HIV/AIDS COMMUNICATION
IN SELECTED AFRICAN
COUNTRIES
Interventions, responses
and possibilities
HIV/AIDS COMMUNICATION IN SELECTED AFRICAN COUNTRIES Interventions, responses and possibilities
© SIDA 2007
Written by
Warren Parker, Asta Rau and Penny Peppa
Acknowledgements
Additional research was conducted by Pumla Ntlabati and Helen Hajiyiannis of CADRE. We are grateful to representatives of various organisations in the countries studied who provided information and commentary on aspects of this report. Thanks to various PSI staff
who provided reports on their programmes.
Thanks to Anette Widholm Bolme (Regional Advisor, Swedish-Norwegian HIV/AIDS Team for Africa) who provided valuable input at various stages of this study.
Disclaimer
The views expressed in this report represent the views of the authors.
Published by
Sida, Swedish Embassy, Haile Selassie Ave., Lusaka, Zambia Tel: +260 1 25 17 11.
Produced by
The Centre for AIDS Development, Research and Evaluation (CADRE), PO Box 30825, Braamfontein, Johannesburg 2017, South Africa
Tel: +27 11 339-2611. www.cadre.org.za. [email protected]
ABBREVIATIONS AND ACRONYMS1
ABC ‘Abstain, be faithful, condomise’
ACHAP African Comprehensive HIV/AIDS Partnerships AIDS Acquired immune deficiency syndrome
ART Antiretroviral treatment/therapy ARV Antiretroviral (drugs) AYA African Youth Alliance
CBO Community-based organisation
CDC Centers for Disease Control and Prevention (USA) CIDA Canadian International Development Agency CSW Commercial sex work(er)
DFID Department for International Development (UK) DHS Demographic and Health Survey
FBO Faith-based organisation FHI Family Health International HIV Human immunodeficiency virus IDU Intravenous drug use(r)
JHUHCP Johns Hopkins University Health Communication Partnership JICA Japan International Cooperation Agency
MSM Men who have sex with men NGO Non-governmental organisation
Norad Norwegian Agency for Development Cooperation OVC Orphans and vulnerable children
PATH Program for Appropriate Technology in Health PEP Post-exposure prophylaxis
PEPFAR US President’s Emergency Plan for AIDS Relief PLHA Person living with HIV or AIDS
PMTCT Prevention of mother-to-child transmission PSI Population Services International
SFH Society for Family Health
Sida Swedish International Development Cooperation Agency STI Sexually transmitted infection
TASO The AIDS Support Organisation TB Tuberculosis
UNAIDS Joint United Nations Programme on HIV/AIDS UNDP United Nations Development Programme UNFPA United Nations Population Fund
UNICEF United Nations Children’s Fund UNIFEM United Nations Fund for Women VCT Voluntary counselling and testing WHO World Health Organization
CONTENTS
EXECUTIVE SUMMARY...6
BACKGROUND ...9
Approach to the review ...9
Context of the epidemic...9
Context of the response ... 10
Identifying communication activities ... 10
Monitoring and evaluation ... 10
CONCEPTUALISING HIV PREVENTION COMMUNICATION... 12
Modes of transmission and prevention technologies ... 12
Implications for communication ... 13
Behaviours, practices, activities and contexts ... 14
Communicating about risk ... 15
Biological risk in context... 15
Positive prevention... 16
Key issues in relation to the study ... 16
FINDINGS ... 17
HIV epidemiology: Variations between countries and heterogeneity within countries... 17
HIV prevention-related responses ... 19
Variations in prevention response... 21
Communication campaigns at the country level... 22
Cross-cutting programmes and methodologies... 22
Communication approaches... 23
Communication for resource-uptake and service delivery... 24
Communicating for HIV prevention... 24
‘Higher-risk’ groups... 25
Conclusions... 25
Implications... 27
Epidemiology-led prevention communication... 27
COUNTRY SUMMARIES... 29
BOTSWANA ... 30
Key individual responses: Botswana ... 30
BOTSWANA: HIV prevention communication... 31
ETHIOPIA ... 34
Key individual responses: Ethiopia ... 34
ETHIOPIA: HIV prevention communication ... 35
KENYA ... 39
Key individual responses: Kenya... 39
KENYA: HIV prevention communication... 40
MALAWI... 43
Key individual responses: Malawi... 43
MOZAMBIQUE... 46
Key individual responses: Mozambique... 46
MOZAMBIQUE: HIV prevention communication... 47
NAMIBIA ... 49
Key individual responses: Namibia ... 49
NAMIBIA: HIV prevention communication ... 50
SOUTH AFRICA ... 52
Key individual responses: South Africa ... 52
SOUTH AFRICA: HIV prevention communication ... 53
TANZANIA ... 55
Key individual responses: Tanzania ... 55
TANZANIA: HIV prevention communication ... 56
UGANDA ... 58
Key individual responses: Uganda... 58
UGANDA: HIV prevention communication ... 59
ZAMBIA ... 62
Key individual responses: Zambia ... 62
ZAMBIA: HIV prevention communication ... 63
ZIMBABWE... 66
Key individual responses: Zimbabwe... 66
ZIMBABWE: HIV prevention communication... 67
REFERENCES ... 69
EXECUTIVE SUMMARY
The Swedish International Development Cooperation Agency (Sida) commissioned this study to inform understanding of the relevance of focused HIV prevention activities in the region. The report serves to guide future support interventions in the area of HIV prevention communication.
The countries reviewed are: Botswana, Ethiopia, Kenya, Malawi, Mozambique, Namibia, South Africa, Tanzania, Uganda, Zambia and Zimbabwe. The country-level reviews include a synopsis of epidemiology, indicators of knowledge, behaviour and service uptake, and information on HIV/AIDS prevention communication activities, approaches and funding. An analysis of HIV epidemiology shows that there is a great deal of variation in HIV prevalence between countries and within countries, leading to the conclusion that HIV is heterogenous in the region and within countries. Variations in HIV prevalence within countries include variation by province or region, urban versus rural location, between genders, age groups, cultural groups and religious groups, and by activity (e.g., sex work, mobility, migration). This heterogeneity has important implications for thinking about national-level HIV prevention communication in relation to the goal of reducing HIV incidence and prevalence.
The report draws the following broad conclusions in relation to national HIV prevention communication interventions:
The overall delivery of communication messages pertaining to awareness of AIDS, and knowledge of key aspects of the disease are extensive, and campaigns are impactful; A number of communication interventions are well theorised, engage audiences in appropriate languages, and achieve a high-reach through mass media;
International and non-indigenous organisations provide an important contribution to country-level communication interventions;
A number of indigenous interventions have been sustained over long periods, and some have expanded to other countries (e.g., Straight Talk and Soul City);
Promotion of uptake of resources and services has been extremely successful (e.g., condoms and VCT);
Considerable expertise for prevention communication exists in the region, via indigenous and non-indigenous organisations.
