Successful HIV Prevention
Programs
Anthropology 393 – Cultural
Construction of HIV/AIDS
Josephine MacIntosh
March 22, 2005
HIV Prevention & Health
Promotion
 HIV prevention: easier said than
done
 Important
components:
Preventing HIV transmission
 Promoting healthy lifestyles
 Promoting sexual health
 Treatment of drug abuse
 Sexual and drug risk reduction
 Assuring health care access

http://hopkins-aids.edu/prevention/pre_toc.html
2
Designing Successful HIV
Prevention Programs
 Developing comprehensive HIV
prevention programs is complex
 Individual-based
interventions
 Community-wide education
 Accessible health care services

Especially HIV counselling, testing & treatment

Accessible drug treatment services
 STD diagnostic and treatment services
http://hopkins-aids.edu/prevention/pre_toc.html
3
Primary Vs. Secondary
 Primary prevention
 Reduces infection by eliminating behavioural risk(s)


Sexual abstinence or avoidance of intravenous drug use
Primary prevention is attractive

But an option only in the long term
 Secondary prevention (bulk of prevention efforts)
 Identification of persons who are already infected
 Encouraging risk reduction in those infected & at
risk of infection
 Reduce HIV risk co-factors (e.g., Other STIs)
http://hopkins-aids.edu/prevention/pre_toc.html
4
Comprehensive HIV
Prevention
HIV COUNSELLING
& TESTING
EDUCATION
CONDOMS
RISK
REDUCTION
NEEDLES
DECREASED RISKY
SEX & DRUG USE
5
Challenges and Barriers
 Community level barriers
 Social norms surrounding sexuality and drug use
 Patient level barriers
 Does person perceive that s/he is at risk?
 Can they integrate change?

Motivations = pleasure seeking
 Substance use
 Can impede intervention efforts two ways


Associated with increased risk-taking behaviour
Associated w/ reduced ability to implement risk-reduction
http://hopkins-aids.edu/prevention/pre_toc.html
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Challenges and Barriers
 Mental illness
 Alcohol and HIV risk behaviours
 Heavy alcohol use associated with




General increases in risky sexual behaviour
Decreased condom use
Increased risk of relapse into risky sexual behaviour
Contextual substance use appears to have the
highest risk
 Non-injecting drug use (e.g., Crack cocaine)
 Related to associated sexual behaviour

Especially drug-related prostitution activities
http://hopkins-aids.edu/prevention/pre_toc.html
7
Cultural & Behavioural
Diversity
 Interventions require current understanding of
HIV epidemiology

E.g. Groups at highest risk for infection
 Interventions designed for one group may be
inappropriate or ineffective for other groups

Highlights need for continuous epidemiological
monitoring and program effectiveness evaluation
 The HIV epidemic is dynamic
 Proportion of cases amongst MSMs decreasing
 Cases amongst IDUs, youth, & women increasing
http://hopkins-aids.edu/prevention/pre_toc.html
8
Cultural Context of
Prevention
 Interventions targeting one risk group have
the potential to alienate or marginalize
members of other risk groups
 Must be designed to account for appropriate
cultural norms


In diverse populations
Cultural norms in one group may be quite different
than in others
http://hopkins-aids.edu/prevention/pre_toc.html
9
HIV Prevention in the
Developing World
 “Any campaign to combat AIDS in the
developing world must be built not only on an
awareness of what has worked or failed
elsewhere, but also on the unique
circumstances of each developing nation”.
(Morin, Chesney & Coates, 2000)
 “Interventions have been developed that have
the capacity to reduce HIV incidence and
relatively risky behaviours by up to 80%.”
(Prabhat Jha et al., 2001)
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Targeting Unique Populations
 Targeting
 Process of customizing design & delivery on basis
of characteristics of intended audiences

Females
 Tailoring
 Customizing messages of specific individuals or a
homogenous group within the target audience

Female sex trade workers
 Intervening upstream
 Targeting or tailoring for those w/ most partners

Wise use of limited resources
From: Singhal & Rogers, 2003
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Nairobi, Kenya (1985)
 Target = 1,000 female CSW in Pumwari
 80% HIV positive
 Provision of:
 Free condoms
 Free healthcare clinic




Treated STIs
Gave counselling
Provided medical check-up every 6 months
Included outreach education
From: Singhal & Rogers, 2003
12
Nairobi, Kenya (1985)
 Results
 Average of four clients per day
 Consistent condom use plus healthcare


1,000 female CSW
80% positive

Estimated to have prevented 6,000 to 10,000 HIV
infections/year
 At a cost of approx. $10 per case prevented
(Moses et al., 1991)
From: Singhal & Rogers, 2003
13
Nairobi, Kenya (1985)
 IF target = 1,000 randomly selected
men
 Provided
similar health services
 Achieved same rate of condom use
 Estimate of prevented infections
 Only 80 /year
(Altman, 1997)
 Illustrates major advantages with
targeted interventions
From: Singhal & Rogers, 2003
14
Ideal Interventions for CSWs
 Effectively select and train peer
educators
 Provide free or low-cost condoms
 Make available
 Literacy
programs
 Health clinics
 Savings plans
 Other services valued by sex trade workers
From: Singhal & Rogers, 2003
15
Sex Trade
Work in
Mumbai,
India
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Mumbai, India
 Epicenter of Indian epidemic
 70,000 sex trade workers
 Largest red-light district in the world

