AIDS Alert International: Sub-Saharan strategies best when tailor-made
Sub-Saharan strategies best when tailor-made
There is no one-size-fits-all message
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When a discussion about HIV risk takes place in some areas of Nairobi, women typically will say that they do not engage in high-risk behaviors because they don’t visit bars or the usual hot spots. That’s when a prevention message needs to be designed expressly for a specific community’s habits and customs, because what the women fail to express and perhaps do not even realize is that they do indeed engage in high-risk behaviors. They may not visit bars, but when they fetch water or wood in the evening, they often meet men and have sex, says Jean-Louis Lamboray, chief of technical network development with UNAIDS in Geneva, Switzerland. "Young people will say they go to church, particularly at Christmas, and they sing in the choir," Lamboray says. "But that’s only the official reason why they go to church."
Evening choir practice also can be a place where young men and women meet to have sex and therefore place themselves at risk of HIV infection. The way in which people place themselves at risk is not important, Lamboray says. "What’s important is that by this process of discussion, they start owning the issue and solution, and that’s what is needed before prevention can begin."
Community meetings are working
Holding community meetings in which HIV risk behaviors are discussed is one prevention strategy that appears to be working in parts of sub-Saharan Africa. Another strategy involves modifying traditions or customs that create opportunities for risky behavior. For example, in one region of Tanzania, it is customary for funerals to last 30 days. During this time, people in the grieving village will engage in indiscriminate sexual activity. Religious leaders, political leaders, and others decided that the way to reduce HIV risk and still preserve the region’s funeral tradition was to reduce the funeral period from 30 days to three days, Lamboray says. These types of solutions, while not perfect, can make a difference.
In other regions, the prevention efforts may more closely resemble those that Western nations use. For instance, in the Gaoua Province in Burkina Faso, an HIV/AIDS facilitator came into the province and mobilized the society to think about the implications of AIDS, Lamboray says. Starting in a central district of about 70,000 people and then expanding to include 300,000 people, the project reached community groups, women’s associations, churches, schools, and others, teaching everyone involved to reflect on what AIDS does to their lives. Then people came up with a plan, which went through the usual problems in terms of delays and funding before something interesting happened, Lamboray says. "There was an ownership of the plan."
The community said it wanted to move faster to distribute condoms and to open testing facilities. "It was the health sector that was more reluctant than the society as a whole," Lamboray says, adding that health care workers in sub-Saharan Africa sometimes are uneducated about HIV and AIDS and therefore fear people with the disease. With assistance from the World Bank and UNAIDS, every single village in the province now has access to funding for their prevention plans, he adds. "These are the activities that make us confident that Africa is turning the corner on AIDS," Lamboray says.
Evidence of the changing tide includes a reduction of HIV prevalence among young people in many sub-Saharan communities. There are also signs that religious groups are working with young people in efforts to improve prevention.
Treating the body and mind
In Zambia, the Chikankata Hospital has had a program for the past 15 years called "Care for Change." The program provides both medical and psychosocial care to people who are sick. Eventually, the program’s work taught the community about the dangers of HIV and high-risk behaviors, and it has led to a change in one risky tradition in which the wife of a deceased man would have sex with the man’s brother, Lamboray says. "Those communities have replaced that inheritance with a symbolic inheritance," he explains. "That was a process where the authorities changed the social norm because they realized the social norm was making them vulnerable to HIV."
In Mwanza in Tanzania, the community has started a method of mapping risk. This is a self-administered process in which women, men, and youths sketch the places where they have put themselves at risk for becoming infected with HIV. The first benefit of this process is that it breaks down individuals’ first line of denial and exposes various risk behaviors.
Also in Tanzania, there is a youth theater that teaches people about AIDS through entertainment. The young actors and actresses learn about HIV and AIDS, observe people’s risk behaviors in their own communities, and then portray these examples in a play before an audience from the community. "People in that community have major emotional reactions to the theater, with some saying, This is not happening here,’ and others responding, Oh, come on man, we are living here, have you forgot?’" Lamboray says. "Then people shout out, Anyway, who told you our secrets?’"
A horizontal process
The chief idea behind this hodgepodge of prevention efforts is that it’s a horizontal process in which each community starts with its hope for a change and learns strategies for creating change in the process of sharing with others, Lamboray says. "When people start taking the chance, they continuously want to share their know-how with neighbors, members of clubs, their churches, etc., so that the decision-making process spreads," Lamboray explains.
The key is to remember that each country and community within a country are different and have diverse cultures and traditions and social norms. So while top government officials in Uganda have spoken out about HIV/AIDS and radio messages and condoms are available as prevention tools in that nation, this won’t work in many other countries, Lamboray says. "If we reflect on what we have learned, people decide the outcome of AIDS and technology, and money and information facilitates their responses but cannot substitute for them," Lamboray notes. "Very often we don’t recognize the processes by which people own their response, and that’s why we don’t fund them."
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