AIDS and cultural practices in Africa: the case of the Tonga (Zambia)

The fight against AIDS in Africa is often presented as a fight against "cultural barriers" that are seen as promoting the spread of the HIV virus. This attitude is based on a long history of Western prejudices about sexuality in Africa, which focus on its exotic aspects only (polygamy, adultery, wife-exchange, circumcision, dry sex, levirate, sexual pollution, sexual cleansing, various beliefs and taboos, etc.). The article argues that those cultural aspects are a wrong target of AIDS prevention programs because they are not incompatible with a safer behavior, and because their eradication would not ensure the protection of people. To fight against them might alienate the people whose cooperation is necessary if one wants to prevent the spread of AIDS. The major problems of AIDS prevention in Africa are not specifically African, but are similar to the problems existing in Europe or America. Therefore, anti-AIDS projects should not fight against one local African culture in order to impose another (Western), but should rather try to make behavior and practises safer in a way that is culturally acceptable to people.     

ASIA-The New Epidemic Zone for HIV/AIDS

Two articles that appear in this journal present unique ethnographic assessments of the commercial sex industry in Thailand. They discuss how culture, society, and organizations interact with respect to communication approaches, information dis semination , and organizational - behavior change in preventing the spread of HIV/AIDS. Each of these articles provides important insights into the many factors that have intensified the epidemic as well as those identified opportunities for concerted community organization, behavioral reinforcement, and social structural approaches for HIV/AIDS prevention and control.     

Injection drug use: harbinger of HIV / AIDS

The spread of HIV infections in southeastern Asia is expected to be significant. In this area, as in other parts of the world, the habits of intravenous drug users (IDUs) who share needles and supplies and engage in high-risk sexual behavior will contribute to the spread of the disease in the general population. Because drug treatment programs that promote abstinence are only successful among the limited number of drug abusers who are motivated to stop taking drugs, a harm-reduction approach to this problem makes the best sense. Reducing HIV risk requires giving priority to HIV prevention rather than to control of drug use. Interventions to prevent HIV transmission among IDUs include counseling for in-treatment drug users, needle and syringe exchange programs, and preventive intervention programs that attempt to change high-risk behavior. In India, drug abuse has a long history, and the northeastern states have experienced a rapid increase in heroin use accompanied by the spread of HIV infection. In other areas, injection of Buprenorphine is increasing. It is important to recognize IDUs as a group at high risk of transmitting HIV infection and to design strategies, such as those that have been successful in New York City, to stabilize sera-prevalence in this rapidly increasing group.     

我国艾滋病防治领域非政府组织绩效评价体系构建研究

非政府组织已经成为我国艾滋病防治工作中的一支重要力量。在其蓬勃发展的同时也暴露出一些不足。绩效评价体系的建立,可以发现非政府组织发展中的不足和困境,从而为艾滋病防治工作提供决策参考。当前我国艾滋病防治领域非政府组织的绩效评价工作仍处于起步阶段,评价目标、主体以及指标方法都有待进一步完善。在今后的工作中,需要明确组织的公益身份,提高评估意识;建立多层次、专业化的评估队伍,确保评价全面;结合艾滋病防治领域现状,保证指标具体化,方法科学化。     

Country watch: Malawi

The Drought Network for information sharing eventually led to the establishment of the more formal Southern Region AIDS Network (SORAN) where representatives from government and nongovernmental organizations (NGOs) focused on awareness raising, lobbying, and advocacy. As an initial step towards networking on HIV/AIDS issues, a festival was organized in Blantyre on December 4, 1993, by NGOs, private companies, church groups, school children, and volunteers to bring about behavior change. About 2000 people gathered to listen to music, learn about HIV transmission through drama group presentations, watch videos with HIV/STD prevention messages, and learn about proper condom use. The participants officially established SORAN in February 1994 to act as a coordinating body for organizations working in prevention and care for HIV/STD-infected persons and their families. Network activities endeavored: to assist organizations interested in developing HIV/AIDS programs and activities; to encourage the business communities to participate in multisectoral coordination and to help channel funds from them to HIV/AIDS programs; to act as a resource center for information about HIV/AIDS; and to lobby among politicians as well as traditional local and religious leaders. When the first multi-party parliamentary election approached in May 1994, SORAN challenged representatives of 7 political parties and a women's organization to speak out publicly on what they envisioned doing about HIV/AIDS. The Grand Walk was also organized by SORAN members representing the Catholic Episcopal Conference of Malawi, the Protestant Blantyre Synod, a local brewery, and UNICEF. About 500 walkers received support from passersby. 70% were school children 10-18 years old who sang AIDS awareness songs and passed out flyers. Three months later the National AIDS Program's Big Walk for AIDS, following a National AIDS Crisis Conference, signaled the government's public recognition of the need for a multisectoral approach to combatting HIV/AIDS.     

