Going Public

Public health campaigns to raise awareness about HIV/AIDS can be very effective and are needed more than ever

By Catherine Zandonella*

A Swiss girl's birthday party is attended by three scantily-clad prostitutes, symbolizing that the girl's father has some lingering worries about his HIV status. A Malawian high-schooler turns away from three male friends and says, "sex can wait." Chinese basketball star Yao Ming, a player for the US team the Houston Rockets, lends his 7-foot 6-inch presence to the message "HIV/AIDS will not affect our friendship."

Public health campaigns to educate people about HIV and AIDS take distinctive forms in different cultures and are an essential part of efforts to fight the pandemic. Anti-stigma and behavior change messages delivered through media outlets and trained communicators often serve as a first exposure to much-needed facts, dispelling rumors, myths, and misconceptions, and empowering people to take control of their own lives. And there have been some outstanding success stories—in Uganda and Thailand, for instance, many credit public health campaigns with making huge inroads to reduce the number of new HIV infections.

The high prevalence and incidence rates of HIV show that such public health campaigns still have much to do in many cultures around the world. According to UNAIDS, the number of people living with HIV continues to climb in every region in the world. Young people between the ages of 15 to 24 accounted for 40% of new HIV infections in 2006. Shockingly, in India, where more HIV-infected people live than anywhere else on the planet, 43% of women have never even heard of HIV. Even in the media-saturated US, misconceptions abound—one study showed that roughly 47% of African Americans believe an AIDS vaccine is available but is being withheld (J. Acquir. Immune Defic. Syndr. 40, 617, 2005). One in five Americans say they would be "very" or "somewhat" uncomfortable working with someone who has HIV or AIDS.

The nature of any behavior-change campaign is to challenge the status quo, and this alone is often sufficient to cause unease and controversy. But campaigns have managed to change behavior in other health areas, like increasing the number of seatbelt users, reducing the number of smokers, and mass immunizations of children. When HIV and sexual practices are the topic, it is even more difficult to balance the message between educating and offending. "It is tempting to think that behavior change is just an impossible goal," says Tony Barnett, an HIV/AIDS researcher at the London School of Economics. "That is not true. People's cultures are very variable and changeable. However, they are more changeable from within than from without."

Change from within

All successful public health campaigns follow certain principles. These include conducting formative research to identify the target population, identifying stakeholders, pre-testing messages and media, and conducting follow-up research to analyze the impact and benefit. A truly effective campaign, however, requires local involvement, national leadership, use of the right sort of media to reach people, and a sense that the campaign originates within the culture rather than being imposed by outsiders.

A Zimbabwean campaign to reduce stigma illustrates how involving local people can make a difference in how the message of the campaign is received, says Devora Joseph, acting director of AIDSMark, a program engaged in the social marketing of HIV prevention products and services and run by the nonprofit organization Population Services International (PSI). PSI and its local partners identified HIV-infected people willing to talk about their experience and featured them in radio and television ads and on posters as part of the campaign, "Don't Be Negative About Being Positive." PSI's research indicated that people who had heard the campaign's messages were more accepting of people living with HIV/AIDS, and that overall they had a greater awareness of HIV/AIDS.

Strong national leadership can also pay off. Many credit Uganda's president, Yoweri Museveni, for his role in the success of his country's campaigns to reduce HIV transmission—prevalence fell from about 15% in the early 1990s to roughly 6.7% in 2005. While debate has simmered over which prevention methods (whether abstinence, being faithful, or condoms) were responsible for this decline, Museveni's leadership and participation is widely praised. For example, Museveni urged men and women to become more sexually responsible through an ongoing series of AIDS radio messages. Each radio message began with the beating of a drum, the traditional instrument used to transmit urgent warnings among villages, a cultural reminder that helped people accept Museveni's message as genuine and urgent.

Another important factor in a campaign's acceptance is the knowledge that the campaign originated from within the country rather than from outsiders. In Thailand the 100% condom campaign, which required that all sex workers use a condom in every sex act, was strongly endorsed by the national government and identified in the public consciousness with health minister Mechai Viravaidya, who became affectionately known as "Mr. Condom." The program involved distributing condoms, educating sex workers and clients, and shutting down venues that did not comply with the law. The policy is credited by the United Nations Development Programme with reducing new infections from 140,000 in 1991 to 19,000 in 2003. In total more than one million Thais have been infected since the start of the epidemic there, but last year the World Bank estimated that if the country had not implemented such an effective prevention campaign then a further 7.7 million people would have been infected by now (see Figure 1 below).

Figure 1. Thai Condom Campaign Poster.

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With a subject as complex as human behavior, billboards, posters, and other mass media cannot be the only outlets for delivering the message. In rural areas people often live miles from the nearest television, radio, or even billboard. Instead educators combine media campaigns with other interventions such as counseling, support groups, peer educators, and traveling-theatre groups. Campaigns have been forced to become creative. In many parts of Africa, health educators stage local soccer matches in the villages. These competitions draw people from the surrounding area, and the health educators use the event as an opportunity to convey messages about HIV/AIDS.

