Andrew Jack wrote in the Financial Times on Wednesday about measures to reduce AIDS in Africa. In a nutshell, he says that there has been too little support for campaigns to change sexual behaviour, even though these efforts appear to have worked in Uganda, Zimbabwe and Kenya. By contrast, there has been more investment in drugs to treat AIDS and condoms to help prevent it.
Purnima Mane, director of policy evidence and partnerships at UNAids, the United Nations' Aids agency, says: "In the last 10 years, the focus has been highly biomedical. Social scientists have withdrawn a bit. They have been seen as playing second fiddle." Furthermore, when programmes have been launched, monitoring and evaluation has often been lacking. "We have launched boutique projects rather than scaling things up," she says. "We don't establish what makes them effective. That has been the tragedy, because we have wanted to act quickly."
I drew several conclusions from this:
- donors do tend to invest more in development programmes for which there is statistically robust evidence of effectiveness, such as clinical trials which demonstrate effectiveness by comparing people who receive the drug with otherwise similar people who don't
- we need to invest more in rigorous impact evaluations of social programmes (e.g. behaviour change campaigns), preferably using random assignment trials wherever this is ethical, practical and cost-effective
- the value that we attach to acting quickly, with the minimum of delay and bureaucracy, to get programmes up and running, militates against embedding rigorous statistical evaluation into new programmes
- the benefits of developing having better information about the effectiveness of social programmes are long term and global, and the costs and delays are mainly borne by the individual donor and the community in which the programme is being conducted; as a result, there are insufficient incentives to do this kind of analysis.
The Center for Global Development report on the Evaluation Gap looks at these issues in more detail. Their conclusion – with which I agree – is that we need a coordinated international effort to increase statistically rigorous evaluation of social programmes in development.
This all sounds very dry and technical. But read the article in the FT: if we had better, more rigorous evaluation evidence we might have done better at reducing the AIDS epidemic in Africa. And that would be quite something.
To tackle a taboo: how Africa is opening up a new front in the fight against Aids
By Andrew Jack
Published: January 18 2007 02:00 | Last updated: January 18 2007 02:00
It was no surprise to Sibongile when her husband died of Aids in 2003, even though he had always refused to take a test. She had suspected that he was HIV positive ever since she learnt of the death of one of his girlfriends two years earlier.
"I was expecting it. He was a real ladies' man," she says with an embarrassed smile. "I knew it for a long time but I stayed. I really loved him and he helped me financially. One of the things in our culture is that you don't question your husband."
Her experience in Swaziland touches on a taboo that a growing number of public health experts believe must be breached if the devastating impact of HIV is to be reversed in southern Africa: the need to change sexual behaviour and, above all, to reduce the number of sexual partners people have.
While the emphasis in the fight against Aids in the developing world since the turn of the millennium has focused on increasing the number of people on treatment, such efforts do nothing to stem the continued rise in new infections.
Although hundreds of millions of dollars of donor and local funding have poured into HIV prevention programmes, far less effort has gone into persuading people to change their sexual practices. "Prevention has concentrated on testing, condoms, safe blood and mother-to-child transmission – things that fall easily off bureaucrats' lips," says Derek von Wissell, who runs Nercha, Swaziland's official National Emergency Response Council on HIV/Aids. "Behaviour change is the difficult side. It needs a whole societal shift."
Recent initiatives in his country and others in the region reflect a new determination to tackle a sensitive subject. The debate has long been politicised. Thabo Mbeki, president of South Africa, was among those who argued that advocates who linked Aids to promiscuity were propagating racist sexual stereotypes of Africans.
In the US and elsewhere, the debate around prevention became polarised around which aspects of the mantra of "ABC" – "abstinence, be faithful and condomise" – should receive priority. Religious groups focused on the first two in an effort to promote more conservative sexuality. More socially liberal advocates argued above all for condoms, maintaining that it was unrealistic to expect A and B to work.
Pepfar, US President George W. Bush's programme of Aids assistance to the developing world, was caught in the middle. Inspired by his alliance with the religious right, its mandate required substantial funds to go to promoting abstinence and fidelity – even though it is also spending considerable amounts on condoms, too.
"When you say ABC, it immediately conjures up George Bush," says Daniel Halperin from Harvard's School of Public Health, who specialises in Aids and behaviour change. "There was an immediate polarisation between those saying condoms were evil and those who argued that only condoms were good."
He helped co-ordinate a letter two years ago to The Lancet, the medical journal, stressing the need for an evidence-based approach. It was signed by leading figures including President Yoweri Museveni of Uganda and Archbishop Desmond Tutu of South Africa. But opinion is changing only gradually – and funding more slowly still.
Mr Halperin and other public health specialists argue that, while all three approaches to prevention have a role in the fight against Aids, changing sexual behaviour and reducing the number of partners has been the "neglected middle child" in ABC.
In countries such as Thailand, Cambodia and Brazil, emphasis on the use of condoms was central to tackling infection rates. But Mark Dybul, the head of Pepfar, argues that the decline was also driven by a fall in the number of men visiting prostitutes – the key driver of the epidemic in those regions.
In southern Africa, Aids has a different pattern. It is not concentrated, as elsewhere, in a few high-risk groups such as sex workers and their clients, intravenous drug users or gay men. It is instead a generalised epidemic, helping explain why the region accounts for two-fifths both of all Aids cases and of new infections.
