Successful Programs


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Successful Programs

  1. 1. Successful HIV Prevention Programs Anthropology 393 – Cultural Construction of HIV/AIDS Josephine MacIntosh March 22, 2005
  2. 2. HIV Prevention & Health Promotion <ul><li>HIV prevention: easier said than done </li></ul><ul><ul><li>Important components: </li></ul></ul><ul><ul><ul><li>Preventing HIV transmission </li></ul></ul></ul><ul><ul><ul><li>Promoting healthy lifestyles </li></ul></ul></ul><ul><ul><ul><li>Promoting sexual health </li></ul></ul></ul><ul><ul><ul><li>Treatment of drug abuse </li></ul></ul></ul><ul><ul><ul><li>Sexual and drug risk reduction </li></ul></ul></ul><ul><ul><ul><li>Assuring health care access </li></ul></ul></ul>
  3. 3. Designing Successful HIV Prevention Programs <ul><li>Developing comprehensive HIV prevention programs is complex </li></ul><ul><ul><li>Individual-based interventions </li></ul></ul><ul><ul><li>Community-wide education </li></ul></ul><ul><ul><li>Accessible health care services </li></ul></ul><ul><ul><ul><li>Especially HIV counselling, testing & treatment </li></ul></ul></ul><ul><ul><li>Accessible drug treatment services </li></ul></ul><ul><ul><li>STD diagnostic and treatment services </li></ul></ul>
  4. 4. Primary Vs. Secondary <ul><li>Primary prevention </li></ul><ul><ul><li>Reduces infection by eliminating behavioural risk(s) </li></ul></ul><ul><ul><ul><li>Sexual abstinence or avoidance of intravenous drug use </li></ul></ul></ul><ul><ul><li>Primary prevention is attractive </li></ul></ul><ul><ul><ul><li>But an option only in the long term </li></ul></ul></ul><ul><li>Secondary prevention (bulk of prevention efforts) </li></ul><ul><ul><li>Identification of persons who are already infected </li></ul></ul><ul><ul><li>Encouraging risk reduction in those infected & at risk of infection </li></ul></ul><ul><ul><li>Reduce HIV risk co-factors (e.g., Other STIs) </li></ul></ul>
  6. 6. Challenges and Barriers <ul><li>Community level barriers </li></ul><ul><ul><li>Social norms surrounding sexuality and drug use </li></ul></ul><ul><li>  Patient level barriers </li></ul><ul><ul><li>Does person perceive that s/he is at risk? </li></ul></ul><ul><ul><li>Can they integrate change? </li></ul></ul><ul><ul><ul><li>Motivations = pleasure seeking </li></ul></ul></ul><ul><li>Substance use </li></ul><ul><ul><li>Can impede intervention efforts two ways </li></ul></ul><ul><ul><ul><li>Associated with increased risk-taking behaviour </li></ul></ul></ul><ul><ul><ul><li>Associated w/ reduced ability to implement risk-reduction </li></ul></ul></ul>
  7. 7. Challenges and Barriers <ul><li>Mental illness </li></ul><ul><li>Alcohol and HIV risk behaviours </li></ul><ul><ul><li>Heavy alcohol use associated with </li></ul></ul><ul><ul><ul><li>General increases in risky sexual behaviour </li></ul></ul></ul><ul><ul><ul><li>Decreased condom use </li></ul></ul></ul><ul><ul><ul><li>Increased risk of relapse into risky sexual behaviour </li></ul></ul></ul><ul><ul><li>Contextual substance use appears to have the highest risk </li></ul></ul><ul><li>Non-injecting drug use (e.g., Crack cocaine) </li></ul><ul><ul><li>Related to associated sexual behaviour </li></ul></ul><ul><ul><ul><li>Especially drug-related prostitution activities </li></ul></ul></ul>
  8. 8. Cultural & Behavioural Diversity <ul><li>Interventions require current understanding of HIV epidemiology </li></ul><ul><ul><li>E.g. Groups at highest risk for infection </li></ul></ul><ul><li>Interventions designed for one group may be inappropriate or ineffective for other groups </li></ul><ul><ul><li>Highlights need for continuous epidemiological monitoring and program effectiveness evaluation </li></ul></ul><ul><li>The HIV epidemic is dynamic </li></ul><ul><ul><li>Proportion of cases amongst MSMs decreasing </li></ul></ul><ul><ul><li>Cases amongst IDUs, youth, & women increasing </li></ul></ul>