Concerns include:
There is a limited focus on conceptualising prevention communication as a broad category of intervention that requires attention to all modes of HIV infection – not only
[hetero]sexual transmission;
Some non-indigenous interventions are constrained by donor and organisational agendas that are not explicitly coordinated at the country level nor with country-level stakeholders. Where indigenous organisations are drawn in, they are often junior partners;
Fixed-period funding of interventions can result in fragmentation of prevention communication, with a loss of sustained emphasis and expertise;
The overwhelming emphasis and resourcing of youth programmes has not translated into significant prevalence reduction among youth, and this requires attention;
Expanded emphasis on adults in the high-prevalence age range of 25-35 years, as well as older persons, requires urgent attention;
Although girls and women are significantly more vulnerable to HIV as a product of biological, socio-cultural and economic factors, there are few programmes that focus extensively on communicating and addressing these disparities;
Very few HIV prevention communication interventions explicitly involve PLHA, are led by PLHA or directed towards PLHA;
There is insufficient focus on commercial sex work (CSW) beyond border and trucking routes, and very little attention given to men who have sex with men (MSM).
The implications of these conclusions are that prevention goals and strategies need to be aggressively set in relation to short-term outcomes and impacts that are specific to HIV risk. These should be prioritised at country level and led by national governments. The promising findings of prevalence reduction in Malawi, Kenya, Uganda and Zimbabwe illustrate that impacts can be made over short periods if the key epidemic drivers are addressed. Important focal areas for prevention include:
Changing the proportions of young people having sex before age 15 and age 18; Framing goals towards limiting an individual’s lifetime number of sexual partners and partner turnover;
Promoting understanding of the high risks of having concurrent sexual partnerships; Promoting correct and consistent use of condoms (and not just condom uptake);
Critically addressing risks to youth with a view to addressing the shortcomings of current highly resourced campaigns that have only made limited impacts on youth prevention; ,Extending the focus of campaigns to other vulnerable and impacted age groups (i.e., 25-35-year-olds where incidence is high, as well as older age groups);
Focusing on PLHA, including maximising the potential of positive prevention as a product of increasing individuals’ awareness of their HIV status via VCT;
Addressing commercial sex work at an expanded level, and assessing and targeting risks related to men who have sex with men.
HIV prevention communication needs to be be led by a comprehensive understanding of HIV epidemiology within each country, and prevention communication interventions need to be designed with specific epidemiological changes in mind. This approach needs to focus on very specific short-term goals related to achieving declines in HIV prevalence and incidence nationally, sub-nationally and in relevant groups and sectors.
A specific focus on addressing the disproportionate risk to girls and women requires urgent attention.
Monitoring and evaluation indicators need to be reviewed and expanded, both to inform the design of communication interventions, and to monitor the impacts of communication
interventions. For example, there is presently insufficient understanding of sexual debut, lifetime numbers of sexual partners, relative duration of sexual partnerships, concurrent partnerships, correct and consistent condom use, among other categories relevant to prevention epidemiology. National surveys seldom attempt to measure the impacts of communication interventions.
Prevention communication is seldom explicitly linked to evidence-based incidence and prevalence goals, and thus interventions are sustained in a milieu of presumed impact rather than demonstrable impact. This passive approach has limited the accountability of
interventions, in spite of massive resources being committed and expended.
Key questions informing prevention communication strategies and the stock-taking of interventions include:
Are HIV prevention communication interventions led by the epidemiology of HIV in each country?
Are vulnerable and marginalised groups effectively taken into account?
Do HIV prevention communication interventions take into account variations in HIV epidemiology within each country?
Are HIV prevention communication goals sufficiently aligned with short-term and long-term goals for acheiving HIV prevalence and incidence declines?
Are HIV prevention communication interventions sustainable, and are interventions with demonstrable impact sustained for sufficient periods of time?
Are HIV prevention communication interventions measured against appropriate indicators of change?
BACKGROUND
The Swedish International Development Cooperation Agency (Sida), which is involved in some HIV/AIDS communication projects in eastern and southern Africa, has commissioned this study to inform understanding of the relevance of focused HIV prevention activities in the region. This report is also intended to guide potential future support interventions in the area of HIV prevention communication.
This study involves a mapping and summary of national-level prevention activities in the following countries: Botswana, Ethiopia, Kenya, Malawi, Mozambique, Namibia, South Africa, Tanzania, Uganda, Zambia and Zimbabwe. Each country’s main HIV prevention communication activities are identified, and various methodologies, approaches and sources of funding are described. The country summaries are preceded by a review of country-level monitoring and evaluation research that has referred to indicators of knowledge and
behaviour. Information on HIV prevalence is also provided.
The preliminary sections of the report provide a theoretical overview of issues concerning HIV/AIDS communication and the relevance of making inter-country comparisons of prevention communication. Country-level communication findings are summarised and analyses of this data is used to inform implications policy and strategy.
Approach
Understanding HIV prevention in eleven countries is a complex process in the context of the considerable differences in country-level HIV epidemiology, varying intensities of the epidemic and the complex histories of response in each country and between countries. Additionally, the response context is extremely fluid.
Context of the epidemic
With a view to understanding each country’s epidemic context, HIV prevalence data derived from the UNAIDS Report on the Global Epidemic, 2006 were utilised.2 This has allowed for consistency to be maintained between country estimates in terms of the underlying methods used for determining overall HIV prevalence and the proportion of the population living with HIV. The report also provides estimates of the proportion of pregnant women receiving treatment for prevention of mother-to-child transmission (PMTCT), and the proportion of people with advanced HIV infection who are receiving antiretroviral therapy (ART).
Antenatal HIV prevalence data are derived from the HIV/AIDS Epidemiological Surveillance Report for the WHO African Region: 2005 Update,3 which includes estimates for urban and rural antenatal prevalence. This data allows for comparison between countries.
Other prevalence data are considered where available, and this has allowed for the inclusion of information on variation of HIV prevalence within each country (eg. variations by age group, sex, province or region, and religion.
Context of the response
A matrix of statistical data for knowledge of HIV prevention, knowledge of PMTCT, engagement with people living with HIV or AIDS (PLHA), and ever having had an HIV test was gathered using data derived from contemporary Demographic and Health Surveys and other surveys as applicable. This information is given in a table of ‘Key individual responses’ at the beginning of each country summary.
Identifying communication activities
Creating a synopsis of HIV/AIDS prevention communication in each country involved a multi-phased approach. Initially, a review was conducted using electronic sources such as institutional websites in combination with documents and reports. Many national AIDS councils, commissions, departments of health, local NGOs and other indigenous institutions have websites, as do the wide range of international donor and implementation organisations that are active in HIV/AIDS communication in the region. Most provide access to reports, and related documents and reports are also available from other sources. This data was used to develop a general understanding of HIV communication in each country.
Additional information was gathered through telephonic and e-mail correspondence and interviews with individuals working in the HIV/AIDS field in each country.
The country synopses concentrate on contemporary and ongoing HIV/AIDS communications activities and one-off events, such as those related to World AIDS Day, are not included. Less emphasis has been placed on advocacy-type communication by leadership and/or media advocacy, except when it forms part of a broader campaign.
