HIV Prevention Strategies in Africa

By Ann Menting

From her post in Dakar, Senegal, Salimata Diallo oversees the administration of the Society for Women and AIDS in Africa (SWAA), a decade-old organization with thirty branches in Africa. Like other non-governmental organizations (NGOs), SWAA mobilizes particular populations—young people, women, and communities—to respond to the threat of AIDS in Africa. "You must give a lot of information and a lot of time before you get change," says Diallo.

Condoms are sold from the conter inside a bar adjoining a roadside hotel between Dombushawa and Harare, Zimbabwe. This establishment serves as a regular meeting place for sex workers and their clients. Photo by Lorien Abroms, her personal collection.

"Recently, we have expanded our mission to reach out to men," Diallo says. "Men are very powerful players in the infection cycle, and we felt it was important for our organization to look at what we could do to work with them to control HIV spread." Toward that end, SWAA held a conference in Senegal that addressed ways to expand men’s participation in HIV prevention.

This evolution of focus mirrors that occurring in many Africa-based groups fighting the epidemic. Campaigns that early on targeted high-risk populations such as sex workers and migrant workers are reaching with greater intensity to other groups in the general population—adolescents, pregnant women, and people in rural communities. And with increasing frequency, campaigns are reaching out to people with HIV and AIDS, including them in prevention efforts that range from home-visit programs to small businesses.

Sustained, Successful Campaign of Prevention
The government of Senegal, a western African nation of nearly
9 million people, began its prevention campaign in early 1986 and has carefully and consistently guided its development to this day.
"Senegal was one of the first countries in Africa to involve its political leaders in the effort to prevent the spread of HIV," says Souleymane Mboup, professor of microbiology at Dakar’s Université Cheikh Anta Diop. Mboup, who has been involved in HIV research since the mid 1980s, oversees his country’s participation in a collaborative AIDS research program that includes scientists at the Harvard AIDS Institute.

"Senegal has taken the initiative in several areas that have proven to be important to our overall success in fighting the epidemic," he adds. "Officials in many African countries would not talk about AIDS for a long time because they were worried about the effects the information would have on tourism. Because my country developed research and training programs early in the epidemic, those of us working against AIDS had a forum in which we could talk about it without causing too much concern among our country’s leaders.

"We also were able to achieve results in the 1970s in some early campaigns before HIV was described in the country, such as our effort to ensure the safety of blood used in transfusions and our effort to treat STDs [sexually transmitted diseases] in high-risk groups."

These early efforts have resulted in a concerted campaign against HIV and AIDS that has involved NGOs, universities, religious and political leaders, and others. Medical treatment for STDs is now actively promoted for all populations in Senegal, as is condom use. In all, Senegal’s efforts have helped keep HIV infection rates low—below 1 percent in the adult populations, even in urban areas.

According to international health groups, this low rate is the result of changes in sexual behavior among Senegal’s people. A recent World Health Organization survey, for example, indicated that sexual activity, especially casual sex with multiple partners, remains high; 43 percent of men and 15 percent of women between the ages of fifteen and twenty-four reported having casual sex partners within the past year. But the survey also showed condom use had increased in each group. More than 60 percent of the men and 40 percent of the women reported using condoms. Condom distribution figures verify this move toward safer sex—more than 7 million condoms were distributed in Senegal in 1997, up from 800,000 distributed in 1988.

"Young women are asking men to use condoms," says Diallo. "This is a big change."

SWAA’s efforts to foster this type of change are focused at the local level. Young women who join the organization are trained as peer educators and are involved in programs such as school-based women’s clubs or associations, where they can talk, give each other support, and get the information and skills they need to protect themselves. According to Mboup, it is this ability to keep the discussion on HIV prevention active and vital that has been pivotal to Senegal’s success against the epidemic.

Early, Aggressive Intervention
Although the northern African nation of Morocco has not suffered the devastating infection rates experienced by nations in sub–Saharan Africa, it should not be lulled into complacency, says Hakima Himmich, president of the Association Marocaine de Lutte Contre le SIDA (ALCS), Morocco’s oldest and most active NGO working against AIDS.

When Himmich began ALCS in 1988, "there were scarcely thirty reported cases of AIDS in our country." But Himmich—a professor of medicine at the University of Casablanca and director of the infectious diseases department at the university’s hospital in that city—knew the deadly effects of the epidemic. She had diagnosed Morocco’s first AIDS case in 1986 and knew that action was demanded.

In Zimbabwe a tailor sits at his sewing machine outside a rural general store where condoms are sold. Because the condoms are heavily subsidized, the store is able to sell them at low cost to people who would otherwise not be able to afford them. Photo by Lorien Abroms, her personal collection.

"We must work on prevention now," Himmich says, "not wait until ten percent of our population has AIDS. We must be extremely vigilant. Many of the preconditions for growth of the epidemic, such as prostitution and sex tourism, are here."