Conveying these messages is especially effective via interpersonal communication, where a trained educator engages members of a target population. One such program in India sponsored by PSI and the United States Agency for International Development is called "Operation Lighthouse." About 3600 educators give out condoms and information to truckers, port workers, fisherman, and sex workers in 12 port cities across the country. The goal is to reach every person in the target group several times during a three-month period with a single, consistent message, such as how to use a condom. After the first three months the educators change the educational message to a related topic such as sexually transmitted diseases. The program has demonstrated behavior changes, but it is very resource intensive. "Thinking that one can just put up a billboard and say 'use a condom' is oftentimes not adequate," says Joseph, "especially with a high-risk, vulnerable population like the sex workers and truckers we work with in India."

One size does not fit all

Without the sense of ownership and strong local leadership, campaigns can be worse than ineffectual; they may be counterproductive. For the 2002-2003 World AIDS Campaign, UNAIDS commissioned a series of posters designed to illustrate AIDS-related stigma and appeal to people in places as diverse as Africa and India. The slogan "Live and Let Live" was featured on posters of headshots of people thinking about family members who had AIDS. An analysis by researchers at McGill University, Canada found that many people were confused and thought that the posters were condoning stigma rather than discouraging it (J. Health Communication 11, 755, 2006). "The 'one size fits all' approach may not be appropriately suited to health-related campaigns," says Leanne Johnny, who conducted the study with colleague Claudia Mitchell.

One-size-fits-all does not apply even within a country's borders, says Kwaku Yeboah, director of prevention and mitigation at the nonprofit health organization Family Health International. Most developing countries do not have homogenous populations-city-dwellers often embrace modern lifestyles while others in rural villages get much of their information and care from elders and traditional healers. "It is absolutely important to have that local participation to guide you in understanding people's thinking processes," says Yeboah, "because perception is sometimes reality."

In Botswana in 1988, the government initiated a campaign to educate people about HIV/AIDS and promote condom use that was highly influenced by Western ideas. At the time many people did not yet know anyone who had contracted or died of AIDS. In rural areas the campaign was met with disbelief and condoms became associated with promiscuity and a breakdown of traditional values. As a result many Tswana people (the southern African people who inhabit Botswana) began to believe that AIDS was a disease brought on by immoral behavior. "Modernity, and indeed the modern state, was increasingly associated with sexual laxity and disease, an affront to Tswana morality," writes Suzette Heald, an anthropologist at Brunel University (J. Biosoc. Sci. 38, 29, 2006). People considered the disease as something that couldn't happen to them and so saw no reason to change their behavior.

Of course these attitudes are not unique, and are often all too apparent in developed countries. To Tony Barnett at the London School of Economics, it is not surprising that such measures are ineffective. "We don't know much about human sexual behavior in general," says Barnett, "let alone cross-culturally." Given that we don't know the reasons that people have sex, said Barnett, we have no reason to believe that it is easy for people to start using condoms, nor should we believe that abstinence is an easy choice.

Finding out why people engage in the sexual practices that they do is essential for designing campaigns that can deliver on the promise of reducing HIV transmission rates, as Barnett and colleague Justin Parkhurst point out in a 2005 article in the Lancet (Lancet 5, 590, 2005). The cultural meaning of sex can vary not only between countries but between social groups in that country. Sexual choices are determined not only by culture but by the social and economic context in which people live. This is especially true among women. "Whether or not people have sex with each other may be less to do with culture and much more to do with decisions that people make in order to survive, particularly where women are concerned," says Barnett.

In many regions of the world, women are economically dependent on men, lack the power to demand fidelity or condom use, and live under threat of violence from an intimate partner. As a result the HIV/AIDS epidemic is becoming increasingly female. In Swaziland, one of the most heavily affected countries, HIV prevalence among pregnant women attending antenatal clinics was 43% in 2004. Similarly high prevalence figures are found throughout southern Africa. In China, women comprised 39% of reported HIV cases in 2004, up from 25% two years earlier.

For many women, particularly those in resource-poor settings, transactional sex is a necessary means of survival. Since the onset of the AIDS pandemic an age old concept has been redefined and poses new threats to young women who see cross-generational sex with 'sugar daddies' as a way to empower their status. These young women are at greater risk of acquiring HIV since, on average, older men are more likely to have had the chance to become HIV infected and to have multiple partners.

To combat the trend, PSI has developed campaigns in Uganda, Cameroon, Kenya, and Mozambique that appeal to parents, young women, and their male partners. The campaigns carry the message that cross-generational sex can increase the risk of HIV infection (see Figure 2 below). In Uganda, PSI is collaborating with political leaders and community organizations to create stigma against these relationships. The campaign includes posters of a leering older man with the caption, "Would you let this man be with your teenage daughter? So why are you with his?" In Cameroon, the "No to Sugar Daddies, No to AIDS" campaign via television, radio, and print is raising awareness and changing societal views about the practice.

