UNESCO - PANOS - YRG CARE REGIONAL CONSULTATION ON HIV PREVENTION INFORMATION IN SOUTH ASIA
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- UNESCO - PANOS - YRG CARE REGIONAL CONSULTATION ON HIV PREVENTION INFORMATION IN SOUTH ASIA
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UNESCO - PANOS - YRG CARE
J
-
(TZegioiitil
On
H&JOO OptteiwntwjL ^tifornutfi^n
chi So uth (Isin
JUNE 26-27, 1999
CHENNAI, INDIA
UNESCO - PANOS - YRG CARE
South cAaIcl
/
JUNE 26-27, 1999
CHENNAI, INDIA
l
Agenda for the
Consultation on HIV Prevention Information addressing the spread of
HIV/AIDS in South Asia. June 26-27, 1999 at Chennai, India
26 June
0800-0845
Particulars of session
Breakfast
0845-0930
0930-1000
1000-1030
Inauguration
Settling down/ Group photographs
Introductions: name, organization and interests,
expectations from the workshop
A report of the previous
Aruni
consultations________________
PANOS, its mission__________ Mitu Verma
A family story: game
Suniti Solomon
Discussion on issues raised in
Anjali Gopalan
the game___________________
Lunch_______________
Recognizing the special needs of Suniti Solomon
persons infected with HIV and
families affected by HIV______
Sexuality: speaking up________ Anjali________
Summing up for Day 1________ By arrangement
Tea Break__________________
Departure to Mahabalipuram. Dinner at “The Golden
Sun’, a sea side resort. Bharatanatyam by Dr. Sreedhara
1030-1045
1045-1100
1100-1300
1300-1330
1330-1415
1415-1515
1515-1530
1530-1600
1600
27 June
0915-0930
0930-1000
i
1000-1130
1130-1145
1145-1245
1245-1330
1330-1430
1430-1530
1530-1600
Resource persons
See inauguration
agenda__________
As above
Particulars of session________ Resource persons
Recap of day 1______________
By arrangement______
“AIDS, an old disease still new: Pramod
a reporter’s dilemma”________
HIV prevention information in
C Y Gopinath
South Asia: Brain storm on the
situation, concerns, challenges,
what is working, evaluation
techniques_________________
TEA Break_________________
Developing effective prevention information: Cross
Fertilizing ideas, Group Work_________________
Lunch______________________
Groups report back on their discussions__________
Multisectoral approach to
Suniti Solomon
prevention information
Akila Sivadas
End of meeting facilitation
Anjali
AIDS, an Old Disease, Still New: A Reporter’s Dilemma
By G. Pramod Kumar
AIDS1, which made its documented entry into India in 1986 is an old disease, that is still new.
Thirteen long years of its presence in the country have made it old while its complexities and the bearish
nature of its emergence make it still new. We have seen a sizeable part of the problem and its catastrophic
characteristics, but a substantial part that will have far reaching consequences of still bigger proportions is
yet to emerge. As the coverage of AIDS in the Indian media loses steam, the reporter who has been
watching the epidemic closely realises that this is going to be the biggest dilemma he/she is going to face in
his/her attempts to sustain media interest. Covering an old disease that is still new challenges the very basic
nature of media mechanism. But this dilemma needs to be resolved if one wants to take media along in
one ’ s campaign against the disease.
But before proceeding further, let’s face the fact that coverage of health is not a priority for much of the
mainstream media in India as much as it is not a priority for the political system and the Government.2. In
this country where realpolitik is almost like an obsession for much of the mainstream media, the space
health manages to get is sparse. And AIDS has to fight with the huge double-burden of diseases and
developments in modem medical scene for that little space. In addition, being an “old” disease which
hasn't yet acquired epidemic proportions. AIDS loses out on the question of newsworthiness. The reporter
has no answer when the newsmanager asks, and justifiably so, “What is new ? ”. We should also keep in
mind that media measures truth in terms of what is expedient and what is popular.
As a reporter, who has been covering AIDS for the last several years in a state which has the best record in
handling the disease through the combined efforts of NGOs, international agencies. Government and the
media, I have been gripped by this dilemma for quite some time now. Compared to the rest of the world,
particularly the West, there is practically no published study on “AIDS and Media” in India except one or
two of no significant value. Hence, my argument is based on my personal experience and information from
somewhere else and, is supported by the yet to be documented nature of coverage of the disease by the
Indian media.
Understanding the dynamics of the media in handling public health issues like AIDS is crucial on many
areas like shaping the opinion of society, addressing the specific needs of specific groups or setting the
agenda of policy makers, governments and even the international agencies.3 For instance, a pilot study by
Mr.B. Westwood of the Queensland Centre for Public Health in Australia on “Public health reporting and
the media" had proposed “that a better understanding of how newspaper reporting deals with health issues
is of great importance to public health professionals. It may help utilise the print media to promote
information on public health issues to the population in a positive and attention-catching manner”.
A cursory glance of the nature and extent of coverage of AIDS during tlie last thirteen years is important to
understand the evolution of the disease in the Indian media and also the reporter’s dilemma. When it first
1 For convenience, all references to AIDS denote HIV/AIDS
2 Economic and Political Weekly, editorial, “Devaluing Development,” March 21, 1998.
3 Convention on mass communication. Annenberg Washington Programme and Centre for Health
Communication, Harvard School of Public Health, October, 1993. Introductory remarks by Prof. Mark
Moore on the objectives. Among other things, he said: “we hope to learn how mass communication shapes
society’s ability to deal with its problems, gets issues on the public and governmental agenda, reinforces or
alters norms and attitudes within the general population and imparts specific information to specific
individuals that changes the way those individuals behave”.
