Getting the AIDS message out to broad populations – and following-up with action

Cross-cutting themes

Getting religious and traditional leaders involved

Public education campaigns; fundraising approaches

Importance of top government leadership

Neither citizens nor governments can respond to HIV/AIDS without awareness of the problem - and awareness of the solutions. A country in which denial flourishes is a country whose population is vulnerable to the silent spread of HIV.

Yet getting the message out is not enough. Sometimes, even when the level of basic knowledge is very high among certain populations, people do not alter their risky sexual behaviour – the implicit goal of most awareness campaigns. Reasons for this vary between populations, but often include lack of skills (e.g., knowing that a condom should be used is not the same as knowing how to negotiate its use with a partner) and poor access to affordable commodities and services.

Correcting ignorance and denial

Simple ignorance or misinformation is an important factor in HIV's spread. For example, rumours recently became widespread in some communities that circumcision acts as a "natural condom" and prevents one from HIV infection. In one study in South Africa, for example, two out of five circumcised men were infected with HIV, compared with three out of five uncircumcised men. Thus, it shows that both circumcised and uncircumcised men can be infected with HIV through unprotected sex.

Community customs and traditional values play their part too: few people are happy to admit that a fatal disease - spread by behaviour branded as "immoral" - could be rampaging through their community or their country. In some countries, denial had a more mercenary motive because AIDS might discourage tourists from visiting their country.

Denial may also have been reinforced by some of the early "scare tactics" used in AIDS awareness campaigns, by declaring that the disease is evidence of (or punishment for) immoral behaviour, and by cultural factors such as taboos against frank discussion of sexual matters.

Fighting stigma and negative attitudes

It is important to reduce stigma about being HIV-positive for a variety of highly practical reasons. In places where stigma is strong, asking a partner to practice safe sex may be seen as an admission that one is HIV-positive, or has doubts about the partner’s infection status. In such an ambiance, many people will choose not to use a condom, even if worried about their own or their partner’s health.

Another reason to attack stigma is that it makes people reluctant to seek HIV services, including voluntary counselling and testing (VCT). Even where VCT facilities are available, stigma may make people reluctant to consult those services, or prefer not to know their infection status. Improving services must therefore go hand in hand with efforts to diminish fear and rejection of seropositive people, and with the establishment of policies and practices to ensure confidentiality of HIV test results and related information.

Countries have had some success in combating the stigma of AIDS through public campaigns urging solidarity with HIV-affected persons and through public statements by respected leaders. Care providers are learning to manage AIDS services without stigmatizing. At the same time, such campaigns can also empower people living with HIV/AIDS to cope with the disease, "live positively" (which may include continuing to have fulfilling sexual lives with their partners safely), and contribute their testimonies to help people change their risky behaviour and prevent transmission of HIV.

Prevention through behaviour change

In the absence of a vaccine or cure, prevention through behaviour change is the most cost-effective way of saving lives. Information, Education and Communication (IEC) programme has been one of the prevention strategies used by national AIDS programmes throughout all the countries in the region. The information and communication contribute to creating awareness, motivation and referral to sources of condoms and services; while the education provides skills and encourages family and peer support. All of these can help promote safer sexual behaviour (including the use of condoms), the seeking of care for sexually transmitted infections and family planning, and positive living. Apart from awareness, IEC programme also provides the information and skills needed to prevent further spread of sexually transmitted infections and HIV.

In general, IEC best practice in recent years has featured:

Replacing "scare tactic" messages with ones promoting hope and pragmatic action

Teaching life skills along with AIDS education

Changing the attitudes of health sector workers to be caring and non-discriminatory against HIV-positive persons

Integration or collaboration with initiatives to increase access to commodities and services.

Examples of Best Practice

Senegal: Muslim and Christian leaders preach tolerance and solidarity

Leadership issues summary

Leadership level(s): highest religious authorities, in cooperation with national AIDS programme; at local level, imams and priests/pastors exercise leadership among their "flocks"

Contribution to success: raised the profile of the epidemic, provided a widespread, highly trusted medium for spreading information

Gaps and insufficiencies: some religious authorities are still unable to support condom promotion

Since almost all Senegalese are active practitioners of Islam or Christianity, religious leaders have an enormously important role in national life. Their support for AIDS prevention activities was vital if the activities were to succeed. And it was clear that religious leaders wanted to be involved in this important area. As early as 1989, a Islamic organisation, Jamra, approached the national AIDS programme to discuss HIV prevention strategies. Although initially rather hostile to condom promotion and some other aspects of AIDS prevention, the group became an important partner in a dialogue between public health officials and religious leaders.

