation and resources thinly spread over heterogenous groups, is it possible (sustainable) to design these culturally sensitive interventions?
Maybe people should try to come on board with globalisation than receed back to their cultural minorities when they get sick.If cultural barriers can be overcome (minimised) for economic reasons (i.e. to manage credit crunch with formation of groups like SADC, EAC,G8,etc), maybe global diseases can take the same approach.


Anne Bagenda, MPH
Makerere University School of Public Health