I
I.
I
appeared in India, demolishing the myth of the foreignness of the disease4 and our incredulity about our
invulnerability, it indeed made headlines. (Even in Amenca and Europe. AIDS was treated first as an
African and then as a homesexual disease. For us who boast of a 5000 year old civilisation, it was a product
of the decadent West and we thought our cultural values will protect us). It fit the demands of
newsworthiness perfectly. It had all the ingredients for a run-of-the-mill, screaming headline. During the
subsequent months and years, it evolved as a news item and also as a favourite theme for feature-stories
First it was the shock value, peppered with myths, half-truths and blunders, for several months, then the
tragedies, doomsday predictions and ultimately the human interest.
As many journalists covering AIDS realised, it was not easy to sustain the interest on a single disease for
such a long period of time. News has its demands like the five Ws and one H5. Even feature-stories have
their demands. Starting with the shock value of the news-break, as a reporter. I think we have exhausted
most of the possible angles: tragedy, human misery, women, children, drama, care, quacks and occasional
sob stones.. We are now left with very limited options and are at a loss as to how to sustain the interest on
the disease though it is still in its nascent stage and what we have seen so far is only the proverbial tip of
the iceberg. Interestingly, the early media coverage had set much of the tone, the terminology and
metaphorical conventions that still operate while talking about AIDS (hapless victims. AIDS patients.
AIDS victims and those images of fear)
At this point, it will be interesting to look at how the Western media handled AIDS. Die situation is
identical in some respects, but quite dramatic things happened in the West for which die disease has been
around smce 1981 when a report on it appeared for the first time6. Die evolution of the disease in the
Western media and its success in creating a favourable impact offers several useful lessons to us. It also
tells us how certain dramatic twists could fuel the interest of people from time to time giving a fresh
impetus each time. One would also notice tliat such tilings did not happen in India, hence could be tried.
Die behaviour of the American media as illustrated by a comprehensive study7 will help us face many
situations which we come across in India.
The first media report in the US appeared in the New York Times on August 8, 1982. The report. "A
disease s spread provokes anxiety” focussed attention on a growing health crisis in the homosexual
community that was baffling the medical world. Though "Time” had reported earlier on a disease causing
opportunistic infections in gay men. this was the first time that the term "acquired immunity deficiency
syndrome” was used. Later the same year, the Washington Post too started reporting on AIDS by
publishing a report on the death of an infant. "Over the next three years, the mainstream media confronted
the challenge of reporting on a deadly and mysterious health problem in a responsible manner - to inform
and not to inflame, to educate and not to alarm”8.
In the earher part of the epidemic, the story was indeed relegated to the margins of social deviance. But
later on they did mobilise public attention around an extraordinarily difficult social issue. In 1985. more
than 150 AIDS stories were broadcast by three major TV networks’ evening news. This was more than
double the combined TV coverage for the whole of 1983 and 84. Diese initial years were marked by stories
that often focussed on the dramatic aspects of the disease, its progressive nature, the death-toll among the
higli risk groups and its potential to affect the public at large. In the next ten years, media coverage moved
well beyond its early focus with the content of reporting often pushing AIDS to the top of the news
agenda.
Susan Sontag s interpretation of AIDS as modem plague. Anne K.Mellor in her introduction to The Last
Man by Mary Wollstonecraft Shelly, University or Nebraska Press, 1993, ISBN 0803292171
5 What Why, When, Where and How
6 D.T.Durack. "opportunistic infections and Kaposi’s sarcoma in homesexual men” (editorial), New
England Journal of Medicine, 1981, 305 (24).
'"AIDS in the News Media, 1985 to 1996”, Columbia Journalism Review, CJR, July/August 1996
8 CJR, July/August, 1996
’
Overall, what the press did best was to maintain broadbased coverage. AIDS did not become a political
story or a story focussed solely on homosexuals or IV drug users. Instead it tended to examine the disease's
impact on multiple groups and communities or put a human face to the disease to demonstrate AIDS’
impact on individuals and their famihes.
The transformation then on is interesting. In 1987, AIDS was the primarv focus on all stories in which there
was a mention of the disease. But by 1994. only 30 per cent had AIDS as the main focus with the
rest only referring to the disease while reporting on something else. One point is extremely
relevant to us here, particularly when talking about prevention information. If in the mid-80s the
greatest portion of coverage on the disease was on information about the transmission and
prevention, by 1989. the public’s level of knowledge on many aspects of AIDS transmission had
topped out. The percentage of stories covering prevention peaked in 1987 (31 per cent) while in
1990, bulk of the stories focussed mainly on information on transmission (21 per cent).
In fact the prevention information in the media was on the wane and something dramatic had to happen to
drive afresh the public knowledge. And it happened in 1991 with Magic Johnson’s dramatic
announcement of his HIV status and retirement from NBA. AIDS coverage swelled
unprecedently. In a single week there were 259 stories on AIDS with a large number writing on
prevention and protection. AIDS coverage looked as if it was starting all over again And most
importantly, at the same time, from the realm of general reporting, it crossed over to sports and
celebrity journalism. The issue thus became more broadbased than ever.