  9. 9. Cultural Context of Prevention <ul><li>Interventions targeting one risk group have the potential to alienate or marginalize members of other risk groups </li></ul><ul><li>Must be designed to account for appropriate cultural norms </li></ul><ul><ul><li>In diverse populations </li></ul></ul><ul><ul><li>Cultural norms in one group may be quite different than in others </li></ul></ul>
  10. 10. HIV Prevention in the Developing World <ul><li>“ Any campaign to combat AIDS in the developing world must be built not only on an awareness of what has worked or failed elsewhere, but also on the unique circumstances of each developing nation”. (Morin, Chesney & Coates, 2000) </li></ul><ul><li>“ Interventions have been developed that have the capacity to reduce HIV incidence and relatively risky behaviours by up to 80%.” </li></ul><ul><ul><ul><ul><ul><li>(Prabhat Jha et al., 2001) </li></ul></ul></ul></ul></ul>
  11. 11. Targeting Unique Populations <ul><li>Targeting </li></ul><ul><ul><li>Process of customizing design & delivery on basis of characteristics of intended audiences </li></ul></ul><ul><ul><ul><li>Females </li></ul></ul></ul><ul><li>Tailoring </li></ul><ul><ul><li>Customizing messages of specific individuals or a homogenous group within the target audience </li></ul></ul><ul><ul><ul><li>Female sex trade workers </li></ul></ul></ul><ul><li>Intervening upstream </li></ul><ul><ul><li>Targeting or tailoring for those w/ most partners </li></ul></ul><ul><ul><ul><li>Wise use of limited resources </li></ul></ul></ul>From: Singhal & Rogers, 2003
  12. 12. Nairobi, Kenya (1985) <ul><li>Target = 1,000 female CSW in Pumwari </li></ul><ul><ul><li>80% HIV positive </li></ul></ul><ul><li>Provision of: </li></ul><ul><ul><li>Free condoms </li></ul></ul><ul><ul><li>Free healthcare clinic </li></ul></ul><ul><ul><ul><li>Treated STIs </li></ul></ul></ul><ul><ul><ul><li>Gave counselling </li></ul></ul></ul><ul><ul><ul><li>Provided medical check-up every 6 months </li></ul></ul></ul><ul><ul><li>Included outreach education </li></ul></ul>From: Singhal & Rogers, 2003
  13. 13. Nairobi, Kenya (1985) <ul><li>Results </li></ul><ul><ul><li>Average of four clients per day </li></ul></ul><ul><ul><li>Consistent condom use plus healthcare </li></ul></ul><ul><ul><ul><li>1,000 female CSW </li></ul></ul></ul><ul><ul><ul><li>80% positive </li></ul></ul></ul><ul><ul><li>Estimated to have prevented 6,000 to 10,000 HIV infections/year </li></ul></ul><ul><ul><li>At a cost of approx. $10 per case prevented </li></ul></ul><ul><ul><ul><ul><ul><li>(Moses et al., 1991) </li></ul></ul></ul></ul></ul>From: Singhal & Rogers, 2003
  14. 14. Nairobi, Kenya (1985) <ul><li>IF target = 1,000 randomly selected men </li></ul><ul><ul><li>Provided similar health services </li></ul></ul><ul><ul><li>Achieved same rate of condom use </li></ul></ul><ul><li>Estimate of prevented infections </li></ul><ul><ul><li>Only 80 /year (Altman, 1997) </li></ul></ul><ul><li>Illustrates major advantages with targeted interventions </li></ul>From: Singhal & Rogers, 2003
  15. 15. Ideal Interventions for CSWs <ul><li>Effectively select and train peer educators </li></ul><ul><li>Provide free or low-cost condoms </li></ul><ul><li>Make available </li></ul><ul><ul><li>Literacy programs </li></ul></ul><ul><ul><li>Health clinics </li></ul></ul><ul><ul><li>Savings plans </li></ul></ul><ul><ul><li>Other services valued by sex trade workers </li></ul></ul>From: Singhal & Rogers, 2003
  16. 16. Sex Trade Work in Mumbai, India
  17. 17. Mumbai, India <ul><li>Epicenter of Indian epidemic </li></ul><ul><ul><li>70,000 sex trade workers </li></ul></ul><ul><ul><li>Largest red-light district in the world </li></ul></ul><ul><ul><ul><li>Different areas known by specialities </li></ul></ul></ul><ul><ul><ul><ul><li>Area 1 = vaginal sex </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Area 2 = anal sex </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Area 3 = oral sex </li></ul></ul></ul></ul><ul><ul><li>Streets differentiated by price </li></ul></ul><ul><ul><ul><li>Youngest, fairest-skinned charge most </li></ul></ul></ul><ul><ul><ul><ul><li>High = $40/night </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Low = 50 cents/act </li></ul></ul></ul></ul>From: Singhal & Rogers, 2003