Monitoring and evaluation
Many interventions include monitoring and evaluation activities that inform their programme design and impact. It is far beyond the scope of this report to analyse particular monitoring and evaluation reports of HIV prevention interventions. It is however noted that the
methodologies of such studies have varied considerably, and that the evaluations are largely conducted sub-nationally.
While most interventions include explicit goals for reducing HIV incidence and prevalence, few programmes have the resources and expertise to explicitly measure such impacts. Instead, the monitoring and evaluation of interventions often devolves to proxy indicators such as knowledge levels, attitudes, condom use, sexual partner turnover, and the like. Such information is regularly included in national surveys – for example, the relatively
standardised Demographic and Health Surveys as well as other HIV/AIDS-related surveys. In all the countries reviewed, changes in knowledge, attitudes and sexual behaviours and practices have occurred over time. However, such changes have not uniformly correlated with declines in HIV prevalence.
In a few countries, recent analyses have shown that prevalence and incidence have declined. In reviews and modelling of HIV prevalence declines in urban Kenya, urban Malawi, Uganda and Zimbabwe, it was concluded that changes in sexual behaviour – particularly delayed
sexual debut and lower rates of partner turnover, as well as condom use with non-regular partners – are strongly associated with prevalence declines.4
In Kenya, where HIV antenatal prevalence has declined, ‘having more than one partner in the previous 12 months’ declined between 1998 and 2003, from 4.2% to 1.8% for females and 24.1% to 11.9% for males, and ‘condom use at last instance of higher-risk sex’ increased for females, from 15.1% in 1998 to 23.9% in 2003.5
In Zimbabwe, statistically significant declines have occurred in ‘number of non-regular sexual partners in the past 12 months’ among 15-29 year-olds, from 17.2% to 8.2% for females between 2001 and 2003, and from 32.2% to 21.3% for males over the same period. Antenatal HIV prevalence among 15-19-year-olds declined from 19.5% in 2001 to 13.7% in 2004, and among 20-24-year-olds, from 28.9% to 24.0% over the same period.6
While these epidemiological studies did not review the impacts of prevention interventions, the findings do highlight the factors and changes that have been associated with HIV prevalence and incidence declines.
CONCEPTUALISING HIV PREVENTION COMMUNICATION
HIV prevention communication should be thought of as a broad-based set of communication activities that consider the implications of all aspects of HIV transmission and risk of HIV infection. This includes all modes of transmission and biological risks, as well as relating to communication about risk factors that are related to social contexts.
Modes of transmission and prevention technologies
HIV is transmitted biologically through various modes of infection, a number of which do not involve sexual transmission (see Table 1). These include transmission through blood
transfusion; exposure to infected blood in various settings, including healthcare facilities; exposure to infected blood through needle-sharing as part of intravenous drug use; infection from an HIV-positive mother to her child, which may occur during pregnancy, during birth or after birth.
Many technologies are available to reduce the risk of HIV transmission, for example: blood screening to prevent transmission through blood transfusion; and infection-control practices, including sterilisation of sharp instruments, needle disposal, use of barrier methods such as gloves, and single-use of syringes and needles. In relation to sexual transmission, approaches include use of barrier methods (condoms), treatment of sexually transmitted infections (STIs); circumcision7; and provision of antiretroviral therapy (ART) as part of post-exposure
prophylaxis (PEP) to limit the possibility of transmission. Knowledge of HIV status is also considered to be an important step in prevention of transmission.
Effectively promoting HIV prevention involves considering all modes of HIV transmission, reviewing risks of exposure, and implementing relevant policies, protocols and interventions at the country level.
In this context, prevention communication has two dimensions – one involving the promotion of knowledge about particular modes of transmission and related knowledge of risk reduction or prevention, and the other dimension involving promotion of resources and services that support prevention.
Table 1: Modes of HIV transmission and biomedical technologies for prevention8
Mode Technology Intervention
Exposure to blood via blood transfusion
• Scientific screening • Screening/selection of blood donors for risk factors
• Screening of blood supplies Exposure to blood in
healthcare settings (via healthcare workers, patients)
• Needle disposal systems • Gloves
• Infection-control practices • PEP
• Guidelines for universal precautions • Availability of PEP
Exposure to blood in other settings (eg. Traditional practices)
• Gloves
• Infection-control practices
• Guidelines for universal precautions
Intravenous drug use (needle-sharing)
• Detoxification
• Clean needles and syringes
• Implementation of detoxification programmes
• Free syringe and needle programmes (harm-reduction)
Mother-to-child HIV transmission
• Assessment of mother’s HIV status • ARVs and other regimens
• Caesarean delivery
• Controlled breastfeeding (exclusive replacement feeding or exclusive breastfeeding) • Implementation of PMTCT programmes Consensual sexual intercourse • Male condoms • Female condoms • HIV testing • STI treatment • Circumcision • Implementation of condom programmes • VCT programmes
• Syndromic management of STIs • Safe male circumcision
Non-consensual sexual intercourse
(rape, coercion)
• ARVs for PEP • STI treatment
• Emergency contraception (to prevent pregnancy and consequent risk to baby)
• Availability of PEP • STI treatment regimen
Implications for communication
The challenge for communication interventions is to assess the implications for
communication for each mode of transmission. Part of this assessment would be data-based – for example, implications for prevention communication, if any, can be assessed against questions including:
What proportion of screened blood is HIV-positive?
What are the levels of knowledge among healthcare workers, traditional healers, and others about universal precautions? What are their prevailing practices?
What is the level of intravenous drug use in the country? Do drug users share syringes and needles?
What is the level of awareness of PMTCT among pregnant women? What proportion of pregnant women is receiving PMTCT treatment?
What is the level of awareness of HIV prevention measures in the case of potential exposure to HIV through sex? What is the degree of awareness of available services? What are the present levels of response in terms of prevention behaviours and practices?
To best address prevention communication at the country level, it is necessary to ensure that all modes of transmission are considered and that strategies are developed accordingly. Intervention designs must consider the primary audience for communication as well as the most efficient and strategic approaches for communicating relevant information. For example, should communication be directed at the population at large to promote an understanding of PMTCT, or should this only be directed to pregnant women via healthcare facilities? In designing and reviewing prevention communication strategies, there is a need to ask whether the relevant modes of HIV transmission have been considered and whether they are being appropriately addressed.
Behaviours, practices, activities and contexts
Overall, the concept of behaviour is poorly defined and seldom clearly explained in relation to HIV prevention. It is clearly insufficient to understand the challenges for HIV prevention communication as being only to do with addressing behaviours. For example, preventing mother-to-child transmission involves a range of activities, which include assessing a
mother’s HIV status providing counselling, obtaining consent, and implementing various risk-reduction activities. These activities are not behaviours as such, yet they are related to HIV prevention.