After 1991. the coverage was never the same. Celebrity activists lent a new vigour to the campaign and
fundraisers became a regular feature. In 1995, a study9 showed that Magic Johnson and Elizabeth
Taylor were the two individuals who were most recognised by the public as national leaders in this
area. In 1996, the biggest AIDS stories were from sports: Magic Johnson’s return to sports and
Tommy Morrison’s banishment from the boxing ring after he tested positive.
There were some dissenting voices too. But these discordant notes also collaborate the role of dramatic
developments or popular interest in influencing the treatment of AIDS by media. Prof. Everett M.
Rogers of the University of New Mexico says in his analysis of “Media Coverage, Polling Data
and Federal Funding” that for nearly two years after the new England journal of medicine
recognised the association between the syndrome and homosesxual men, AIDS was virtually
ignored by the major national print and broadcast news media, the public and Federal funding
agencies. The discovery of the human immunodeficiency virus in 1983 sparked somewhat more
interest in the scientific aspects of the disease and its transmission. "But it was not until a
Hollywood leading man and a young schoolboy succumbed to the disease, two people with whom
the white, middle class heterosexual mainstream could identify with, that the media and the public
recognised AIDS as a social phenomenon and a threat to public health. “The media discovered
AIDS not because of the statistical measure of its world importance. Rogers asserts, “but because
two famous people, Rock Hudson and Ryan White, got it and gave the story a human touch”.
The 1990s also saw the coverage of drug trials and stories of success. The media had a new paradigm to
write on. that AIDS was not death. The combination therapy bred a new series of stories, stories on how
AIDS wards are becoming empty and how people are coming to terms with a new prospect of life and how
people are going back to work. The ongoing research and drug trials still offer much scope to the Western
media to write about. It may also be noted, however, that the burden on the Western media to sustain the
interest on the disease is less as levels of awareness and intervention are remarkably high there.
The coverage of AIDS in Indian media at present is identical to the situation in the West in 1990. Nothing
dramatic has happened here to give a fresh propulsion. No celebrities or popular figures have come out
actively as campaigners and given the disease a human face. Other than the images of misery and poverty,
AIDS is yet to attain a face like that of Magic Johnson. Arthur Ashe or Greg Luganis. At this juncture the
9 Kaiser Family Foundation’s AIDS media monitoring project
J
onus is entirely on the managers of the AIDS control and prevention, committed campaigners. NGOs and
creative media people to drive it further for several years to come. One has to admit that much of the
prevention information will be the same and will be repetitive, but one has to look for innovative ways to
dress them up as newsworthy and new. Here the confession byProf. Mark L. Rosenberg of the Centres
for Disease Control and Prevention, Harvard School of Public Health, that he indulges in a kind of
“creative epidemiology” to get media attention for his injury mortality statistics, comes extremely handy.
This strategy has worked as a Washington Post article reported: ‘Firearms kills more teenagers than
cancer, heart diseases. AIDS and all other biological diseases combined”. Could be tried here too.
So it is a question of innovative social marketing of AIDS through the news columns of the media. As
nothing dramatic is happening to give a fresh impetus to the media interest, the prevention and control
programs should have a media component built into it. This component should be carefully crafted and
tinkered with from time to time so that the dissemination of information continues all the time. Feedback or
inputs should be from active joumahsts who know the demands of the newsroom. The quality of feedback
or consultation is extremely important in this respect as one wrong step could derail the intentions.
Establish media monitoring cells all over the place and create a network of committed, serious
reporters/writers in place.
My suggestions are:
Bring in the celebrity element right away. Bring in sportsmen, film stars, politicians, important
personalities and literary figures for campaigns in different forms. Create events at regular intervals that
will get reported. Mobilise activities that will get reported. Play with the five Ws and one H. Develop an
informal, but methodical system of information-flow from officers concerned. NGOs and the AIDS
administration to the media on a constant basis. Make carefully crafted statements to catch the attention of
the media, not to make sensation, but to repackage messages. At this point of time, one thing that could
work is to play up the positive aspect of the disease, die changing paradigm that “AIDS is not Death”.10
The response to an interview with Dr.Sunithi Solomon with such a headline in a Malayalam Magazine and
the follow-up coverage is a case in point.
Ultimately, it will be the realisation that we still have several years to go before we can relax that will
work.
10 Arogya Maasika, Mathrbhoomi Publications. Calicut.
L
*
India
Epidemiological Fact Sheet
X
on HIV/AIDS
and sexually
transmitted
diseases
X
♦
I
UNAIDS
UNICEF • UNDP • UNFPA
UNESCO»WHO ■WOR1D BANK
World Health
Organization
2 - India
>-
Country information
Population pyramid, 1997
UNAIDS/WHO Working Group
on Global HIV/AIDS and STD
Surveillance
80+
60-64
a
ZD
40-44
20-24
0-4
Si
8
Swwwww ■
Gender
|B MALE B FEMALE |
Indicators
Year Estimate Source
Total Population (thousands)
1997
960,178
UNPOP
Population Aged 15-49 (thousands)
Annual Population Growth
1997
494.756
UNPOP
% of Population Urbanized
1996
27
UNPOP
1980-1996
3
UNPOP
1995
340
World Bank
1985-1995
3
World Bank
Kiman Development Index Rank (HDI)
138
UNDP
Real GDP Per Capita Rank - HDI Rank
5
UNDP
Gender Related Development Index Rank
118
UNDP
Gender Empowerment Measure Rank
86
UNDP
Human Poverty Index Value (HPI)
36.7
UNDP
38
ILO
Average Annual Growth Rate of Urban Population
Net Migration Rate
GNP Per Capita (USS)
GNP Per Capita Average Annual Growth Rate
% Population Economic Active
1991
Unemployment Rate
Total Adult Literacy Rate
Adult Male Literacy Rate
Adult Female Literacy Rate
Male Secondary School Enrollment Ratio
1990-1995
59
UNESCO
Female Secondary School Enrollment Ratio
1990-1995
38
UNESCO
Crude Birth Rate (births per 1,000 pop.)