Primary Prevention of Sexually Transmitted HIV Infections: Transferring Behavioral Research Technology to Community Programs

Behavioral research to prevent the spread of human immunodeficiency virus (HIV) infection has made significant progress over the past decade. Most importantly, studies have repeatedly shown that theory-based prevention interventions that build self-efficacy through self-management and communication skills training successfully reduce HIV risk behaviors. Simultaneously, communities have mobilized to develop programs that assist persons in reducing their risk for HIV infection. The degree to which behavioral sciences have contributed to community-based HIV prevention programming is examined in this paper through a systematic assessment of technology transfer in the area of sexual risk behavior reduction. We analyzed the content of twelve community-based HIV risk-reduction programs targeting gay and bisexual men developed by seven of the nation's largest AIDS service organizations. Telephone interviews were conducted with community program developers to determine the source of their programs and whether they had been influenced by behavioral sciences. Evidence was mixed with respect to the degree to which behavioral sciences have contributed to the development of community-based programs. Program elements often reflected research-based models but with questionable fidelity. Evidence for diffusion of research-based information occurred most often when community organizations received direct consultation from behavioral scientists. We suggest that technology transfer in HIV prevention requires behavioral scientists working in communities to serve as translators of theoretical constructs for practical applications. Preventing the spread of HIV could therefore be improved through partnerships between behavioral researchers and communities.     

Knowledge, attitudes, beliefs, and behaviors of the business community relative to HIV-AIDS

One of the goals of the Centers for Disease Control's (CDC) policy on the prevention of human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) is to support business organizations in implementing HIV and AIDS information, education, and prevention activities. However, the response of the American business community to HIV infection and AIDS has been varied. Although company executives consider AIDS to be one of the leading problems in the country, surveys typically indicate that less than one-third of businesses have or are developing some type of AIDS policy. The workplace appears to be a valid site for AIDS information and education programs, given the weight employees attach to information received there. However, workplace education and information programs are undertaken primarily by large companies. Many small companies do not devote much time and effort to these activities, even though extensive, indepth educational programs are likely to have positive impacts on worker attitudes and behavior, whereas short programs or literature distribution may only increase workers' fears. The question of what is an effective workplace program still needs additional research. Very little is known about the magnitude of the costs of HIV infection and AIDS to business. These costs, which are affected by the changing roles of employer-based health insurance, cost shifting, and public programs, will influence how employers react to the epidemic and how they respond to CDC's prevention initiatives.     

HIV Infection and AIDS in Africa and the Third World

Acquired immunodeficiency syndrome (AIDS) threatens to undermine the health status and economic development of Third World populations unless there is global cooperation to prevent the further spread of infection. Poor people in developing countries are considered to be at greatest risk of developing AIDS because their immune systems have been compromised by prior infections. The poor are further placed at risk by their lack of accessibility to health care services and information about AIDS. Despite a host of competing health problems (e.g., childhood diarrhea and malnutrition) and scarce funds for mass educational campaigns, some Third World countries have launched government-sponsored prevention programs. Leaders in this area include Zambia, Rwanda, Uganda, and Brazil. The fact the 90% of those with AIDS are in the economically productive age group (10-49 years) has serious implications for the future of Third World countries. In Zaire, for example, it has been projected that premature deaths from AIDS will reduce the gross national product by 8% in 1995. The World Health Organization (WHO) is in the best position to spearhead the global campaign against AIDS and has called for the integration of AIDS prevention activities into family planning programs. The US's withdrawal of financial support from family planning programs that provide abortion and its reduction in recent years in its contributions to the WHO general budget are unfortunate, given the need for massive international assistance to stop the transmission of AIDS in developing countries.     