The term behaviour-change communication (BCC) has often been used in relation to
interventions dealing with the prevention of sexual transmission of HIV. Even in this context, the term is somewhat limiting. For instance, there is a sequence of actions involved if an individual wishes to use condoms to prevent HIV transmission. These include procuring a condom, having a condom available during sex, effectively negotiating condom use with one’s partner, using and removing the condom correctly, and disposing of the condom. Should these steps be called behaviours, practices or activities? Which of these actions are influenced by biological factors such as hormonal stimulus; which by psychological factors such as the need for love and affirmation; which by knowledge and awareness of HIV transmission; which by conscious intentions to use a condom; which by external factors such as availability of condoms; and, which by the many dimensions of decision-making between partners?
It is beyond the scope of this report to attempt to answer these questions, but they are raised to open up thinking around how prevention communication is conceptualised, and particularly about the responses such communication is intended to bring about. Thinking about HIV prevention only in terms of the concepts of ‘behaviour’ and of ‘changing behaviour’ is limiting.
Communicators also need to consider socio-cultural, economic and other factors that inhibit effective prevention. These may include various forms of disempowerment and
marginalisation which severely limit an individual’s control over sex; for example rape, sexual violence and coercion markedly limit control over the integrity of one’s body (and related HIV risk). Conversely, economic and material needs may be powerful incentives to engage in unprotected sex. Other factors such as economic activity (for example, truck driving or sex work), living in an informal settlement (where communities are fragmented), alcohol and drug consumption (which diminishes rational control over sexual behaviour), all
pose challenges for HIV prevention communication. Such factors illustrate that thinking about HIV prevention as being mainly related to conscious individual choices made about sexual behaviour, imposes unnecessary limits on strategic thinking.
Communicating about risk
Risk of HIV infection is relative to a wide range of factors. For example, risk of acquiring HIV through blood transfusion is generally low (but not non-existent) in most countries, and it is relative to overall HIV prevalence, systems for gathering blood for transfusion, and protocols for screening blood.
Risk of transmission of HIV from a mother to her baby is relatively high, ranging from 15-30% without breastfeeding, to 30-45% in the case of breastfeeding for up to two years.9 Risk of HIV transmission otherwise varies according to a range of biological and other factors. Gray et al.10 calculated probabilities of infection between serodiscordant monogamous couples in Uganda and found the unadjusted probability of HIV infection was 0.001 (95% CI 0.0008–0.0015) per single sex act – which indicates an overall very low risk of transmission. Higher viral load, younger age and the presence of genital ulcerations reportedly increase the probability of HIV transmission per sex act. Recent HIV infection is correlated with higher viral load, which in turn, increases the risk of transmission when people have concurrent sexual partners. HIV transmission risk by modes of infection can be summarised as follows:11 transfusion of infected blood, 95 in 100;
transmission from mother to infant without AZT, 1 in 4; transmission from mother to infant with AZT, less than 1 in 10; Sexual intercourse, male to male, 1 in 10 to 1 in 1,600;
Sexual intercourse, male to female, 1 in 200 to 1 in 2,000; Sexual intercourse, female to male, 1 in 700 to 1 in 3,000; needlestick injury, 1 in 200;
needlestick injury followed by PEP with AZT, 1 in 10,000.
In relation to the most common mode of HIV transmission – heterosexual intercourse – there are significant differences in the risks for females versus males, and this is clearly evident in epidemiological data that show HIV prevalence to be many times higher among young females than young males. Sex between males poses far higher risk of infection.
Biological risk in context
A number of social factors exacerbate risk of HIV acquisition, including earlier sexual debut, higher turnover of sexual partners, having concurrent sexual partners, and not using condoms. Importantly, the measure of risk with these factors is inter-related with biological risk factors. Recent infection with HIV increases an individual’s viral load and also potential to transmit the virus.12 Exposure to a recently infected individual is more likely to occur in instances of rapid partner turnover or concurrent sexual partnerships recent infection is not easily
prevalence of concurrent sexual partnerships was likely to increase HIV prevalence by a factor of two or three, suggesting that prevention messages promoting ‘one partner at a time’ are as important as promoting fewer partners.
Recent findings in relation to circumcision have also illustrated the potential for risk reduction through affecting biological transmission, although concerns remain about disincentives for other risk-reduction measures accompanying male circumcision (namely, partner reduction and condom use).
Positive prevention
Focusing on prevention among people who know their HIV status is considered an important intervention15 as well as an important area for prevention research and strategy.16 A review of randomised, controlled trials found that risk-reduction interventions focusing on behavioural risk among PLHA increased condom use.17 A similar review found that prevention
interventions focusing on PLHA reduced unprotected sex and decreased acquisition of STIs.18 HIV prevention communication tends to focus on audiences that are assumed to be HIV-negative, and there has typically been little focus on PLHA. This has obvious limitations, particularly in the context of increasing access and uptake of VCT.
Key issues in relation to this study
The core intention of HIV prevention communication is to bring about particular changes among individuals at-risk. It is assumed that human psychology incorporates a natural tendency towards health-risk avoidance and that there is a correlation between one’s knowledge of risk and consequent action. But evidence of the limits of this model can be found through an analysis of decades of HIV/AIDS communication, where the allocation of massive resources and intensified interventions have not brought about desired declines in HIV prevalence.
Key issues include the need to interrogate whether deficiencies in communication strategies and/or the orientations of prevention communication programmes have contributed to an insufficient impact. Alternately, are the contexts of HIV transmission/infection – which include interactions between socio-economic factors, demographic factors, resource and response frameworks and human psychology – so complex that dramatic impacts on HIV prevalence should not be thought of as attainable in the short term?
FINDINGS
HIV epidemiology: Variations between countries and heterogeneity within countries
HIV in Africa is understood epidemiologically as being generalised and all the countries reviewed in this report have relatively high overall HIV prevalence levels. However, some distinct differences between countries influence their intervention priorities. Countries to the south have higher HIV prevalence (Figure 1). Botswana and South Africa have the highest antenatal HIV prevalence, with estimates for Malawi, Namibia, Zambia and Zimbabwe in the middle range, and those for Ethiopia, Kenya, Tanzania and Uganda in the lower range.
Figure 1: Cross-country comparison of antenatal HIV prevalence
Figure 2 illustrates HIV prevalence at population level using data from actual studies as well as modelling. Although overall prevalence levels are lower than antenatal levels, the
Figure 2: Cross-country comparison of population-based HIV prevalence
Figures 3 and 4 illustrate how HIV prevalence varies by sex and age group, using data from South Africa and Kenya,19 where young females are three to four times more likely to be HIV-positive. Age is an overall important variable in understanding HIV prevalence, and in these two countries, older age groups have similar or greater HIV prevalence than younger age groups.