Different areas known by specialities
– Area 1 = vaginal sex
– Area 2 = anal sex
– Area 3 = oral sex

Streets differentiated by price

Youngest, fairest-skinned charge most
– High = $40/night
– Low = 50 cents/act
From: Singhal & Rogers, 2003
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Mumbai, India
 More migrant workers than other cities
 Form main customer base
 Males, 17 to 30
 Manual labourers




No access to healthcare
Little or incorrect knowledge of HIV
May have STIs
Return to home place once or twice/year


Bring infections with them
May infect wife/girlfriend
From: Singhal & Rogers, 2003
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Mumbai, India
 Empowerment of CSW
 Gradual
process of independence in trade
 Begin under total control of brothel owners

Many spend their days in cages (cage girls)
 2nd

year, may get 50/50 deal with owner
May have “husband” & children by then
 3rd
year may leave brothel to work on own
 Almost all are HIV-positive by this time
From: Singhal & Rogers, 2003
19
Mumbai, India
 HIV-positive sex trade workers
 Often stigmatized
 Mistreated
 Turned away from govt health clinics


May self-medicate
Preyed on by phony doctors w/ phony cures
 Onset of AIDS-related illnesses
 Thrown out of sex business
 Forced to fend for self
From: Singhal & Rogers, 2003
20
Mumbai, India
 Sex trade controlled by powerful mafia
 Population Services International (PSI)
intervention programmers met with mafia



Pointed out HIV prevention good for business
Not aimed at getting women out of the business
Intervention uses peer-educators




Most former STW, some HIV+
Speak variety of Indian languages
Bright yellow shirts, identification badges (official looking)
Contacted over 30, 000 STW in past decade
– Recall Kenya
From: Singhal & Rogers, 2003
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Healthy Highways, India
 Targets Indian truck drivers
 Estimated 3.5 million truck drivers in India
 Numerous sexual contacts with STW
 10,000 truckers/day arrive in Mumbai

Sex
– Red-light districts
– Truck stops eat, drink, rest, and …
 Thousands
of truck stops on major
highways
From: Singhal & Rogers, 2003
22
Healthy Highways, India
 Sex trade is subtle and supported
 Frequent

intercourse defines masculinity
Never in truck
– Sacrosanct
 Most truckers are heterosexual
 Trucker
lingo for sex with
Men = ‘reverse gear’
 CSW = ‘forward gear’

From: Singhal & Rogers, 2003
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Healthy Highways, India
 Peer education using flipcharts depicting
condom use w/ CSW

HIV = round, spiny, w/evil face
 Adopted motto of:

“Sex without condoms is like driving without brakes”
– Makes sense to audience

Persuade drivers to protect family



Outreach workers
Free condoms
Comic books of flip chart characters/stories
From: Singhal & Rogers, 2003
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Healthy Highways, India
 STIs among truckers in Tamil Nadu
 1997 = 20%
 2001 = 10%
 Project was decentralized in 2001


Lost momentum
Now defunct
 Need for evidence-based policy
 This appears to have been working

Need for secure funding
From: Singhal & Rogers, 2003
25
Pittsburgh, 1986-87
 Target = 600 homo & bisexual men
 Intervention had 2 components


First = hour-long small group lecture
Second = Skills-building
–
–
–
–
Condoms
Negotiation skills
Role-playing
Discussion
 One half did group lecture only (control grp)
 Other half did both
From: Singhal & Rogers, 2003
26
Pittsburgh, 1986-87
 Target = 600 homo & bisexual men
 Goal = condom use for anal sex w/ man



Control group (lecture only)
– No change
• Before = 40%
• After = 40%
Experimental group (lecture + skills)
– Increased condom use
• Before 40%
• After 70%
Demonstrates the importance of providing skillsbuilding in conjunction with knowledge
From: Singhal & Rogers, 2003
27
Migrant Farmer Workers
 Target = ~ 300 Mexican migrant farm
workers in southern California
 At
risk due to STW brought to camps
 Goal: Education via fotonovelas

8 page story books with pics and captions
– Highlight need to use condoms with STW

Condoms & instructions provided
– Pop of interest consulted re: approach
– Pop of interest models for fotonovelas pics
From: Singhal & Rogers, 2003
28
Migrant Farmer Workers
 Target = ~ 300 Mexican migrant farm
workers in southern California
2/3 received educational materials
 1/3 did not (control grp given info later)
 All received condoms

only – none used
 Educational materials and condoms
 Condoms
Increased knowledge (small but significant)
 Increased condom use w/ STW (substantially)

From: Singhal & Rogers, 2003
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Successful HIV Prevention Programs