"Applying lessons [of condom use] from a concentrated epidemic to a region where there is a generalised epidemic was bordering on scientific insanity," says Mr Dybul. "We have not listened enough to Africans. It is tough to find one who doesn't say A, B and C is what we need."
There is no single or satisfactory explanation for why HIV in southern Africa – which has infected up to 40 per cent of the adult population in Swaziland and nearby Lesotho – is so much higher than in the rest of the world. Poverty, malnutrition, lack of circumcision and the low status of women play a strong part. However, a growing body of evidence points to the predominant role of one aspect of sexual behaviour.
As far as research into such sensitive questions
can be relied on, many aspects of African sexuality mirror practices elsewhere. The average total number of sexual partners a person has in a lifetime may even be lower than in many western countries. But in much of the region, men and women often have several concurrent sexual partners over months or years.
In countries such as Swaziland, which traditionally practised polygamy and where King Mswati himself has 13 wives, it is almost institutionalised. Elsewhere in the region it is widespread – though rarely discussed in public.
The practice sharply intensifies the spread of the epidemic for at least two reasons. First, HIV's ability to be transmitted reaches a peak in the weeks after someone has been infected. So those in multiple partnerships can rapidly spread the disease to others.
With one study in Malawi suggesting that in seven villages, 65 per cent of sexually active adults were linked into a single network, such concurrence means HIV can quickly spread across entire communities.
A second explanation is that long-term sexual partners, who show greater trust in and commitment to each other, are far less likely to use condoms. That also increases the likelihood that if one is HIV positive, the infection will be eventually passed on to the other.
The importance of such patterns of behaviour are beginning to be recognised. Public health specialists convened last year by the Southern African Development Community concluded in a report: "Key drivers of the epidemic in southern Africa . . . included multiple concurrent partnerships by men and women with low consistent condom use." It highlighted instances where HIV infections appeared to be falling and linked these to successful programmes aimed at changing behaviour, notably in Kenya, Uganda and Zimbabwe.
Why has it taken public health professionals so long to reach this conclusion? One reason is the complexity of establishing the link. Drug trials can often quickly and clearly demonstrate a quantifiable effect of taking a medicine. Behavioural studies are much more complex. Efforts to change sexual behaviour may take many years to have any effect – and the impact on reduced HIV can often be attributed to a range of factors other than prevention programmes.
Perhaps most importantly, few programmes specifically intended to change behaviour have taken place – and fewer still have focused directly on reducing the number of partners. That reflects ideology, the sensitivity of the subject and a distaste for the social coercion attempted in programmes such as Uganda's "zero grazing" initiative in the late 1980s, in which local councils assumed powers to monitor young people's sexual activity.
The lack of behaviour-change programmes also mirrors a concentration by funders and doctors on medicines and other "technological" solutions to Aids. Purnima Mane, director of policy evidence and partnerships at UNAids, the United Nations' Aids agency, says: "In the last 10 years, the focus has been highly biomedical. Social scientists have withdrawn a bit. They have been seen as playing second fiddle."
Furthermore, when programmes have been launched, monitoring and evaluation has often been lacking. "We have launched boutique projects rather than scaling things up," she says. "We don't establish what makes them effective. That has been the tragedy, because we have wanted to act quickly."
Warren Parker, a public health consultant based in Johannesburg, is more blunt. "It's very frustrating that so much money is going to imbeciles," he says. "Everyone is putting money into youth programmes but we've been much less focused on partner reduction."
He was an outspoken critic of loveLife, a glitzy South African programme targeted at young people, which received tens of millions of dollars in support from agencies including the Kaiser Foundation in the US and the Global Fund to fight Aids, TB and Malaria. Disappointment with the ineffective and poorly managed scheme eventually led the Fund to cut short its support.
With so little data available, making the case for partner-reduction programmes is only the beginning. Ms Purnima argues: "People have often shied away even from presenting the message because of the sensitivities of language and culture."
Roger Kunene, who is studying for the priesthood, who works with Aids orphans in Swaziland, highlights the absence of role models. "In our culture, you have to have a lot of girlfriends to be a man," he says. "Many people don't practise what they preach. A lot of teachers warn about Aids but are having relationships with their pupils."
Swaziland has been one of the boldest recent experimenters, launching a media campaign last year denouncing the widespread practice of having "secret lovers". It quickly ran into controversy, accused by local HIV activists of stigmatising sufferers, and toned down its approach within two weeks.
But polls afterwards suggested that most people across the country knew about the campaign, the majority supported it and a significant proportion claimed that it would influence them to reduce their number of partners.
Behavioural change programmes will provide only a partial solution to tackling Aids in southern Africa and other heavily affected parts of the world. As has been seen in the developed world, "disinhibition" can set in, causing infection rates to rise again. "The messages get old, people get sick of them and are not afraid of dying any more," says Mr Dybul.
But there is a growing sense that partner reduction should receive far greater support and evaluation than it has so far, supplementing a growing number of medical and other approaches. These include increased HIVtesting, counselling and malecircumcision.
"We need to create a rising tide of societal change," says Nercha's Mr von Wissell. "My gut feeling is that behaviour change works. While all these academics are talking, we have to act."
Copyright The Financial Times Limited 2007