Activities of the Centers for Disease Control in AIDS Education

The aim of the Centers for Disease Control (CDC) is to educate individuals about protecting themselves from becoming infected with HIV because there is no vaccine or therapy; this approach can be effective in controlling the epidemic. An estimated 1-1.5 million Americans are infected with HIV; the people are largely asymptomatic. The educational programs are designed to modify behaviors that affect the spread of HIV; namely, sexual intercourse with an infected person, using needles an infected person has used, or having a baby while infected with the virus. Within the Public Health Service, CDC has an AIDS prevention program that includes information and education programs directed toward the general public, school and college-age youth, persons at increased risk for infection, and health workers. 1 group at risk is teenagers because of their behaviors in sexual activity and drug use. Since 1987, the CDC school health program has been carried out by the Office of School Health and Special Projects, Division of Health Education. The program includes working with 15 state and 12 local departments of education in areas with a high cumulative incidence of AIDS. Additionally, national AIDS education training centers have been established to help personnel plan and implement programs; 15 national private section organizations help schools provide effective AIDS education. Educational resources also are developed and disseminated by CDC, such as a computerized bibliography and guidelines for education. National working meetings about AIDS education have been held by CDC for private, local, state, and national departments and organizations.     

Progress in efforts to prevent the spread of HIV infection among youth.

The Human Immunodeficiency Virus (HIV) that causes AIDS will continue to threaten public health for years to come. Despite some popular misperceptions, adolescents are at risk of infection. Twenty percent of persons reported with AIDS have been ages 20 through 29. Given the long incubation period between HIV infection and AIDS, some of these young adults probably were infected while they were teenagers. Young people must develop the skills they will need to avoid HIV infection and other related health problems. In 1987, the Centers for Disease Control (CDC) launched a national program to help schools and other agencies that serve youth across the nation provide effective health education to prevent the spread of HIV. CDC supports and works closely with national health and education organizations, State and local education agencies, colleges and universities, and local health departments to establish HIV prevention policies and programs, training and demonstration centers, information development and dissemination activities. The impact of these efforts are assessed through applied surveillance and evaluation research. Through this system, CDC is attempting to institutionalize the means for continuously providing educational programs that will be effective in preventing HIV infection and other important health problems.     

The indirect cost of AIDS

AIDS afflicts mainly people aged 15-45 years. The syndrome seriously threatens the social and economic development, and even political stability, of nations by depriving them of citizens in their most productive years. AIDS now dominates public health programs and health services in several countries and may eventually dominate in many more. As the number of AIDS cases rises steeply over the next few years, the economic, social, political, and cultural impact will be difficult to control. AIDS deserves special attention. The spread of AIDS, HIV, sex education, risk groups, desired interventions, and saving costs are discussed. Public health surveillance for HIV is critical in areas where an extensive spread of the virus has not yet occurred. Nongovernmental organizations can play a vital role in prevention, care, and community support programs.     

Enhancing HIV prevention requires addressing the complex relationship between prevention and treatment

Abstract

Globally each year, HIV continues to infect millions of people, and the number of people living with HIV and AIDS grows. While there has been an increase in funding for HIV and AIDS, there is a growing gap between the funds available and the funds needed for both prevention and treatment. Yet, one of the means of closing that gap – preventing new infections – has slipped down the agenda. In arguing for a significant intensification of the HIV prevention response, and the relevance of a strong social stance within this response, this paper addresses the need to manage finding a balance between prevention and treatment and care. Not only is there not enough being spent on HIV prevention, but also in some instances, the prevention agenda has been hijacked by those who favour morally conservative, but ineffective, HIV prevention strategies. We argue that effective prevention needs to be firmly located within the everyday realities affecting communities and societies, and needs to focus on what is known to work. In particular, we need to move beyond a public health underpinned by neo-liberal notions of agency and individual responsibility to a public health that recognises the collective nature of epidemics, and works with communities and networks to transform social relations. This latter, more ‘social’ public health, is concerned with the social, political and economic factors that produce HIV risk and responses to it. Contrary to what some might suggest, HIV prevention has not failed, rather, governments and donors have failed HIV prevention.     