Figure 4: HIV prevalence in Kenya by sex and age group, 2004
Country-level data is useful for broadly understanding the scale of the epidemic and for assessing the implications for communication. However, HIV prevalence also varies considerably within countries. As the country reports illustrate, HIV prevalence varies between cities, regions and provinces as well as between cultural and religious groups. In Kenya, for example, HIV prevalence at the province level ranges from 0-4% in North Eastern and Eastern provinces to 15.1% in Nyanza. By ethnic group it ranges from 1.3% for Somalis to 21.8% for Luo, and by religion from 2.9% for Muslims to 6.9% for Catholics.20
HIV prevalence is also known to vary according to other factors, such as residence type. For example, in South Africa HIV prevalence in informal settlements is twice as high as the prevalence found in formal urban settlements.21
Data on HIV prevalence levels amongst particular groups is also important – for example, men who have sex with men (MSM) or commercial sex workers. Whilst small scale studies have provided insights into elevated HIV prevalence amongst sex workers, little is known about MSM as a product of marginalisation and a lack of prioritisation in African
epidemiological research.
HIV prevention-related responses
Knowledge about HIV/AIDS is generally high amongst the general population in most countries, but not uniformly high. As pointed out in the country summaries, there are variations in key individual response by sex and other factors. A few examples from the country summaries illustrate these differences:
In Botswana, 78.5% of females and 77.8% of males surveyed indicated that condoms prevented HIV, but only 23.4% of females and 25.8% of males recognised the importance of having one partner;
In Ethiopia, recognition of the importance of limiting sex to one partner was indicated by 65.4% of females and 88.0% of males, but the importance of condom use was only indicated by 33.5% of females and 60.0% of males;
In Kenya, 61.0% of females and 74.2% of males believed that HIV could not be
transmitted by mosquitoes, while in Mozambique the proportions were lower – 36.0% of females and 49.0% of males.
Practices that increased HIV risk also varied by country. Figure 5 illustrates the variations between countries for age at first sex among 15-24-year-olds. Mozambique, Kenya and Zambia have a high prevalence of early sex, and Botswana and South Africa have the lowest.
Figure 5: First sex before age 15, by country22
In relation to sexual partner turnover, there are also wide variations between females and males, and between countries. Table 2 illustrates the proportions of males and females aged 25-29 in each country who had two or more sexual partners during the year before they were surveyed. Males in Tanzania and Mozambique were most likely to have had two or more partners in the previous year, while males in South Africa and Ethiopia were least likely.
Table 2: Males and females aged 25-29 with two or more partners in the past year23
Country Females (%) Males (%)
Ethiopia 1.4% 10.6% Kenya 1.9% 13.1% Malawi 0.9% 11.5% Mozambique 5.0% 33.0% Namibia 3.1% 25.6% South Africa 4.0% 8.7% Tanzania 4.3% 33.0% Uganda 3.2% 24.8% Zambia 3.2% 24.8%
Particular individual responses to HIV prevention, such as condom use and HIV testing, are illustrated in Figures 6 and 7. Reported condom use at last sex among 15-24-year-olds is relatively high in South Africa, Namibia, and Tanzania, and very low in Ethiopia.
Figure 6: Condom use at last sex among 15-24-year-olds, by country24
Figure 7 illustrates uptake of HIV testing. Ethiopia and Mozambique have the lowest rates of testing, while Botswana, Namibia and South Africa have the highest.
Figure 7: Responses to ‘ever had an HIV test’, by country25
Variations in prevention response
Overall, in all countries, significant impacts have been achieved over time in terms of increases in knowledge, adoption of prevention behaviours and practices, and utilisation of services such as VCT. This is demonstrated through analysis of sequential national-level surveys, as well as monitoring of service uptake. These changes can demonstrably be
attributed to HIV prevention communication and related interventions as is illustrated through intervention-specific evaluations. However, relatively high levels of some risk practices still
prevail (e.g., high levels of partner turnover), and data is lacking about whether condoms are consistently and correctly used (as such information is not gathered in most surveys).
Communication campaigns at country level
The country summaries provide an overview of HIV prevention communication activities. This includes information on organisations conducting interventions and campaigns, funders of communication activities, broad themes communicated, and mediums utilised.
For the most part, national-level prevention communication is conveyed via mass media, but not exclusively so. National-level activities include information that is conveyed through interactive approaches such as drama, as well as via small media such as posters, booklets, and leaflets or branded promotional items.
Cross-cutting programmes and methodologies
Many communication interventions are conducted by non-indigenous organisations (largely headquartered in the United States) and these rely mainly on funds from major donors (such as USAID/PEPFAR among others). Intervention models are similar across countries, and implementing agencies include Population Services International (PSI), Family Health International (FHI), PATH, Pathfinder International, the Johns Hopkins University Center for Communication Program (JHUCCP), and the Centers for Disease Control and Prevention (CDC). Certain United Nations programmes (such as UNICEF, UNFPA, UNDP and UNAIDS) are also influential.
A lesser volume of funding has flowed from European funders (such as DFID, the European Union, Sida, the Norwegian Agency for Development Cooperation (Norad), the government of The Netherlands), and smaller foundations. Large foundations, such as the Bill and Melinda Gates Foundation, have not been oriented towards funding communication
programmes in the study countries, with the exception of a large grant in the early phases of the loveLife campaign in South Africa.
This is not to say that indigenous funding, leadership, or involvement in implementation of HIV prevention communication has been absent. On the contrary, all countries reviewed have national HIV/AIDS councils or commissions, one or more government departments are typically involved in HIV prevention communication,26 and state funding has been provided. In some countries, indigenous NGOs have been central to HIV prevention response at the national level (for example, The AIDS Support Organisation [TASO] in Uganda, Straight Talk Foundation, and Soul City. Approaches such as Straight Talk and Soul City products have been adapted and utilised in a number of countries).
All foreign organisations and donors mentioned have some level of interaction with indigenous organisations or governments. Interaction may take the form of bilateral arrangements, partnerships, or subcontracting arrangements. Some large flows of funding occur through particular organisations (such as the Global Fund for HIV/AIDS, TB and Malaria). These funds typically flow directly to national governments, although in some instances, the funds go directly to indigenous organisations.
Global funding strategies considerably influence prevention programming at country level. For example, USAID/PEPFAR has focused on product and service delivery – such as
emphasising the provision of ART and PMTCT services, as well as assuming a strong orientation towards programming that promotes abstinence and funding of FBOs. Funding of donor-financed interventions is time-bound – typically involving programmes running over three to five years. Many programmes are discontinued at the end of their funding periods (whether or not they are successful), with new activities being developed and new implementing agencies becoming involved. This contributes to fragmention.
There are many examples of cross-country programmes led by international organisations. PSI, for example, follows a well-established approach to the social marketing of products and services and the organisation conducts similar activities in all the study countries. In the case of social marketing for condoms, a condom brand is introduced and then marketed at a subsidised rate. Branding is nuanced utilising local language and visual treatment (for example, Chishango [‘shield’] in Malawi and JeitO [‘style’] in Mozambique). Promotional activities between countries are usually similar, like combining mass media with point-of-purchase materials, promotional events, sponsorships, branded promotional items, as well as engaging in generic prevention communication in conjunction with brand-specific
communication. In all instances this approach has led to increased sales of condoms. Condom promotion and distribution has been significantly expanded through government-implemented public-sector programmes that provide free condoms through health facilities and other sites. A number of countries have also shifted from unbranded public-sector condoms to branding (for example, Choice in South Africa and Smile in Namibia).