1996
26
UNPOP
Crude Death Rate (deaths per 1,000 pop.)
1996
9
UNPOP
Maternal Mortality Rate (per 100,000 live births)
Life Expectancy at Birth
1990
1996
570
62
WHO/UNICEF
UNPOP
Total Fertility Rate
Infant Mortality Rate (per 1,000 live births)
1996
73
UNICEF/UNPOP
Under Five Mortality Rate (per 1,000 live births)
1996
111
UNICEF/UNPOP
% Population Access to Safe Water
% Population Access to Adequate Sanitation
Contact address:
UNAIDSAA/MO Working Group on Global HIV/AIDS and STD Surveillance
20, Avenue Appia
CH-1211 Geneva 27
Switzerland
Fax: +41-22-791-4878
e-mail: Surveillance@UNAIDS.org
http 7/www. who. ch/emc/d iseases/h iv
http://www.unaids.org
UNAIDS/WHQ Epidemiological Fact Sheet
Global surveillance of HIV/AIDS and
sexually transmitted diseases (STDs) is a
joint effort of WHO and UNAIDS. The
UNAIDS/WHO Working Group on Global
HIV/AIDS and STD Surveillance, initiated in
November 1996, guides respective
activities. The primary objective of the
working group is to strengthen national,
regional and global structures and networks
for improved monitoring and surveillance of
HIV/AIDS and STDs. For this purpose, the
working group collaborates closely with
national AIDS programmes and a number ot
national and international experts and
institutions. The goal of this collaboration is
to compile the best information available
and to improve the quality of data needed
for informed decision-making and planning
at national, regional and global levels. The
Epidemiological Fact Sheets are a first
output of this close and fruitful collaboration
across the globe.
Following a series of consultations, the
working group and its partners established c
framework standardizing the collection of
data deemed important for a thorough
understanding of the current status and
trends of the epidemic, as well as patterns
of risk and vulnerability in the population.
Within this framework, the Fact Sheets
collate the most recent country-specific data
on HIV/AIDS prevalence and incidence,
together with information on behaviours
(e g. casual sex and condom use) which
can spur or stem the transmission of HIV.
The data include prevention indicators
developed by WHO's Global Programme on
AIDS, which aim to measure trends in
knowledge of AIDS, relevant behaviours,
and a host of other factors influencing the
epidemic. Additional indicators - for
example, on care and support - will be
included when available.
/
Not unexpectedly, information on all of the
agreed-upon indicators was not available
for many countries in 1997. However, the
fact sheets do contain a wealth of
information which allows identification of
strengths in currently existing programmes
and comparisons between countries and
regions. The fact sheets may also be
instrumental in identifying potential
partners when planning and implementing
improved systems.
The fact sheets can be only as good as
information made available to the
UNAIDS/WHO Working Group on Global
HIV/AIDS and STD Surveillance.
Therefore, the working group would like to
encourage all programme managers as
well as national and international experts
to communicate additional information to
the working group whenever such
information becomes available. The
working group also welcomes any
suggestions for additional indicators or
information proven to be useful in national
or international decision making and
planning.
June 1998
%
India - 3
Estimated number of people living with HIV/AIDS______________
In 1997 and during the first quarter of 1998, UNAIDS and WHO worked closely with national governments and research
institutions to recalculate current estimates on people living with HIV/AIDS. These calculations are based on the previously
published estimates for 1994 (WER 1995; 70:353-360) and recent trends in HIV/AIDS surveillance in various populations.
Epimodel 2, a microcomputer programme originally developed by the WHO Global Programme on AIDS, was used to
calculate the new estimates on prevalence and incidence of AIDS and AIDS deaths, as well as the number of children
infected through mother-to-child transmission of HIV, taking into account age-specific fertility rates. An additional
spreadsheet model was used to calculate the number of children whose mothers had died of AIDS.
The current estimates do not claim to be an exact count of infections. Rather, they use a methodology that has thus far
proved accurate in producing estimates which give a good indication of the magnitude of the epidemic in individual
countries. However, these estimates are constantly being revised as countries improve their surveillance systems and
collect more information. This includes information about infection levels in different populations, and behaviours which
facilitate or impede infection.
Adults in this report are defined as women and men aged 15 to 49. This age range covers people in their most sexually
active years. While the risk of HIV infection obviously continues beyond the age of 50, the vast majority of those who
engage in substantial risk behaviours are likely to be infected by this age. Since population structures differ greatly from
one country to another, especially for children and the upper adult ages, the restriction of the term adult to 15-to-49-yearolds has the advantage of making different populations more comparable. This age range was used as the denominator in
calculating adult HIV prevalence.