Using goal setting as a strategy for dietary behavior change

Recent reviews have noted that behavioral theory-based nutrition education programs are more successful at achieving food behavior change than knowledge-based programs and that a clear understanding of the mechanisms of behavior change procedures enable dietetics professionals to more effectively promote change. Successful dietary behavior change programs target 1 or more of the personal, behavioral, or environmental factors that influence the behavior of interest and apply theory-based strategies to influence or change those factors. Goal setting is a strategy that is frequently used to help people change. A 4-step goal-setting process has been identified: recognizing a need for change; establishing a goal; adopting a goal-directed activity and self-monitoring it; and self-rewarding goal attainment. The applications of goal setting in dietary interventions for adults and children are reviewed here. Because interventions using goal setting appear to promote dietary change, dietitians should consider incorporating the goal-setting strategies to enhance the behavior change process in nutrition education programs.     

Improving community support for HIV and AIDS prevention through national partnerships.

If the transmission of human immunodeficiency virus (HIV) is to be prevented, the environment in which people live should predispose them to engage in and sustain safe behaviors. Too often in public health, the range of organizations that make up that environment are overlooked, and prevention strategies are limited to familiar medical and public health institutions. Improvement in public health does not occur in isolation, apart from the other institutions of society--and so it is with the HIV-AIDS epidemic. Education; business and labor; religion; government; voluntary, civic, and social organizations; and the media can all serve as facilitators or as barriers to creating the environment--at the national, regional, State, or local level--that will prevent and control the spread of HIV infection and AIDS and support the needs of those already infected. Collectively, they become a comprehensive HIV prevention network with access to and influence on the total public. One of the most significant benefits of this network is the multiplier effect on the limited resources of public health. Therefore, as part of its HIV and AIDS prevention strategy, the Centers for Disease Control (CDC) has developed national partnerships to involve the leadership of business, labor and industry, religious institutions and organizations, and voluntary organizations in HIV and AIDS prevention and service. Some of these partnerships are federally funded, others are not. The national partnership program described in this paper has produced increased resources for HIV education and services and has demonstrated the synergistic benefits resulting from public and private cooperation in addressing the HIV epidemic.     

Reorienting health and social services

The global HIV/AIDS epidemic poses the particular challenge of how to concentrate resources and bring about results without provoking stigmatization against those groups who are highly vulnerable. AIDS-based discrimination is increasing around the world and is manifested in the unwillingness to fund programs claiming that the victims are at fault. This means that sexually transmitted diseases (STDs) and AIDS programs are responsible for promoting nondiscriminatory approaches. STD treatment programs generally provide pre- and post-test counseling, but broader antistigmatization efforts have been carried out by AIDS service organizations and nongovernmental organizations. A well-developed response to HIV/AIDS and STDs involves service and program providers, community health workers, traditional health practitioners, general and private practitioners, pharmacists, traditional birth attendants, and social workers. Outreach staff need to link with community workers and volunteers close to the client groups. HIV/STD diagnosis and treatment programs need to be coupled also with intensive community-led prevention and support activities in order to influence sexual behaviors. Programs conducted in this spirit share information more easily, provide authoritative roles for nonbiomedical workers, and have clear goals that are supported by the clients. These programs forge alliances between clients, service providers, and community leaders. The underlying concept of human rights embraces a broader perspective looking for the determinants and remedies for vulnerability to HIV/STD. HIV/AIDS/STDs must be fought to defeat both the virus and social backlash. This two-pronged struggle requires the reorientation of health and social services centering on partnerships and a conducive management style. Health and social services can be constrained by a trend toward reduced funding, but HIV-affected communities induce them to change whereby new partnerships could be forged.     

