Why HIV prevention programmes fail

Catherine Campbell explains the reasons behind this, which may also apply to other programmes

Why do many well intentioned HIV prevention programmes have disappointing results? How do the beliefs and practices of medical doctors and researchers contribute to the success or failure of prevention efforts? In seeking to explain the obstacles to effective management of HIV and AIDS, attention is usually given to factors internal to affected communities (such as exotic aspects of local cultures; or individuals' health, attitudes, or behaviours). The spotlight also often falls on technical aspects of control regimens for sexually transmitted infections (STIs) or the content of health educational messages. Less attention has been given to the way in which prevention efforts are conceptualised and managed, and to the challenges that face those trying to build partnerships between medical doctors and researchers and the non-traditional partners they need to work with if the epidemic is to be effectively managed in the marginalised communities in which it often flourishes.

Good intentions

CRISPIN HUGHES/PANOS PICTURES

Backing for HIV prevention

These factors are showcased in a case study of a state of the art prevention programme in a South African mining community.¹ This programme was well funded and backed by an impressive array of local and international experts. On paper it seemed ideal. It was initiated by a group of township residents concerned about rocketing levels of HIV (baseline research showed that levels of HIV were 22% among mineworkers, 68% among sex workers, and 50% among young people). The programme was managed by a representative group of "stakeholders" living or working in the local community-grassroots groupings, mining industry doctors and human resources personnel, private GPs, traditional healers, trade unionists, representatives of local and national health departments, biomedical and social scientists, and foreign donor agencies.

GIACOMO PIROZZI/PANOS PICTURES

A peer educator demonstrating condom use

Why the programme failed

Launched on a wave of optimism and goodwill the project's impact was disappointing. Levels of STIs actually rose among mineworkers, one of the key target groups. Part of the explanation for the project's results lie in social, economic, and cultural obstacles, which reduced the likelihood that project beneficiaries (in particular mineworkers, commercial sex workers, and young people) would derive maximum benefit from state of the art control efforts and peer education. These factors are discussed in great detail in the study.

The other part of the explanation lies in the various ways in which differences between project stakeholders undermined its effective implementation. The rationale underlying "multi-stakeholder partnerships" is that epidemics are extraordinary events, arising because existing medical systems and practices are inadequate for addressing them. Furthermore, HIV, with its mix of biomedical, behavioural, and social roots, is too complex for any one group to deal with, requiring the collaboration of biomedical and social scientists and practitioners; actors and agencies from the public sector, the private sector and civil society; and players at the local, national, and international levels.

The stakeholder team showed various forms of resistance to developing new ways of thinking and acting in collaboration with non-traditional partners. Medical experts were over-represented on the team. Committed to biomedical rather than social understandings of disease transmission and prevention, their primary commitment was to implement control for sexually and distribute free condoms. Little acknowledgment existed of the need to supplement these approaches with efforts to create social environments that would support increased condom use and uptake of STI services.

The project also suffered from variable levels of commitment by key stakeholders. Deprived township residents seemed locked into a cycle of fatalism and denial about HIV. Adult denial of the problem hindered prevention among young people. Potentially influential stakeholders ranging from mine medical officers to mineworkers' trade unions chose not to follow through their initial commitment to implementing all the strategies laid out in the project proposal. In the three year study period most miners were not exposed to peer education, nor were miners' representatives mobilised to participate in project activities and decision-making-although these had initially been highlighted as key project goals.

Given the narrow biomedical framework that informed many key stakeholders' participation, it is not surprising that the project suffered from poor capacity in areas such as organisational development, project management, and social science. The project coordinator was a senior scientist with no management training or experience, for example. Despite his strong commitment to a "social change" approach to public health he and other stakeholders lacked the skills needed to implement such an approach. Although around three quarters of the project's intended beneficiaries consult traditional healers, virtually no effort was made to facilitate the traditional healers' participation.

