Transcript comm-campaigns-wparker

Evaluation of HIV/AIDS
Communication Campaigns:
The importance of critique
Centre for AIDS Development, Research and Evaluation
www.cadre.org.za
Warren Parker • [email protected]
HIV/AIDS Campaigns





HIV/AIDS campaigns are formal organised activities,
typically utilising various forms of communication to achieve
objectives related to prevention, care, treatment, support and
rights
There are hundreds of campaigns operating at national and
sub-national level in South Africa
National campaigns incorporating programmatic activities
include Khomanani, Soul City, Soul Buddyz, loveLife, the
school-based life-skills programme, TAC, condom social
marketing
Educational programmes – Tsha Tsha, Gazlam, Beat It
Focused campaigns around condoms, STIs, VCT, TB
HIV/AIDS Campaigns


Sub-national campaigns include activities of provincial and
local governments, NGOs, community-based organisations,
sectoral organisations (eg. Workplaces, faith-based
organisations), etc
HIV/AIDS communication also occurs outside the domain of
formal campaigns and is influenced by
• News, features, documentaries, talk-shows
• Interpersonal communication
• Knowing people who are living with HIV or who have died
of AIDS
• Being directly affected by HIV/AIDS (eg. Living with HIV,
family affected, orphaning)
Have campaigns worked?
Yes… For example:


Progressive increase in reported last intercourse
condom use
• 1998, DHS, females, 15-19, 21.2% (unmarried partner)
• 2000, BAC, males and females, 15-30, 52%
• 2002, NM/HSRC, females 15-24, 46.1%; males, 57.1%
• 2003, RHRU, females 15-19, 55%; males, 57%
Increase in perceived ease of access
• 2000, BAC, males and
females 15-30, 75%
SA public sector condom procurement:
2001-2004
• 2002, NM/HSRC, males
and females, 15-24, 95%
Increased public sector
procurement
Demand-based logistics
system, widespread access
(including commercial and
social marketing availability)
Quality control of product
400
350

346
302
300
282
267
250

Millions
200
150
100
50

0
2001
2002
2003
2004
Why…







Cumulative effect of campaigns over past decade
Cumulative effects of social and individual responses in the
context of a growing epidemic
Normalisation / social acceptance of condoms
Progressive improvements in public sector condom quality
control
Progressive improvements in condom distribution
Demand-based logistical system
Increased annual budgets and procurement
Successful as a result of the interplay between
• Multiple and sustained campaigns
• Quality of product/resource
• Efficiency of service/system
• Sustainability (budget)
But… Why is prevalence increasing?



HIV prevention through condom use is only one
prevention strategy – insufficient on its own
Perceptions of availability, and reported use are high but
impact may be reduced as a result of
• inconsistency of use
• incorrect use
– when to put condom on
– what to do if breakage
– causes of breakage
• lack of use in high risk contexts
– sex work, truck driving
– lesser availability in under-serviced contexts - informal
settlements, rural areas
• limited locus of control (gender, economic, institutional,
coercion, violence)
Further research is needed to build on successes and
consolidate condom promotion as a strategy
What about HIV prevention
campaigns targeting youth?
Well…



Youth focus has been based on assumptions that:
– Youth prevalence drives adult prevalence
– Controlling youth prevalence has a positive ‘knock-on’
effect on individual HIV risk later on in life
– HIV prevalence amongst youth can be rapidly reduced
through intensive campaigns
Most campaigns in South Africa include a youth
prevention focus
– massive budgets allocated to youth HIV prevention by
government and through funders including Global Fund,
bilateral agencies, foundations
– great deal of overlap, but little co-ordination
Campaign evaluations show some impact on
knowledge, attitude and behaviour indicators…
But…


Youth antenatal prevalence
has remained much the same
over the past four years
Population-based studies
show high prevalence, and
disproportional effects on
young females (RHRU 2004)
Males 15-19, 2.5%
Females 15-19, 7.3%
Males 20-24, 7.6%
Females 20-24, 24.5%
Teen pregnancy
rates have
increased, eg.
15-19, DHS 1998,
RHRU 2004
SA Antenatal data, females < 20
20.0%
18.0%
16.0%
15.4%
14.8%
15.8%
16.1%
14.0%
12.0%
<20
10.0%
8.0%
6.0%
4.0%
2.0%
0.0%
2001
2002
2003
2004
45.0%
38.0%
40.0%

35.0%
30.2%
30.0%
25.0%
18.0%
20.0%
15.0%
10.0%
5.0%
DHS 1998
RHRU 2003
19.8%19.0%
10.7%
5.2% 5.0%
2.0% 1.0%
0.0%
15
16
17
18
19
And…
HIV prevalence in young adults and adults escalates
rapidly from early 20s (NM/HSRC 2002) – little apparent
‘knock-on’ effect.
19%
7%
7%
8%
11%
12%
5%
5%
Males
Females
8%
10%
7%
15%
12%
20%
14%
17%
25%
18%
22%
30%
24%
35%
24%
32%
40%
4%

0%
15-19
20-24
25-29
30-34
35-39
40-45
45-49
50-54
55+
Can campaigns actually make a
difference to youth prevalence?
Points to consider…



Campaigns are mainly about promoting knowledge and
awareness
– Communication should be focused, clear and simple
– Little evidence that indirect focus on ‘consumerism’,
‘aspiration’ and ‘healthy lifestyle’ amongst youth will
lead to sexual risk reduction
Rational volitional model of sex is problematic
– Sexual relationships are relative to partner dynamics
– Risk may be influenced by physical power [male/female],
cultural power [age/gender], economic power
[poverty/reification of consumption], abuses of institutional
power [schools]
– Sex includes emotional and irrational elements
Prevention should not be separated from the continuum
of treatment, care, support and rights
– Integrated approaches incorporating community-level
mobilisation, eg. Gay community response in US,
community-level response in Uganda
– support services important
What’s missing?


Lack of direct focus on communication about key
epidemiological drivers
– Early sexual debut
– Age differentials between partners
– Multiple partners
– Coercion (as a product of power differentials)
– Violence (rape, statutory rape)
Lack of focus on youth risk as a product of vulnerability:
– Specific risks to young females
– Children affected by HIV/AIDS in their families (orphaning)
– Poor promotion of grants and assistance to vulnerable
youth
– Inadequate promotion of rights and legal framework
– Little emphasis on young PLHA
Where to from here?
Expand prevention focus…


Epidemiological drivers affecting all age groups
– Children under 14
– Young adults and adults 25-35
– Older adults (50+)
Contexts of risk
• mobility in the context of work (eg. Truck driving)
• labour migration and workseeking (feminisation of
migration), informal settlement
• Sex workers, gay men, IDU (emerging)
• A focus on PLHA is virtually absent
Extend focus…

Address information needs along the continuum
– ‘Treatment seeking’, STI, PMTCT, PEP, TB, ARV
– universal precautions overlooked
– ’Support seeking’, counselling, VCT, grants
– Care including palliative care
– Support to PLHA, affected families, orphans
– Legal recourse in relation to law and rights
A coherent approach…


There is an urgent need to develop an overarching
strategy that sets the agenda for campaigns. This strategy
should:
– Address overlap and improve co-ordination between
campaigns
– Focus intensively in key areas
– Use research to inform campaigns
– Ensure accountability of campaigns to national indicators
The broader context should also be taken into account
– Resource and service environment
• Formal health system
• NGOs and CBOs with HIV/AIDS focus
• Civil society organisations
• Businesses
• Social mobilisation and grassroots response
– Political environment
– Macro-economic system
Our actions count…