Issues in the evaluation of AIDS education programs. The case of California

Health education is currently considered the most important factor in the prevention of HIV infection. Many AIDS education programs have started within the past several years, but few have undergone rigorous evaluation. This article presents findings from an outcome evaluation of the state of California AIDS Education and Prevention Program, the largest AIDS public education program in the country. The data suggest that the specific educational intervention programs suffered from many design defects which made it impossible to determine accurately the effectiveness of the programs. The programs did not use standard pre/post design, for example, or use standardized testing procedures. Moreover, only cognitive knowledge about AIDS transmission and prevention was stressed in the educational interventions and measures of effectiveness. The Education and Prevention Program must now move to promoting and measuring attitude and behavior change in addition to cognitive knowledge. The article concludes that AIDS education and prevention programs must place greater emphasis on conducting thorough evaluations, if the goals of attitude and behavior change are to be achieved.     

Creating a different international HIV response for young people

This paper demonstrates that certain notions of young people in the HIV and AIDS response reveal an overly generalised understanding of 'youth' that does not reflect a realistic view of young people's identity and lives. Faulty stereotypes of 'youth'--such as the perceptions that young people are necessarily victims or risk-takers--result in many HIV programmes based on generalisations about young people, rather than their actual needs and realities. These stereotypes and generalisations dominate million dollar prevention programmes that have little effect on HIV incidence rates amongst young people. To create a different future for young people and achieve real and lasting change, this paper recommends three discrete but interrelated actions for the international HIV community to undertake now; to base programmes on definitions of young people that emerge from the setting in which the programme will be implemented; to ensure HIV prevention programming is targeted at specific groups of young people, rather than a 'one-size-fits-all' package; and to incorporate structural approaches into AIDS programming to address the underlying factors that make younger age groups more vulnerable to HIV--including age-related stigma, discrimination and human rights abuses.     

AIDS Service Organizations and Their Presence on the Internet

Summary

AIDS service organizations have been the driving forces behind providing HIV/AIDS-positive individuals and the public with up-to-date information about the disease, treatment regimens, and prevention measures. It is critical that these organizations develop and maintain Internet sites for the rapid dissemination of information. The Internet offers the capability of providing a communication and publication means to reach a wider audience, reach greater numbers of HIV/AIDS-positive individuals, and reach even those in the most remote areas. This article discusses six major AIDS service organizations (Gay Men's Health Crisis, San Francisco AIDS Foundation, AIDS Project Los Angeles, AIDS Action Committee of Massachusetts, AID Atlanta, and the Howard Brown Clinic) and their presence on the Internet. All six organizations have made a national impact on the provision of HIV/AIDS services, programs, information, and advocacy efforts.     

Sexual risk behavior among people living with HIV/AIDS in Togo

Since HIV in Africa is spread primarily through unprotected sex, safe sex practices such as condom use can reduce HIV spread significantly. Nevertheless, because sexual behavior involves complex dynamics, condom use is not an easy option for many people in Africa despite years of condom distribution intervention. In fact, the complex nature of sexuality complicates efforts to combat HIV spread and limits the effectiveness of many prevention efforts. This paper uses theoretical explanations--social representation theory, situated rationality theory, and social action theory--to examine the patterns of sexual risk behavior and the underlying reasons and rationalization among people living with HIV/AIDS in Lomé, Togo. Qualitative interviews were conducted with 151 people living with HIV/AIDS, recruited from 3 HIV/AIDS centers. The results of this in-depth study suggest that although people living with HIV/AIDS may be aware of the risk of infecting their sexual partners, they deliberately ignore the risk because other considerations, such as wanting a baby, take precedence. Consequently, condom access is inadequate to change risky sexual behavior that spreads HIV. It must be supplemented with adequate empowerment.     

Asia--the new epidemic zone for HIV/AIDS

Two articles that appear in this journal present unique ethnographic assessments of the commercial sex industry in Thailand. They discuss how culture, society, and organizations interact with respect to communication approaches, information dissemination, and organizational-behavior change in preventing the spread of HIV/AIDS. Each of these articles provides important insights into the many factors that have intensified the epidemic as well as those identified opportunities for concerted community organization, behavioral reinforcement, and social structural approaches for HIV/AIDS prevention and control.