PSI have also been active in the social marketing of VCT services under the New Start brand name as well as promotional themes (for example, an emphasis on Trusted Partner
campaigns), while most governments have provided and promoted VCT in public-sector clinics and hospitals.
Indigenous organisations may also have a regional orientation. For example, Soul City has a regional programme that includes adaptation of its materials in a number of countries, In the current phase of implementation this has largely related to establishing links with local partners, and developing local variations of Soul City educational booklets, television and radio dramas, and providing training.
Country-level governmental and organisational approaches may also be coordinated at a regional level – for exampe, a recent Southern African Development Community (SADC) think-tank meeting reviewed issues in HIV prevention,27 with a follow-up meeting on social-change communication for HIV prevention.28
Communication approaches
The centralisation of communication and the unidirectional orientation of mass media results in limited potential to nuance communication for sub-national audiences, sectors or groups. Mass media approaches are best suited to simplified and discrete messages or themes, which can then be expanded, applied and nuanced through other forms of communication.
Approaches utilised beyond mass media include various degrees of interaction that may directly or indirectly involve interpersonal communication. Some examples are: aesthetic approaches such as drama, songs, poetry and murals; small-media approaches such as leaflets,
posters and booklets; events such as integration into sports, music, rallies or other activities; promotional and utility items such as point-of-distribution materials, key rings, peaks, umbrellas, etc.; and specific forms of interpersonal communication such as peer education, counselling, and discussion as a product of resource and service delivery.
Nuanced and localised sub-national and non-mass-media communication approaches allow for wide variations to be addressed – for example, differences in culture, language, race, religion, age, economic level, institutional dimension (e.g., workplaces and schools), and level of HIV risk (e.g., migration, sex work).
Virtually all the programmes reviewed have employed multimedia approaches, typically including a cascading communication model that devolves to activities beyond mass media. Moreover, these may be directly linked: for example, the interlinking of mass media VCT promotion with local-level promotion and service delivery.
Communication for resource-uptake and service delivery
There are many examples of successful communication involving resource uptake and service delivery. Social marketing approaches (such as those employed by PSI and others) are
directly linked to measurable objectives of service uptake. Thus, it is possible to increase the uptake of resources and services (e.g., condom sales, VCT) through appropriate monitoring and operational research.
Similar trends in resource uptake and service delivery have been observed in the promotion of public-sector condoms, public-sector VCT, and delivery of ARVs. The PEPFAR programme is also particularly oriented towards numerical monitoring and quantification of resource uptake and service delivery.
Assertive and coordinated campaigns can have a rapid impact on resource uptake and service delivery. For example, Botswana’s systematic emphasis on VCT has seen a rapid response, while in South Africa the introduction of systematic logistics around public-sector condoms has resulted in a high perception of ease of access to condoms, alongside increased levels of reported condom use at instance of last sex.29
Communicating for HIV prevention
It is important to stress that HIV prevention is multi-dimensional, involving infection in relation to particular risk factrs. All countries reviewed include systems for communicating information about various modes of transmission, as relevant. For example, screening of blood supplies is centrally conducted in all countries. Similarly, global and country-level policies, strategies and systems include programmes for addressing PMTCT and syndromic management of STIs. Intravenous drug use is not extensive in African countries at present – although it may potentially increase. There is also complacency in terms of promoting an understanding of universal precautions in general as well as in healthcare settings, including traditional healing contexts and related practices (e.g., circumcision and scarification).30 Coordination of campaign themes and approaches is fostered in various countries through national structures and networks, for example national communications strategies (in some countries), networks and partnerships.
Centralised resource centres (e.g., the AIDS Resource Centre in Ethiopia and the Red Ribbon Centre in South Africa) allow for dissemination of materials through a wide variety of organisations, allowing for consistent messages. Telephone helplines also help provide more detailed responses and break down myths.
The overarching framework of prevention communication in the study countries includes an emphasis the ABC message: ‘abstain, be faithful, condomise.’ But it is clear from the statistical data that this emphasis has not been sufficiently nuanced. As various survey data indicate, delayed debut of first sex and reduction in partner turnover, for example, have not been sufficiently addressed.
An increase in uptake of VCT has occurred in most of the countries, although it is unclear whether or how such uptake has influenced HIV prevention.
‘Higher-risk’ groups
In all the countries reviewed the predominant emphasis remains a focus on primary prevention among young people. Even so, this is contradicted by overall epidemiological trends on a number of levels. In the first instance, HIV vulnerability is gendered, with females – particularly young females – being three to four times more likely to be HIV-positive than males in the same age group. While part of this difference is accounted for biologically, it is clear that vulnerability is also socially driven. For younger girls, evidence exists that HIV infection is introduced into this youth cohort in part by interaction with older males.31 However, the predominant focus of youth campaigns is on the risk of HIV infection as a product of sex between young people – thus the culpability of older adults in youth vulnerability is de-emphasised. Although this is not exclusively the case, a number of countries do have messages that consider gender issues, but these are patchy at best. Even as there has been a focus on sex work and mobility in relation to HIV risk, this has largely been contained to border areas and main transport routes, rather than at the national level.
Interventions have been extended to uniformed services, including the military and police, and various other sectors, such as agriculture.
There were no extensively resourced national programmes that addressed MSM. Similarly, there was no extensive resourcing of HIV prevention communication that addresses groups with disabilities, such as the blind (although some countries have produced a small number of specialised materials).
PLHA who are aware of their status are integral to thinking in relation to so-called high-risk groups, given that they may have HIV-negative sexual partners. The concept of focusing on HIV-positive individuals in prevention campaigns is not apparent, although some VCT interventions (e.g., in Uganda, Kenya and Zimbabwe) include post-test clubs as part of VCT service delivery.
Conclusions
The following broad conclusions are drawn in relation to national HIV prevention interventions reviewed:
The overall delivery of communication messages pertaining to awareness of AIDS, and knowledge of key aspects of the disease are extensive, and campaigns are impactful A number of communication interventions are well-theorised and include theoretical models to support their communication strategies. The vast majority of interventions have addressed the importance of communicating in indigenous languages, and extensive reach is achieved through use of broadcast, print and outdoor media.
International and non-indigenous organisations provide an important contribution to country-level communication interventions;
A number of indigenous interventions have been sustained over long periods, and for the most part have systematically expanded their activities within their respective countries; Some are now providing models, support and resources in other countries (e.g., Straight Talk and Soul City).
Promotion of uptake of prevention-related services such as VCT and PMTCT has been successful, and while communication of service uptake is relative to resources on the ground, where these services and resources exist uptake can be achieved quite rapidly. Certain approaches, in particular the social marketing of condoms or VCT, and the promotion and distribution of public-sector condoms or VCT services, have been replicable across countries.
Considerable expertise for prevention communication exists in the region, via indigenous and non-indigenous organisations.