In order to understand the needs of the religious constituency, the government supported a survey of Muslim and Christian leaders. The survey results showed that religious leaders felt they were poorly informed about AIDS, and wanted more information to enable them to give clear guidance to their followers. They also specified what they were prepared to support. For example, they were reluctant to support condom use between unmarried youngsters, but were prepared to support it within marriages.

In response, educational materials were designed to meet the needs of religious leaders. They focused in part on testimonials from people living with AIDS - the human face of the epidemic, often hidden where prevalence remains low.

Training sessions about HIV were organised for Imams and teachers of Arabic, and brochures were produced to help them disseminate information. AIDS became a regular topic in Friday sermons in mosques throughout Senegal, and senior religious figures addressed the issue on television and radio. In March 1995, 260 senior Islamic leaders gathered for a conference on AIDS. The result of the conference was clear support for AIDS prevention efforts. The religious leaders declared that HIV was not a divine retribution for immoral behaviour. They supported the rights of people living with AIDS, including the use of condoms to prevent HIV from spreading within marriage if one partner is infected. And they stated that everyone should have access to full and accurate information about HIV and AIDS.

Among Christians, there was substantial resistance to AIDS prevention at first. And yet Christian organisations are important providers of health services in Senegal, and AIDS clearly threatened to become a major health issue if it were not prevented. Led by a Catholic NGO, SIDA Service, the churches gradually developed a more supportive outlook on prevention. They provided important counselling and psychosocial support, and frequently referred those in need to alternative providers where they could not meet needs, for example for condom provision.

In January 1996 Christian leaders gathered in another conference on AIDS. Every bishop in Senegal was in attendance. Again, the result was a consensus that AIDS prevention was an important national activity.

The moral support for AIDS prevention given by religious leaders allowed secular and health authorities to work productively in providing education and specific HIV prevention services.

Ghana: Social marketing of female condoms

Leadership issues summary

Leadership level(s): national authorities working with international agencies and private sector; prominent woman lending her support to a subject that is difficult to talk about in local culture

Contribution to success: willingness of national leadership and health authorities to adopt innovative approaches to prevention

A programme to market the female condom in Ghana was officially launched on 25 May 2000, with Her Excellency, Nana Konadu Agyeman Rawlings, the First Lady of Ghana presiding over the ceremony.

In her speech, the First Lady emphasised the importance of giving women more control over their own reproductive health and said that "the female condom will give Ghanaian women a greater voice in sexual and contraceptive decision making…. Since the female condom is worn by women themselves, it is found to be empowering and is particularly more popular where men are reluctant to use condoms themselves".

To back up the programme, Ghanaian government announced that it had ordered half a million female condoms from the US-based Female Health Company, which will be marketed at subsidised prices. Since such marketing must be backed up by knowledgeable support, the Minister of Health stated that more than 3,000 medical and non-medical service providers had been trained to provide the female condom.

The protective device was first tested in Ghana by UNFPA and the Ghana Social Marketing Foundation. National planning was further assisted by the Ministry of Health, UNAIDS, and the Society for Women and AIDS in Africa (SWAA).

Tanzania: Partnership with traditional healers

Leadership issues summary

Leadership level(s): traditional healers and medical staff

Contribution to success: willingness to share experiences and recognize the other groups’ strengths and advantages; willingness of medical authorities to tolerate "non-medical" practitioners

In 1989, the increasingly apparent impact of HIV/AIDS resulted in collaboration between traditional healers and medical health workers in the Tanga region of northeastern Tanzania. Meetings between the two groups resulted in a spirit of mutual respect, and permitted them to share experiences on care and prevention of AIDS and other illnesses. The success of the collaboration resulted in the formation of the Tanga AIDS Working Group (TAWG) in 1992.

Since then, TAWG has been collaborating in two districts of Muheza and Pangani with about 60 traditional healers and 60 traditional birth attendants. Training of traditional healers includes basic information about sexually transmitted infections, HIV and AIDS, along with building skills in AIDS counselling and care, condom promotion and community behaviour change. In addition, traditional healers are trained in hygiene and how to sterilise their tools. Field supervision and monitoring follow training as the healers begin adding to their usual activities such tasks as home visits to persons living with HIV/AIDS, promotion of HIV testing and referrals to the biomedical health system. Much of this is done in close cooperation with existing village health projects.

The healers have also worked with doctors and nurses to conduct hundreds of joint educational sessions, both with community groups and with local leaders. Among other results, they have been successful in condom promotion and sales, helping increase "Salama" condom sales by a reported 50%