Figure 2. Ugandan Campaign Poster

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Some programs encourage men to treat women more respectfully, as does a campaign aimed at seasonal farm workers in South Africa. During harvesting season, male supervisors often have sex with female workers in exchange for better working conditions, extra money, or to secure employment in the first place. Women often have less knowledge of HIV/AIDS than men and are unlikely to request that their partner wear a condom. Sonke Gender Justice, a Cape Town-based non-governmental organization (NGO), runs weeklong workshops that teach supervisors not to abuse their position of authority to sexually harass or exploit female workers.

Future campaigns may be modeled on interventions like a recent one in South Africa. The Intervention with Microfinance for AIDS and Gender Equity (IMAGE) study assessed a structural intervention that combined loans to poor households for income generation, such as retail businesses selling fruit and vegetables, new or second-hand clothes, or tailoring businesses. The women also received a gender and HIV training curriculum. The blinded randomized study looked at outcomes such as interpersonal violence, an independent risk factor for HIV infection, and rate of unprotected sex with a non-spousal partner. The intervention led to a 50% reduction in levels of intimate-partner violence although it did not reduce episodes of unprotected sex (Lancet 368, 1973, 2006).

The strength of this type of intervention, says Barnett, is that it doesn't try to alter people's behavior by telling them what they should or should not do, but rather it gives women economic opportunity that they wouldn't otherwise have and with it the potential to change their decision making around sex.

Campaigns that empower women and provide economic opportunities can reduce HIV-related risks. In Uganda, Museveni recognized the benefits of empowering women and created a Ministry of Women's Affairs, charged with enforcing laws against sex with minors. Gender-equity messages became a part of general education in the schools, and the government started up programs to offer loans to women for small businesses.

Major international organizations are also now embracing the need for cultural and structural interventions to assist women. Campaigns in many developing countries aim to alter the structural reasons that contribute to HIV transmission by changing male attitudes towards women and empowering women economically. "To stop the feminisation of the epidemic, as well as the epidemic itself, we have to initiate legal but also social, cultural and economic changes to challenge some of the most pervasive social patterns and gender norms that continue to fuel the AIDS epidemic," wrote Peter Piot, head of UNAIDS, in a March 9, 2007 editorial in the Bangkok Post.

AIDS vaccine campaigns

The developing world has no monopoly on misunderstandings about HIV and AIDS. In the US misconceptions are common among the very populations in which the epidemic is growing fastest—AIDS diagnoses among African Americans have grown from 25% of cases diagnosed in 1985 to 50% in 2005. Lack of accurate knowledge about HIV/AIDS among African Americans and Latinos is hurting not only transmission rates but also recruitment of participants in vaccine trials.

Only about 17% of people enrolling in AIDS vaccine trials in the US are African American or Latino, according to Cornelius Baker at the Academy for Educational Development (AED), an organization that designs public health campaigns. AED is the recipient of a five-year contract worth $2.7 million per year from the National Institute of Allergy and Infectious Diseases (NIAID), and the goal of the campaign is to create an environment where people are willing to participate in those trials.

One of the first steps will be to educate target populations about the facts. The long history of medical injustice towards African Americans in the US has left a legacy of distrust. The belief that a vaccine against AIDS is available but is being withheld is not fantastical when one considers that poor African Americans are on long waiting lists in states like South Carolina to receive antiretroviral therapy. "There are deeper belief systems operating that standard social marketing is not going to be able to eliminate," says Baker.

AED is currently studying how to penetrate groups that are resistant to the facts about HIV despite being exposed to mass media. In keeping with the need for locally-grown campaigns, Baker says AED will parcel the money out to local organizations to create campaigns or work within existing outreach groups, rather than design a national campaign. One strategy is to identify local or community leaders or role models, rather than looking to national leaders, says Katharine Kripke, assistant director of research at NIAID. "We are asking, 'Who do people look up to? Who do they get their information from?'"

Think locally, act globally

Bringing expertise from affected communities is just one way in which public health officials plan to refine and sharpen public health campaigns. Increasingly, international agencies are moving away from top-down approaches and instead are funding local or community planners. These agencies are recognizing that structural efforts to improve the economic and social power of women could go a long way toward rolling back infection rates.

Yet women are not the only target. While the Thai sex-worker campaign was a success, that success came at the expense of rising transmission rates among ignored populations, namely men who have sex with men (MSM) and intravenous drug users. HIV prevalence among MSM increased from 17% in 2003 to 28% in 2005. In February the Thai government began its first public health campaign to target these populations. The five-month-long Sex-Alert campaign, run by Family Health International, NGOs, and the country's Ministry of Public Health, will deliver safe sex messages through magazine and radio advertisements, cell phone and text messages, the internet, and posters. Condoms and lubricants will also be distributed.

The future of public health campaigns will undoubtedly become more complex with the availability of new HIV interventions—male circumcision, vaccines, microbicides, diaphragms, pre-exposure prophylaxis, and other measures—that could all one day require new messages that must be crafted and disseminated to a wide range of people. This time, consideration of the underlying reasons for people's sexual behavior could inform a more effective set of public health campaigns.

*Catherine Zandonella, MPH, is a freelance writer whose work has appeared in Nature and New Scientist.