Concerns include:
There is limited focus on prevention communication as a broad category of intervention that requires audience attention to all modes of HIV transmission – not only [hetero]sexual transmission.
Some non-indigenous interventions are constrained by donor and organisational agendas that are not explicitly coordinated at the country level nor with country-level stakeholders. Where indigenous organisations are drawn in, they are often junior partners.
Fixed-period funding of interventions can result in fragmentation of prevention communication, with a loss of sustained emphasis and expertise.
The overwhelming emphasis and resourcing of youth programmes has not translated into significant prevalence reduction among youth, and this requires attention.
Expanded emphasis on adults in the high prevalence age range of 25-35 years, as well as older persons, requires urgent attention.
Although girls and women are significantly more vulnerable to HIV as a product of biological, socio-cultural and economic factors, few programmes focus extensively on communicating and addressing these disparities.
Very few HIV prevention communication interventions explicitly involve PLHA, are led by PLHA or directed towards PLHA.
There is insufficient focus on commercial sex work beyond border and trucking routes, and very little attention given to men who have sex with men.
Implications
The implications of these conclusions are:
Prevention goals and strategies need to be aggressively set in relation to short-term outcomes and impacts that are specific to HIV risk. These should be prioritised at country level and led by national governments. The promising finding of prevalence reduction in Malawi, Kenya, Uganda and Zimbabwe illustrates that impact can be achieved in a short period if the key epidemic drivers are addressed.
Change in the proportions of young people having sex before age 15 and before age 18 should be envisaged as an urgent goal, particularly in contexts of high HIV prevalence where early sex carries a high risk of infection. Such changes have had a demonstrable impact on HIV prevalence.
Framing goals towards limiting an individual’s lifetime number of sexual partners and reducing partner turnover may stimulate the refining of behavioural communication strategies towards this goal. It would also allow guiding of understanding of risk away from addressing individuals only, towards addressing HIV risk in contexts of risk. Concurrent sexual partnerships carry a heightened risk of HIV infection and this is a
significant factor driving the epidemic. Communication relevant to increasing an
understanding of the risks that accompany having concurrent sexual partners merits urgent attention.
Overall, there have been high levels of response to condom promotion and a high uptake of condoms alongside high levels of reported condom use at last sex. However, these high-use levels have not translated into significant impacts on prevalence, which suggests that condoms may be inconsistently or incorrectly used. The importance of correct and consistent condom use is typically not emphasised in campaigns, and this deficiency should be addressed.
Communication interventions need to shift from over-emphasis on HIV prevention directed towards youth, to urgently address middle age-ranges where HIV incidence is high (i.e., the 25–35 age group, and older age groups).
To date, interventions have seldom focused on PLHA in spite of an increasing proportion of individuals who know their status as a product of expanded VCT service delivery and uptake. PLHA have diverse communication needs and their important role in HIV prevention needs to be addressed.
Commercial sex work should be addressed at an expanded level throughout countries, and assessing and targeting risks related to men who have sex with men requires attention.
Epidemiology-led prevention communication
In the final analysis, HIV prevention communication needs to be be led by a comprehensive understanding of HIV epidemiology within each country, while prevention communication interventions need to be designed with specific epidemiological goals in mind. The approach needs to focus on very specific short-term goals related to achieving declines in national and sub-national prevalence and incidence levels, and among relevant groups and sectors of the
population. A specific focus on addressing the disproportionate risk to girls and women requires urgent attention.
Monitoring and evaluation indicators need to be reviewed and expanded, both to inform the design of communication interventions, and to monitor the impacts of communication interventions. At present there is insufficient understanding of sexual debut, lifetime numbers of sexual partnerss, relative duration of sexual partnerships, concurrent partnerships, correct and consistent condom use, and other aspects relevant to prevention epidemiology. National surveys seldom attempt to measure the impacts of communication interventions.
Prevention communication is seldom explicitly linked to evidence-based incidence and prevalence goals, and thus interventions are sustained in a milieu of presumed impact, rather than demonstrable impact. This passive approach has limited the accountability of
interventions, in spite of the massive resources committed and expended.
Key questions to inform prevention communication strategies and the stock-taking of interventions include:
Are HIV prevention communication interventions led by HIV epidemiology in each country?
Are vulnerable and marginalised groups effectively taken into account?
Do HIV prevention communication interventions take into account variations in HIV epidemiology within each country?
Are HIV prevention communication goals sufficiently aligned with short-term and long-term goals for achieving HIV prevalence and incidence declines?
Are HIV prevention communication interventions sustainable, and are interventions with demonstrable impact sustained for sufficient periods of time?
Are HIV prevention communication interventions measured against appropriate indicators of change?
COUNTRY SUMMARIES1
1
Note that data was gathered during 2006, with an emphasis on current programmes operating at national level. Programmes and interventions that were not fully established may not be included.
BOTSWANA
The population of Botswana is estimated to be 1,765,000.32 An estimated 270,000 people, 15.3% of the total population, are HIV-positive.33 Antenatal HIV prevalence is 38.5%. The urban-rural population ratio is 54:46, and urban-rural antenatal HIV prevalence is 34.4% vs 39.9%.34 Anestimated 14,000 children are living with HIV, and there are an estimated 120,000 orphans aged 0-17 due to AIDS.
HIV prevalence varies considerably by age and gender, with young males aged 15-19
considerably less likely to be HIV-positive than females (3.1% vs 9.8%). This pattern persists in other age groups; for example, for 20-24-year-olds the comparative rates are 9.1% for males vs 26.2% for females, and for 25-29-year-olds, 22.9% for males vs 41% for females. HIV prevalence in the 50-54 age group is 23.3% for men and 19.3% for women.35
HIV prevalence among males and females aged 15-49 also varies by place of residence, with Chobe having the highest (29.4%) and Kgalagadi South (11.8%) and Kweneng West (10.8%) having the lowest.36
Key individual responses: Botswana
HIV prevention-related knowledge (15-49 age group)37 Females Males All
Use condoms 78.5% 77.8% -
Abstain from sex 52.1% 49.0% -
Have one partner 23.4% 25.8% -
HIV can’t be transmitted by mosquito bites38 49.6% 49.4% -
A healthy-looking person can be HIV infected39 76.1% 74.6% -
HIV prevention-related practices
Had sex before age 15 (15-24 age group)40 - - 7.0%
Used a condom at last sex (15-19 age group)41 - - 85.1%
Used a condom at last sex (20-24 age group)42 - - 80.0%
Knowledge of PMTCT and ARVs (15-49 age group)43
ARVs prevent infection - - 66.6%
Engagement with PLHA (15-49 age group)44
Know someone with HIV 32.6% 27.1% -
Would not want to keep a family member’s HIV status secret 63.8% 68.9% - Willing to care for a family member with AIDS 93.5% 90.7% - HIV-infected teacher should be allowed to teach 73.4% 66.3% - HIV testing (15-49 age group)45
Ever-tested 30.3% 19.5% -
PMTCT and ARVs46
Pregnant women receiving PMTCT treatment 60.3% - -
BOTSWANA: HIV prevention communication
The national strategy for behaviour-change interventions and communications in Botswana builds on the National Strategic Framework for HIV/AIDS (2003-2009) and guides the national communication response.