Estimated number of adults and children living with HIV/AIDS, end of 1997
These estimates include all people with HIV infection, whether or not they have developed
symptoms of AIDS, alive at the end of 1997
Adults and children
4100000
Adults (15<49)
4100000
1000000
48000
Women (15-49)
Children (0-15)
0.82
Adult rate (%)
Estimated number of AIDS cases
Estimated number of AIDS cases in adults and children that have occured since the
beginning of the epidemic:
Cumulative no. of AIDS cases
430000
Estimated number of deaths due to AIDS
Estimated number of adults and children who died of AIDS since the beginning of the epidemic:
Cumulative deaths
350000
Estimated number of adults and children who died of AIDS during 1997:
Deaths in 1997
140000
Estimated number of orphans
Estimated number of children who have lost their mother or both parents to AIDS (while
they were under age 15) since the beginning of the epidemic:
Cumulative orphans
120000
Estimated number of children who have lost their mother or both parents to AIDS and who
were alive and under age 15 at the end of 1997:
Current living orphans
UNAIDS/WHO Epidemiological Fact Sheet
110000
June 1998
4- India
HIV Sentinel surveillance
This section contains information about HIV prevalence in different populations. The data reported in the tables below are
mainly based on the HIV data base maintained by the United States Bureau of the Census and are a compilation of data from
different sources, including national reports, scientific publications and abstracts. To provide for a simple overview of the
current situation and trends over time, summary data are given by population group, geographical area (Major Urban Areas
versus Outside Major Urban Areas), and year of survey. Studies conducted in the same year are aggregated and the median
prevalence rates (in percentages) are given for each of the categories. The maximum and minimum prevalence rates
observed, as well as the total number of surveys/sentinel sites, are provided with the median, to give the reader an overview
of the diversity of HIV-prevalence results in a given population within the country.
The differentiation between the two geographical areas Major Urban Areas and Outside Major Urban Areas is not based on
strict criteria, such as the number of inhabitants. For most countries, Major Urban Areas were considered to be the capital city
and - where applicable - other metropolitan areas with similar socio-economic patterns. This distinction assumes that capital
cities in many countries have specific characteristics related to the prevalence of higher risk behaviour and a concentration of
HIV infections. The term Outside Major Urban Areas considers that most sentinel sites are not located in strictly rural areas,
even if they are located in somewhat rural districts. Site/study-specific data on which the medians were calculated are printed
in an annex at the end of this fact sheet.
| Group
HIV prevalence in selected populations in percent
KBHH1
HIHi ESQ IFF3 IM
im Ewa IM eoi im im
Pregnant women
Pregnant women
Major Urban Areas
Outside Major Urban Areas
I Group
Area
Sex wort en
Major Urban Areas
Sex worters
Outside Major Urban Areas
1
i
3
3
4
3
2
3
2
2
Minimum
0
o
0
0
0
0
0.8
0
0.5
0.69
Median
0
0
0
0.01
1.55
0.3
1.44
0
0
0
0.5
0.26
0.7
0.7
Maximum
0.8
2.5
2.25
2.38
2.47
4.25
N_Sites
1
4
4
8
6
4
6
0 1
0.1
0
0
0
0.1
0
8
0.6
9
Minimum
0
0.25
3.4
Median
0.1
0.1
0
0
0.56
0.75
0.185
1.83
045
2.585
3.4
Maximum
0.1
0.1
0
0.05
2.44
3.8
191
2.5
4.25
4.18
3.4
httiga fcEi&i Kl&bi
N_Sites
i
1
1
2
8.76
13.2
21.11
0.5
2
0.7
1.4
0.89
8.76
13.2
21.11
17.215
13.65
26 195
089
8 78
13.2
21.11
33.93
26.6
50.99
26
51
4
3
5
4
5
6
6
3
Mirwnum
0.89
Median
Maximum
0.9
0
0
0
0
0
0
0
1
1
Median
0.9
1.5
1 805
1.42
494
16.85
19
21 105
21.105
23.25
29
Maximum
0.9
3.14
3.7
5
85
24.23
31.6
33.73
46.8
34.9
Outside Major Urban Areas
N.Stes
1
1
1
Minimum
0
0
0
[Group
Area
STD patients
Major Urban Areas
Outside Major Urban Areas
Bte^XI I'teraB brrhi iPr1?! ■rbm
BkRil
1
i
1
3
4
2
8.8
39.1
448
67.2
25.4
0
55.7
1
76.7
0
0
0
8.6
39.1
44.8
67.2
55
19.185
39.815
76.7
0
0
0
8.6
39.1
44.8
67.2
85.63
61.05
73.28
76.7
■Psya ■Pw.-i
■ivjl Eppii
N_ Sites
1
1
Minimum
0.4
Median
Maximum
IHMtl
BREM ■EsaB EFwi
1
2
1
1
1.4
1.99
0.5
0.4
1
1.4
1.99
2
0.4
1
1.4
1 99
3.5
BtefcEl Ihum fcW-'M
KteU*! |tePl»l
N.Stes
1
1
1
1
i
1
1
2
2
1
Minimum
1
9.7
9.9
3.3
5.3
6.1
2.7
3.78
5
32.8
Median
1
9.7
99
3.3
5.3
8.1
17.7
32.6
9.9
3.3
5.3
6.1
2.7
2.7
32.6
9.7
36
31
32.6
N_ Sites
1
1
1
i
1
4
1
4
21
23
16
Minimum
0.4
0.8
1.6
1.8
0.9
18
0
0
0
0
Median
0.4
0.8
0.6
0.6