Early and aggressive intervention has been shown to produce impressive results. Research conducted within a cohort of 500 Kenyan sex workers, 80 percent of whom were infected with HIV, showed that early intervention campaigns encouraging the workers’ use of condoms raised the percentage-of-use from 10 percent to 80 percent. When researchers calculated the number of new HIV infections that likely were averted by this level of condom use among this group of women, the tally came to 10,200.

Female and male sex workers were among the first groups ALCS targeted with its prevention message. Initially, the group only used its own workers to distribute condoms. But this effort soon evolved to include sex workers as educators and to include the creation of peer education networks. In addition to distributing condoms, these networks disseminate information on AIDS and STDs.

The group organizes the distribution of HIV prevention/condom use booklets to all Moroccan schools. It also operates a bus, specially outfitted with audiovisual equipment, that stops at beaches and at markets known as souks, where ALCS volunteers distribute condoms, talk with people about HIV, and show movies about AIDS.

ALCS also works with groups of men who have sex with men to help motivate safer sex behavior. One such group meets regularly at the association’s headquarters in Casablanca to discuss prevention, and pilot projects are planned for groups that would meet at ALCS sites in other Moroccan cities. "In each case we do a survey of knowledge, attitudes, and practices," says Himmich. "We also recruit and train peer educators and support peer education within the gay community."

The association has tackled the need for more and better testing facilities by setting up anonymous testing centers in four cities: Casablanca, Agadir, Rabat, and Tangiers. At these centers, tests are paid for by the government, and patients are seen by physicians who volunteer their time.

As the epidemic grows, Himmich is exploring ways to increase the effectiveness of ALCS and sister organizations in northern Africa and the Middle East. "We are working to form a regional collective," she says. "By combining our efforts, we can better promote the setup of regional pilot programs for prevention, improve access to care, and better serve all actors fighting against AIDS—medical professionals, decision makers, and persons with HIV and AIDS."

Talking to Families and Couples
As with the diverse programs of the ALCS, the HIV prevention effort in the eastern African nation of Uganda targets the needs of many populations. In Uganda, however, the epidemic is deeply entrenched.

In 1982, when many regions of the African continent were as yet unaware of a potential AIDS problem, the Rakai region of Uganda recognized its first AIDS cases. By the end of 1986, the nation was being ravaged by the epidemic. According to some, infection rates in particular populations ran as high as 25 percent. In 1986, the new president, Kaguta Yoweri Museveni, reacted decisively, and for many, surprisingly. In quick order, he acknowledged the presence of the epidemic in his country, organized a conference of donors who could help support prevention and care efforts, and established an AIDS oversight office, the National AIDS Control Programme, within his Ministry of Health.

This broad effort produced a number of education and prevention campaigns that cumulatively have been effective; studies show 90 percent of the general population exhibit a significant level of awareness to the facts concerning HIV and AIDS.

One current campaign aims at controlling the high incidence found in couples in which one partner is infected and the other is not—the serologically discordant couple. Studies in Uganda have demonstrated that more than 50 percent of new cases of HIV infection occur in discordant couples.

"Testing and counseling centers have been set up in rural areas and have targeted couples," says David Serwadda, senior lecturer in the Institute of Public Health at Uganda’s Makerere University. "These centers use sales and marketing techniques to encourage people to come in. For example, on certain holidays, they will run specials, 50 percent off the cost of testing for couples who come in to be tested."

Another Uganda-based group, the Family AIDS Education and Prevention Through Imams Project (FAEPTI), was founded in 1992 by the Islamic Medical Association of Uganda to bring HIV prevention messages to the Muslim community. The organization helps imams (prayer leaders) incorporate accurate information about HIV and AIDS into their religious teachings. It also trains teams of community volunteers in basic counseling and behavior-change techniques and organizes visits by these volunteers to the homes of Muslim families. The organization finds that bringing its message to all individuals within a community enhances peer acceptance of safer sexual practices. To date, nearly 7,000 trained volunteers have visited families in more than 100,000 homes in ten regions of Uganda.

Teaching prevention and providing support are also important aspects of the mission of The AIDS Support Organization (TASO), an NGO established in Uganda in early 1987, which runs myriad programs serving families affected by the epidemic. These include HIV and AIDS awareness training, dissemination of educational materials, promotion of income-generating efforts, and community-based counseling. The counselors are community volunteers, some of whom are living with HIV or AIDS.

These prevention efforts in Uganda may be bearing fruit, especially among the young. According to the World Bank, between 1989 and 1994, the percentage of young men between the ages of 15 to 19 who were sexually active dropped from 69 percent to 44 percent. Among young women in the same age group, the drop was from 74 percent to 54 percent. The United Nations Joint Programme on HIV/AIDS (UNAIDS) reports that condom usage has increased substantially. In 1995 in the capital city of Kampala, for example, condom use was reported by 24 percent of the sexually active population, up from 7 percent in 1989. In addition, prevalence of the virus in the general population of Uganda is reported to have declined by 3.5 percentage points between 1997 and 1994.