  18. 18. Mumbai, India <ul><li>More migrant workers than other cities </li></ul><ul><ul><li>Form main customer base </li></ul></ul><ul><ul><li>Males, 17 to 30 </li></ul></ul><ul><ul><li>Manual labourers </li></ul></ul><ul><ul><ul><li>No access to healthcare </li></ul></ul></ul><ul><ul><ul><li>Little or incorrect knowledge of HIV </li></ul></ul></ul><ul><ul><ul><li>May have STIs </li></ul></ul></ul><ul><ul><li>Return to home place once or twice/year </li></ul></ul><ul><ul><ul><li>Bring infections with them </li></ul></ul></ul><ul><ul><ul><li>May infect wife/girlfriend </li></ul></ul></ul>From: Singhal & Rogers, 2003
  19. 19. Mumbai, India <ul><li>Empowerment of CSW </li></ul><ul><ul><li>Gradual process of independence in trade </li></ul></ul><ul><ul><li>Begin under total control of brothel owners </li></ul></ul><ul><ul><ul><li>Many spend their days in cages (cage girls) </li></ul></ul></ul><ul><ul><li>2nd year, may get 50/50 deal with owner </li></ul></ul><ul><ul><ul><li>May have “husband” & children by then </li></ul></ul></ul><ul><ul><li>3 rd year may leave brothel to work on own </li></ul></ul><ul><li>Almost all are HIV-positive by this time </li></ul>From: Singhal & Rogers, 2003
  20. 20. Mumbai, India <ul><li>HIV-positive sex trade workers </li></ul><ul><ul><li>Often stigmatized </li></ul></ul><ul><ul><li>Mistreated </li></ul></ul><ul><ul><li>Turned away from govt health clinics </li></ul></ul><ul><ul><ul><li>May self-medicate </li></ul></ul></ul><ul><ul><ul><li>Preyed on by phony doctors w/ phony cures </li></ul></ul></ul><ul><li>Onset of AIDS-related illnesses </li></ul><ul><ul><li>Thrown out of sex business </li></ul></ul><ul><ul><li>Forced to fend for self </li></ul></ul>From: Singhal & Rogers, 2003
  21. 21. Mumbai, India <ul><li>Sex trade controlled by powerful mafia </li></ul><ul><ul><li>Population Services International (PSI) intervention programmers met with mafia </li></ul></ul><ul><ul><ul><li>Pointed out HIV prevention good for business </li></ul></ul></ul><ul><ul><ul><li>Not aimed at getting women out of the business </li></ul></ul></ul><ul><ul><li>Intervention uses peer-educators </li></ul></ul><ul><ul><ul><li>Most former STW, some HIV+ </li></ul></ul></ul><ul><ul><ul><li>Speak variety of Indian languages </li></ul></ul></ul><ul><ul><ul><li>Bright yellow shirts, identification badges (official looking) </li></ul></ul></ul><ul><ul><ul><li>Contacted over 30, 000 STW in past decade </li></ul></ul></ul><ul><ul><ul><ul><li>Recall Kenya </li></ul></ul></ul></ul>From: Singhal & Rogers, 2003
  22. 22. Healthy Highways, India <ul><li>Targets Indian truck drivers </li></ul><ul><ul><li>Estimated 3.5 million truck drivers in India </li></ul></ul><ul><ul><li>Numerous sexual contacts with STW </li></ul></ul><ul><ul><li>10,000 truckers/day arrive in Mumbai </li></ul></ul><ul><ul><ul><li>Sex </li></ul></ul></ul><ul><ul><ul><ul><li>Red-light districts </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Truck stops eat, drink, rest, and … </li></ul></ul></ul></ul><ul><ul><li>Thousands of truck stops on major highways </li></ul></ul>From: Singhal & Rogers, 2003
  23. 23. Healthy Highways, India <ul><li>Sex trade is subtle and supported </li></ul><ul><ul><li>Frequent intercourse defines masculinity </li></ul></ul><ul><ul><ul><li>Never in truck </li></ul></ul></ul><ul><ul><ul><ul><li>Sacrosanct </li></ul></ul></ul></ul><ul><li>Most truckers are heterosexual </li></ul><ul><ul><li>Trucker lingo for sex with </li></ul></ul><ul><ul><ul><li>Men = ‘reverse gear’ </li></ul></ul></ul><ul><ul><ul><li>CSW = ‘forward gear’ </li></ul></ul></ul>From: Singhal & Rogers, 2003