1.6
1.8
3.3
18
17.785
4.75
4.93
5.6
16.8
Maxi mum
0.4
08
0.0
8
18
8.37
13.87
292
15.9
33.0
ij^J
Outside Major Urban Areas
1.2
Median
[Group
Truck drivers
1.2
Maximum
Maximum
STD patients
1
1.2
Minimum
4
Injecting drug users
Area
2
1
HBHH IteKl Ite^l EM Eteftll 1$$! Emil
Outside Major Urban Areas
2
N.Sites
Area
Prisoners
H-'Mi literal |]
ikKsi ermu
[Group
[Group
emi ibi biwmi
N_ Sites
BfrEM
N.Sttes
2
3
8
2
Minimum
3.13
2.55
1
4 98
Median
3.255
2.7
8.15
6.59
Maximum
3.38
5.2
3.8
6.19
UNAIDS/WHO Epidemiological Fact Sheet
6
4.5
June 1998
India - 5
Assessment of epidemiological situation
Assessment of country
epidemiological situation
Systematic sentinel surveillance for HIV in
adopting unlinked anonymous screening of
blood collected for Syphilis serology was
planned for 65 sites from 31 states and Union
territories of India in 1994. Most sites included
STD patients while women attending antenatal
clinics were usually only included if the
prevalence of HIV had already reached at
least 5% in certain risk groups like sex
workers or drug users in the respective state.
For the injecting drug users, only three states
in the north eastern region (Manipur, Mizoram
and Nagaland) could provide sizeable
numbers in the sentinel clinics. All the states
were expected to initiate at least one site by
the end of 1994 and new sentinel sites were to
be developed to allow for a representative
assessment for the each state. Some of the
states, however, could not launch the
surveillance and not all the initial sites could
provide regular data until 1997. Thus, at the
end of 1997 results were available from 55
sites of 22 states or union territories. For some
of the sites, data were available only for
certain years. Out of the four major
metropolitan cities of India (Calcutta, Mumbai,
Chennai and Delhi) Calcutta did not
participate in the sentinel surveillance.
The available results show that the prevalence
of HIV among women attending antenatal
clinics has gone up from 2.5% (1994) to 4.3 %
(1997) in Mumbai, the major metropolitan city
in the Western part of India. Similar
prevalence (3.4%) was also reported from
Pune, another city near Mumbai in the same
year. Another city from south India
(Pondicheery) also showed 4 % prevalence
among the antenatal women in 1996. All other
cities outside major urban area documented a
prevalence of 0-0.8% with the overall median
of 0.8% for all cities outside major urban
areas in 1996.
Prevalence of HIV among STD patients for
1996 was 17% and 31% (33% in 1997) in
Chennai and Mumbai respectively and
between 0% to 16% in cities outside major
urban areas (median 5.2 %).
HIV surveillance among injecting drug users
has unfortunately been discontinued in two of
the three states that initiated this surveillance.
HIV levels in Manipur appear to have
stabilized around 65%, while results from
serosurveys from Calcutta and Chennai show
that the prevalence of HIV among IDU is still
increasing.
Similarly, serosurvey results among sex
'workers show that HIV rates increased from
less than 1% in 1986 to 15% in 1989 and to
more than 50% by 1994 in Mubai whereas the
same has remained low in Calcutta
(increasing from less than 1% in 1986 to
around 5 percent among sex workers by 1995).
UNAIDS/WHO Epidemiological Fact Sheet
Regional maps
Seroprevalence of HIV-1 for Pregnant Women
Middle South Asia
.wig han I at an
Iran •'
i-
“
.
'■) .
Bhutan ■
•N«ghl..
^.-•
E«iN
India
Pviixnil SBrapusliva
.-'EJjinglariexh
\
;
o
<1.0
(»
&
0.1 - 0.3
1.0-4.3
.. Cslorifatf.'. Sri Lanka
iiiu-na
seroprevalence ot mv-i Tor sex VMricer&e nd
I.V. Drug Users In \1lddle South Asia
k>n
P4r^i
FrllA
* '
. -i-w
=.' Wfl SJTCpWb.V
.V -hi4J IAah
VArkw
•xj-i:
I Lin<k
•xJ-11
<•
?
June 1998
6 - India
Reported AIDS cases
■
AIDS cases by year of reporting
1980
1979
1981
I 0 | 0 j 0
Date of last report:
1982
1983
1984
1985
1986
1987
1988
1989
1990
|~0 | 0 | 0 | 0 | 0 I 0 I 0 I “"“T 57
1991
pr
1993
1994
140 | 252
523
1992
1996
1997
| 1078 | 901
I 1984 I
1995
Total
1998
I
Unknown
4980
30-Ncv-1997
AIDS cases officially reported to WHO. Due to gaps in
diagnosis, underreporting, and reporting delays, officially
reported AIDS cases represent only a portion of all cases
in a country. Completeness of reporting varies
substantially from one country to another, from less than
10% in some countries with fewer resources to more than
80% in most industrialized countries (please also compare
with the section on estimates). Therefore, distribution by
age, sex and modes of transmission may not be
representative for all people living with AIDS in a given
country.