The project suffered greatly from a lack of conflict mediation skills. This was a key shortcoming in the face of the personal and political conflicts and controversies, and the frequent lack of inter-group trust, which will inevitably arise when such a diverse group of partners seek to address a problem as fraught and stigmatised as HIV/AIDS. An appropriate health systems infrastructure was lacking to facilitate the collaboration of this group of non-traditional stakeholder partners with their very different skills, abilities, and motivations.

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"Puppets against AIDS"narrator demonstrating condom use

Lessons for future work

What of the broader context of HIV prevention beyond this community? With poor government leadership the ground has been left open for international development agencies and externally funded non-governmental organisations. The discourses of HIV prevention are often the discourses of Western science and policy, regardless of the extent to which these are appropriate for local conditions. Projects are often designed by "overseas experts," with only minimal and "tokenistic" consultation of local people, who may have little sense of "ownership" of project proposals and lack the conceptual understandings, technical skills, or trained staff to implement them properly.

The potential impact of the project was also hampered by the assumption by more educated, affluent, and powerful stakeholders that it was "others" that needed to change in order for HIV prevention to succeed. Their unwillingness to accept that they too would need to change was at the root of their lack of effort in working towards genuinely collaborative relationships with non-traditional partners in the interests of creating social conditions that were supportive of improved sexual health.

More attention needs to be given to the way in which biomedical frameworks ofunderstanding of health and disease can hinder attempts to develop holistic approaches to HIV/AIDS management. The roots of the HIV epidemic are complex. Medical interventions-such as STI control and, more recently, antiretroviral drugs-are clearly vital. But these need to be supported by efforts to create social environments that enable vulnerable individuals and communities to derive maximum benefit from drugs and treatments.

Holistic approach

A call to medical doctors and researchers to adopt more holistic and multidisciplinary approaches runs counter to the current tide of increasing specialisation and compartmentalisation. Yet the nature of the HIV/AIDS epidemic challenges this culture of specialisation. This is particularly the case for those who seek to rise to the challenge of slowing the rate of HIV transmission, supporting those lay people who often have to carry the burden of AIDS care and enhancing the abilities of deprived communities to respond to future health threats.

1. Campbell C Letting them die: why HIV prevention programmes fail. Oxford:James Currey/Bloomington: Indiana University Press/Cape Town: July,2003.

       

           

Responses published this month Articles Responses EDITORIALS Why HIV prevention programmes fail       Catherine Campbell (December 2003) Anand Kukkamalla (February 07, 2005) Read this response EDITORIALS Why HIV prevention programmes fail       Catherine Campbell (December 2003) Anand Kukkamalla (February 07, 2005)       Sr. Grade Lecturer im Microbiology, Melaka Manipal Medical College anandkukk@yahoo.com I completely endorse the views expressed by the author. There are many facets to explain why HIV prevention programmes fail. Firstly we are working with a virus which basically target the most important cells of the immune systen (CD4 helper cells) which is important for immunity of an individual. The main reason for the failure of prevention programmes is even though most of the community is very well aware about the disease through various informative media, there is still a stigma attached in all spheres. The infected individuals even though aware, would not inform the doctors or others as they feel that they would be looked down and looked as outcasts. It has retarded the process of identifying the infected individuals for further treatment to reduce the spread. Also, since the spread is also associated with sexual activities (route of spread), prevention becomes difficult as it is dependent on individuals. With the recent changing trends of social activities (premature sex, sexual promiscuity, multiple sex partners, drugs, prostitution etc..) and behaviour of individuals, preventing spread of HIV is becoming more difficult. Most of the infectious diseases in the world have been effectively prevented by good vaccines like small pox, Polio etc..In case of HIV infection, vaccines are not available for effective prevention, even though most of them are still on trial. A few of these have gone to the level of human trials and will be available. The difficulty in the vaccine preparation is due the inherent activity of the HIV to undergo antigenic variation. If the vaccines are ready it can be effetively used to prevent the infection. Further, the vaccines should be affordable for every one so as to reach the general population. The drugs used for the treatment is also very costly and hence it becomes difficult for a common man to procure it and also the duration for therapy is too long (may be for life time). Probably if a drug is discovered which is less costly and requiring a shorter duration of therapy it will increase the effectivity of prevention.