  24. 24. Healthy Highways, India <ul><li>Peer education using flipcharts depicting condom use w/ CSW </li></ul><ul><ul><li>HIV = round, spiny, w/evil face </li></ul></ul><ul><ul><li>Adopted motto of: </li></ul></ul><ul><ul><ul><li>“ Sex without condoms is like driving without brakes” </li></ul></ul></ul><ul><ul><ul><ul><li>Makes sense to audience </li></ul></ul></ul></ul><ul><ul><li>Persuade drivers to protect family </li></ul></ul><ul><ul><ul><li>Outreach workers </li></ul></ul></ul><ul><ul><ul><li>Free condoms </li></ul></ul></ul><ul><ul><ul><li>Comic books of flip chart characters/stories </li></ul></ul></ul>From: Singhal & Rogers, 2003
  25. 25. Healthy Highways, India <ul><li>STIs among truckers in Tamil Nadu </li></ul><ul><ul><li>1997 = 20% </li></ul></ul><ul><ul><li>2001 = 10% </li></ul></ul><ul><ul><li>Project was decentralized in 2001 </li></ul></ul><ul><ul><ul><li>Lost momentum </li></ul></ul></ul><ul><ul><ul><li>Now defunct </li></ul></ul></ul><ul><li>Need for evidence-based policy </li></ul><ul><ul><li>This appears to have been working </li></ul></ul><ul><ul><ul><li>Need for secure funding </li></ul></ul></ul>From: Singhal & Rogers, 2003
  26. 26. Pittsburgh, 1986-87 <ul><li>Target = 600 homo & bisexual men </li></ul><ul><ul><li>Intervention had 2 components </li></ul></ul><ul><ul><ul><li>First = hour-long small group lecture </li></ul></ul></ul><ul><ul><ul><li>Second = Skills-building </li></ul></ul></ul><ul><ul><ul><ul><li>Condoms </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Negotiation skills </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Role-playing </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Discussion </li></ul></ul></ul></ul><ul><li>One half did group lecture only (control grp) </li></ul><ul><li>Other half did both </li></ul>From: Singhal & Rogers, 2003
  27. 27. Pittsburgh, 1986-87 <ul><li>Target = 600 homo & bisexual men </li></ul><ul><ul><li>Goal = condom use for anal sex w/ man </li></ul></ul><ul><ul><ul><li>Control group (lecture only) </li></ul></ul></ul><ul><ul><ul><ul><li>No change </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Before = 40% </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>After = 40% </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Experimental group (lecture + skills) </li></ul></ul></ul><ul><ul><ul><ul><li>Increased condom use </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Before 40% </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>After 70% </li></ul></ul></ul></ul></ul><ul><ul><li>Demonstrates the importance of providing skills-building in conjunction with knowledge </li></ul></ul>From: Singhal & Rogers, 2003
  28. 28. Migrant Farmer Workers <ul><li>Target = ~ 300 Mexican migrant farm workers in southern California </li></ul><ul><ul><li>At risk due to STW brought to camps </li></ul></ul><ul><ul><li>Goal: Education via fotonovelas </li></ul></ul><ul><ul><ul><li>8 page story books with pics and captions </li></ul></ul></ul><ul><ul><ul><ul><li>Highlight need to use condoms with STW </li></ul></ul></ul></ul><ul><ul><ul><li>Condoms & instructions provided </li></ul></ul></ul><ul><ul><ul><ul><li>Pop of interest consulted re: approach </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pop of interest models for fotonovelas pics </li></ul></ul></ul></ul>From: Singhal & Rogers, 2003
  29. 29. Migrant Farmer Workers <ul><li>Target = ~ 300 Mexican migrant farm workers in southern California </li></ul><ul><ul><ul><li>2/3 received educational materials </li></ul></ul></ul><ul><ul><ul><li>1/3 did not (control grp given info later) </li></ul></ul></ul><ul><ul><ul><li>All received condoms </li></ul></ul></ul><ul><ul><li>Condoms only – none used </li></ul></ul><ul><ul><li>Educational materials and condoms </li></ul></ul><ul><ul><ul><li>Increased knowledge (small but significant) </li></ul></ul></ul><ul><ul><ul><li>Increased condom use w/ STW (substantially) </li></ul></ul></ul>From: Singhal & Rogers, 2003