CADRE and SIDA

This 80-page report, commissioned by the Swedish International Development Cooperation Agency (Sida), is intended to guide potential future support interventions in the area of HIV prevention communication in eastern and southern Africa. 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. The study involves reviews of national-level prevention activities in the following countries: 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). According to the document, this heterogeneity has important implications for thinking about national-level HIV prevention communication in relation to the goal of reducing HIV incidence and prevalence.

Excerpt from the executive summary

“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 voluntary counselling and testing (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 people living with HIV/AIDS (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 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, and 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 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?
• Are monitoring and evaluation findings integrated into on-going interventions?”

CADRE website on July 13 2007 and on March 24 2009.