Teach English, Prevent AIDS
At a recent press conference, the health minister of Cameroon announced a new effort by the National Committee for the Control of AIDS that is designed to produce changes in HIV-related knowledge and behavior in Cameroon’s population in much the way Uganda’s efforts are doing for its people.

His announcement was the articulation of years of efforts to modify the HIV prevention policies of Cameroon’s government and associated organizations. In 1992, for example, the government published articles calling for better approaches to AIDS prevention and encouraged NGOs to address the issue of prevention within the contexts in which they operated.

"We had been developing a program aimed at improving knowledge and language skills using AIDS information as content," says Gabriel Kwenthieu, the United States Peace Corps’ associate director of education in Cameroon. "[Peace Corps] volunteers worked with a group of secondary and university educators and with individuals from the ministries of education and public health to develop a curriculum tool, ‘Teach English, Prevent AIDS’ [TEPA], for use in teaching English to students in secondary schools."

"At first we used a direct approach," says Kwenthieu, "in which we only gave medically accurate information on STDs and AIDS. Then we modified the message to one based on values—the value that education, family, or getting a good job had for the student. From this foundation, the student was gradually directed to talk about dangers to achieving these things of value—involvement in prostitution, becoming infected with HIV. This approach has been effective."

The program’s effectiveness was supported by data from a controlled study conducted in 1996, in which 37 percent of the students tested from schools using TEPA could identify three ways to prevent HIV transmission, compared to only 20 percent of students in a control group not using TEPA. In addition, students in schools using TEPA were 20 percent more likely to practice safer sex than their peers in the control schools. To date, hundreds of Peace Corps volunteers have used the curriculum tool to introduce English to more than 15,000 students and roughly 1,800 native Cameroon teachers have adopted TEPA for use in their classes.

Prevention efforts in Cameroon may be succeeding in controlling the level of HIV transmission among the country’s population. Condom use is up among females between the ages of 20 and 29, a cohort that is also sexually active. And UNAIDS reports suggest that HIV prevalence has stabilized or dropped slightly among rural and urban pregnant women in the past several years.

A Cooperative Approach
In South Africa, workers at the AIDS Action Group in Cape Town know they have not yet seen the worst of the epidemic. "Incidence in areas of the Western Cape was recently reported to be around five percent," says Sophia Louw, social worker at the organization, "but we believe that figure may not be representative. We know that certain informal settlements have incidence rates as high as fifteen percent and that nine other South African provinces have incidence rates higher than that. And we know that HIV incidence in the western provinces is growing."

Louw and her counterparts in sister NGOs are consolidating efforts in the face of this onslaught. At a recent workshop funded by the country’s Department of Health, twenty NGOs decided to form a loose cooperative to share information and resources. "Because few organizations concentrate exclusively on HIV and AIDS, it’s useful to be able to work with other organizations that have experience with the disease. For example, a hospice group that has some AIDS patients in its population is talking with us about organizing education programs for its staff on proper caregiving for AIDS patients," says Louw.

Bringing groups such as these Cape Town NGOs together to increase their effectiveness is an aim of South Africa’s government. Less than one year ago, then-Deputy President Thabo Mbeki called for South Africans to change "the way we live and how we love." He also issued a strong plea to union groups, businesses, religious groups, women, and youth to unify and commit their efforts to the work of the President’s Partnership Against AIDS. "We can only win against HIV and AIDS if we join hands to save our nation."

A boy on a farm in Mazowe, Zimbabwe, where a non-government organization works with farm owners to distribute condoms to their workers. Photo by Lorien Abroms, her personal collection.

Now as South Africa’s president, Mbeki is confronting his role as leader in the government’s efforts at HIV prevention and control. Early campaigns by his Ministry of Health include the targeting of particular high-risk groups using methods that have proven successful elsewhere on the continent. Following models of prevention campaigns conducted by groups such as the African Medical and Research Foundation, South Africa is establishing peer education groups among sex workers and is developing a similar campaign to increase condom use and knowledge about HIV prevention among truck drivers. The country is also organizing a nationwide effort to treat STDs, infections that are widely believed to be co-factors of HIV infection. This initiative aims for results similar to those obtained in a controlled, randomized trial conducted in Mwanza, Tanzania, in which management of STDs cut HIV prevalence by 42 percent.
Campaigns to increase condom use are also being undertaken by NGOs such as Population Services International (PSI). The organization introduces its product to urban populations using television spots that feature celebrities who endorse PSI’s brand of condom. Rural populations are reached by sales staff who travel in vans emblazoned with the condom’s logo and name. Condoms are distributed to outlets such as bus and gas stations, and staff perform in street theater events designed to impart prevention information.

Throughout South Africa, people are readying themselves for the fight to control the spread of HIV. "We’re a small group, but we try to give each person emotional support, and try to guide them to services that they may need to support their care and prevention efforts," says Louw of AIDS Action Group in Cape Town.

"It’s difficult on a day-to-day basis to tell or determine our success. We just focus on preventing the virus from spreading."

—Ann Menting is the associate editor of the Harvard AIDS Review.