AIDS cases by age and sex
Sax
Age
All
Al
<1994 94/<95 1995
1996
1997 1998 Unkn. Total
%
0-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60+
AIDS cases by mode of transmission
Hetero: Heterosexual contacts.
Homo/Bi: Homosexual contacts between men.
IDU: Injecting drug use. This transmission category also
includes cases in which other high-risk behaviours were
reported, in addition to injection of drugs.
Blood: Blood and blood products.
Pennatai: Vertical transmission during pregnancy, birth or
breastfeeding.
NS: Notspecified/unknown.
NS
Male
Al
0-4
5-9
10-14
15-19
20-24
25-29
Sex
Tram, group
30-34
<94 94/<95 1995 1996 1997 1998 Unkn. Total %
35-39
40-44
Al
Hetero
45-49
Homo/9
50-54
I DU
55-59
Blood
60+
Perinatal
Other known
Unknown
Male
NS
Female
0-4
Al
5-9
Hetero
10-14
Homo/BI
15-19
IDU
Blood
20-24
25-29
Other known
30-34
Unknown
35-39
Female AH
Hetero
40-44
45-49
IDO
Blood
50-54
55-59
Other known
60+
Unknown
NS
Al
Hetero
IDU
Blood
Pennatai
Other known
Unknown
<
"Til
NS
NS
Al
0-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60+
NS
UNAIDS/WHO Epidemiological Fact Sheet
June 1998
India - 7
*
Curable STDs
Control and prevention of sexually transmitted diseases (STD) have been recognized as a major strategy in the prevention
of HIV infection and ultimately AIDS. Consequently, monitoring different components of STD control can also provide
information on HIV prevention within a country. One of the cornerstones of STD control is adequate management of patients
with symptomatic STDs. This includes diagnosis, treatment, and individual health education and counselling on disease
prevention and partner notification.
Estimated incidence and prevalence of curable STDs
Incidence
STDs
Year
Male Female
Prevalence
All
Year
Male
Female
All
Chlamydia trach.
Gonorrhoea
Syphilis
Trichomonas
Comments
Source
STD Incidence, men
Prevention Indicator 9: Proportion of men aged 15-49 years who reported episodes of urethritis in the last 12 months.
Year
Area
Age
Rate
1996
Delhi/Haryana-Rural
15-49
2.4
1996
Delhi/Haryana-Urban
15-49
3.6
1996
Maharashtra-Rural
15-49
1.7
1996
Maharashtra-Urban
15-49
2.5
1996
Tamil Nadu-Rural
15-49
2.8
1996
Tamil Nadu-Urban
15-49
0.8
1996
West Bengal-Rural
15-49
1.7
1996
West Bengal-Urban
15-49
32
N=
Comments
Sources
NACO
STD Case management (counselled)
Prevention Indicator 6: Proportion of people presenting with STD in health facilities assessed and treated in an
appropriate way (according to national standards).
Year
Area
Age
Rate
1996
Calcutta-Urban
All
36.1
1996
Calcutta-Urban
All
66.5
1996
Chennai-Urban
All
80.2
1996
Chennai-Urban
All
88.5
1996
Delhi-Urban
All
62.5
1996
Delhi-Urban
All
39.3
1996
Mumbai-Urban
All
12.5
1996
Mumbai-Urban
All
27.8
N=
Comments.
Sources:
NACO
STD Case management (treatments)
Prevention Indicator 6: Proportion of people presenting with STD in health facilities assessed and treated in an
appropriate way (according to national standards).
Year
1996
Area
Calcutta-Urban
Age
Rate
All
66.5
N=
Comments. Partner notification only reflected in number, regardless of advice on condom use.
Sources:
NACO
UNAIDS/WHO Epidemiological Fact Sheet
June 1998
8 - India
Health service indicators
HIV-prevention strategies depend on the twin efforts of care and support for those living with HIV or AIDS, and targeted
prevention for all people at risk or vulnerable to the infection. These efforts may range from reaching out to vulnerable
communities through large-scale educational campaigns or interpersonal communication; provision of treatment for STDs;
distribution of condoms and needles; creating an enabling environment to reduce risky behaviour; voluntary testing and
counselling; home or institutional care for persons with symptomatic HIV infection; and preventing perinatal transmission and
transmission through infected needles or blood in health care settings. It is difficult to capture such a large range of activities
with one or just a few indicators. However, a set of well-established health care indicators - such as the percentage of a
population with access to health care services; the percentage of women covered by antenatal care; or the percentage of
immunized children - may help to identify general strengths and weaknesses of health systems. Specific indicators, such as
access to testing and blood screening for HIV, help to measure the capacity of health services to respond to HIV/AIDSrelated issues.
Access to health care
Indicators
Year
Estimate
Source
% of pregnant women immunized against tetanus:
1995-1996
78
UNICEF
% fully immunized - Tuberculosis:
1995-1996
96
UNICEF
% fully immunized - DPT:
1995-1996
89
UNICEF
% fully immunized - Polio:
1995-1996
90
UNICEF
% fully immunized - Measles:
1995-1996
81
UNICEF
% of births attended by trained health personnel:
Latex condoms are the only technology available that can prevent sexual transmission of HIV/STD. Persons needing
protection in situations that carry risk should have consistent access to high quality condoms. National AIDS Programmes
implement activities to increase both availability of and access to condoms. The two condom availability indicators below are
intended to highlight areas of strength and weakness at the beginning and at the end of the distribution system so that
programmatic resources can be directed appropriately to problem areas.