Decentralisation of the national response is being achieved through the development of multi-sectoral AIDS committees at the district and village levels. Communication activities aim to promote accurate information, stimulate community responses, build capacity, help people recognise and change risk behaviour, and empower PLHA.
The African Comprehensive HIV/AIDS Partnership (ACHAP)47 and the National AIDS
Coordinating Agency have developed an intervention entitled the Get Involved Campaign, utilising mass media. Plans include creating advertising on buses, which will draw on traditional Setswana proverbs in combination with photographs; the adverts will list an HIV/AIDS hotline that in turn can refer individuals to information/counselling centres. The Botswana Network of AIDS Services Organizations (BONASO) is an umbrella body of all AIDS service organisations in Botswana and was registered in 1997. Its mission is to facilitate a coordinated response to the changing needs of HIV/AIDS service organisations through capacity-building, information-sharing, advocacy and lobbying. A small grants project was started in October 2001 with financial support from ACHAP to cover four years. The project aimed to support HIV/AIDS-related community-based initiatives that work towards preventing new infections by means of education and awareness, stigma reduction, care and support, and community mobilisation through outreach activities, and theatre and drama. Partnerships include Japan International Cooperation Agency (JICA) and the United Nations Fund for Women (UNIFEM).
A radio drama called Makgabaneng (‘Rocky Road’) is broadcast throughout Botswana in two 15-minute episodes per week over two national stations.48Makgabaneng first aired in 200149 and follows the MARCH50 methodology initiated by the United States Centers for Disease Control and Prevention (CDC). It has run through 2006. A cross-sectional survey in 2003 found that nearly half the respondents listened to the drama at least once a week and the regular listeners were more open to HIV testing and knowing their status.51
USAID, the African Youth Alliance, BONASO, the National AIDS Coordinating Agency, ACHAP, and the Botswana government have initiated a prevention programme linked to the Corridors of Hope project being implemented in other SADC countries. The programme targets mobile populations, focusing on safer-sex practices through peer education and outreach activities.
The Botswana USA Project is a collaboration between the Botswana Ministry of Health and the CDC and has worked since 1995 to implement AIDS and TB programmes. Since 2000, Tebelopele centres, supported by the Know Your Status and Show You Care campaigns, have formed part of a VCT promotion strategy that was developed by the CDC in collaboration with PSI. These campaigns have been marketed through billboards, bus shelter ads, banners, print advertisements and regular radio programmes throughout Botswana. By October 2005, the network had expanded to sixteen centres and eight satellite centres and had provided free VCT services to over 230,000 visitors.
PSI has marketed Lovers Plus condoms since 1993 and Care female condoms since 2002. This initiative has been carried out in conjunction with multi-media advertising campaigns. In 2003, the Government of Botswana, with funding from ACHAP, launched an extensive condom distribution and marketing campaign, installing 10,500 condom dispensers in traditional and non-traditional venues throughout the country.
The government of Botswana, the UN Foundation and UNAIDS conduct an Urban Youth Project. The project’s target groups include street children, orphans, young sex workers, and unemployed youth. Project activities include communication and skills-building, provision of youth-friendly health services, advocacy, and addressing gender inequality and income generation.
The Youth Health Organisation, a youth-run NGO with support from the CDC, promotes sexual health among young people aged 14–29 through art festivals, drama, peer education and group discussions. School-based plays educating young people about HIV and AIDS have been developed with the Ministry of Education. Particular initiatives include: The Peer Education Programme, The Media and Advocacy Programme (which supports youth initiatives through electronic and print media), The Voice of Life (a 30-minute radio programme on Yarona-FM)and the Theatre and Arts Programme. Advocates for Youth assists the group in its efforts to increase youth participation in policymaking bodies by offering advocacy and leadership skills training sessions.
Talk Back is a live interactive television programme aired weekly on Botswana Television. It is the main communication vehicle of the Teacher Capacity-Building for HIV/AIDS
Prevention in Botswana, implemented by the Ministry of Education with support from UNDP and ACHAP. The programme allows post-broadcast discussion and it reaches teachers and students in nearly 1,000 educational institutions.52 The programme won an international award at the Highway Africa Awards for innovative use of new media in 2004.
The African Youth Alliance is a partnership-based intervention.53 Focused primarily on youth, but also addressing intermediaries (such as healthcare workers, teachers and youth workers), its overall theme is to promote responsible sexual behaviour. Specific strategies are divided between the partners and include: policy and advocacy led by UNFPA, behavioural
communication and livelihood skills development led by PATH, provision of youth-friendly services led by Pathfinder International, and coordination and dissemination of information by UNFPA. A condom-promotion campaign called 53Youth Voices uses stage shows, dramas, and capacity-building activities to promote youth-friendly services.54
In 2000, PSI together with the African Youth Alliance established a radio programme called Straight Up, which combines music, question-and-answer sessions and listener call-ins. Key to this campaign has been providing sexually active youth with HIV prevention skills. In 2001, an educational booklet targeting 12-16-year-olds and titled Choose Life was produced by the Soul City Institute for Health and Development Communication55 in partnership with PSI and with support from DFID. This partnership was extended for 2006. Choose Life initiatives also include an edutainment radio series (26 episodes, in Setswana) that is aimed at youth between 8-12 years, and the distribution of booklets titled Living Positively and Violence Against Women.
UNICEF’S Unite for Children, Unite Against AIDS campaign focuses public attention – through mass events and media – on the ‘four Ps’56 : prevent HIV infection among
adolescents and young adults, prevent mother-to-child transmission of HIV, provide paediatric treatment, and protect and support children affected by HIV.
To assist young people living with HIV, ACHAP is supporting The Centre for Youth of Hope. The centre’s activities include the annual production of The Miss Stigma-Free
competition which brings together HIV-positive women as contestants in a pageant; the winner goes on to become a ‘positive living’ role model and an activist in advocating for prevention, de-stigmatisation and ARV adherence.
The Botswana National Youth Council in collaboration with Panos Southern Africa and Southern African AIDS Dissemination Services carried out a gender-specific HIV-prevention project called Men, Sex, and AIDS and also produced a booklet. The booklet focuses on harmful cultural beliefs and practices that contribute to the spread of HIV.
Delayed sexual debut is promoted by the South African Youth initiative,57 whereby support
for OVCs is provided through UNICEF, and a ‘Know your status, know your rights’ campaign is run by the Botswana Network on Ethics, Law and HIV/AIDS. The latter campaign provides support to PLHA through radio advertising, small print media and workshops.58
The CDC supported the Total Community Mobilisation programme, a door-to-door campaign that uses peer educators to deliver information on HIV prevention and treatment in five health districts.
ACHAP have supported the efforts of the Botswana Christian AIDS Intervention Programme in its efforts towards the destigmatisation of HIV through community mobilisation and outreach programmes.