Condom availability (central level)
Prevention Indicator 2: Availability of condoms per capita in the country over the last 12 months (central level).
Year
Area
N
Rate
1996
West Bengal-Urban
1.4
1996
West Bengal-Rural
0.5
9.3
1996
Tamil Nadu-Urban
1996
Tamil Nadu-Rural
1.8
1996
Maharashtra-Urban
1.45
1996
Maharashtra-Rural
2.95
1996
Del h i/Ha rya na-U rba n
7.4
1996
Delhi/Haryana-Rural
4.4
Comments:
Sources:
NACO
*
Condom availability (peripheral level)
Prevention Indicator 3: Proportion of people who can acquire a condom (peripheral level).
Year
Area
N
Rate
1996
West Bengal-Urban
1996
West Bengal-Rural
53
1996
Tamil Nadu-Urban
1996
1996
Tamil Nadu-Rural
100
57.9
Maharashtra-Urban
100
1996
Maharashtra-Rural
100
100
1996
Delhi/Haryana-Urban
100
1996
Delhi/Haryana-Rural
78.5
Comments:
Sources:
NACO
UNAIDS/WHO Epidemiological Fact Sheet
June 1998
India - 9
Knowledge and behaviour
Information on knowledge and behaviour related to HIV/AIDS is essential in identifying populations at risk for HIV infection. It
is also critical in assessing changes over time as a result of prevention efforts. Guidelines and recommendations have been
published in the publication: "Evaluation of a National AIDS Programme: A methods package. 1. Prevention of HIV infection
WHO/GPA/TCO/SEF/94.1 Geneva, 1994,,.
Knowledge of HIV-related preventive practices
Prevention Indicator 1: Proportion of people citing at least two acceptable ways of protection from HIV infection.
*
Female
Area
Age group
1996
Delhi/Haryana-Rural
1996
Delhi/Haryana-Urban
1996
1996
1996
Maharashtra-Rural
15-49
15-49
15-49
43.6
57.2
27.5
Maharashtra-Urban
15-49
55.1
Tamil Nadu-Rural
1996
Tamil Nadu-Urban
1996
1996
West Bengal-Urban
15-49
15-49
15-49
15-49
63.8
77.9
13.4
54.4
Year
West Bengal-Rural
Male
All
Comments:
Sources
NACO
Reported Non-Reguler Sexual Partnerships
Prevention Indicator 4: Proportion of sexually active people having at least one sex partner other than a regular
partner in the last 12 months.
Year
Area
Age group
1996
Delhi/Haryana-Rural
1996
Delhi/Haryana-Urban
15-49
15-49
15-49
15-49
15-49
15-49
15-49
15-49
1996
1996
1996
1996
1996
1996
Maharashtra-Rural
Maharashtra-Urban
Tamil Nadu-Rural
Tamil Nadu-Urban
West Bengal-Rural
West Bengal-Urban
Male
Female
All
2.5
2.1
1.1
3.2
4.2
0.9
0.7
2.7
Comments:
NACO
Sources:
Reported condom use in risk sex (gen pop)
Prevention Indicator 5: Proportion of people reporting the use of a condom during the most recent intercourse of risk.
Male
Female
All
Year
Area
Age group
1996
Delhi/Haryana-Rural
15-49
25
1996
1996
1996
1996
De I h i/Ha rya na-Urba n
15-49
28.6
1996
1996
West Bengal-Rural
15-49
10
1996
West Bengal-Urban
15-49
19.4
Maharashtra-Rural
15-49
9.1
Maharashtra-Urban
15-49
62.2
Tamil Nadu-Rural
15-49
8.6
Tamil Nadu-Urban
15-49
77.8
Comments:
NACO
Sources
UNAIDS/WHO Epidemiological Fact Sheet
June 1998
10- India
Knowledge and behaviour
Ever use of condom
Percentage of people who ever used a condom.
Year
Area
Age group
n/a
n/a
n/a
n/a________________
Male
Female
All
Male
Female
All
15-19
15-49
20-24
25-49
Comments:
Sources
Median age at first sexual intercourse
Median age of people at which they first had sexual intercourse.
Year___________ Area__________ Age group
n/a
20-24
n/a
25-49
n/a_____________________________ 45-49
Comments:
Sources:
Adolescent pregnancy
Percentage of teenagers 15-19 who are mothers or pregnant with their first child.
Year___________ Area_______
Age group
n/a
n/a
n/a
15
15-17
16
n/a
17
n/a
n/a
n/a
18
18-19
19
Rate
N
♦
Comments:
Sources:
UNAIDS/WHQ Epidemiological Fact Sheet
June 1998
India
Annex: HIV Surveillance data by site
Group
(Area
Prtgrart woman
Outside Major Urban Aran
| 1985 | 1986
1987
1988
1989
Ahmedabad disbict
1990
1991
0
0
1992
Bangalore rfisbict
1993
1995
1994
0
Imphal
1
.7
1
Jaipur disbict
0
Lakhadeep, Kavaratti
0
Lakhadsep, Mini coy
0
Madurai
0
0.3
Maharnhba State
0.8
Maharashtra, Pune
Mandurai
4 25
4
' 0.45
0.6
Manipir State
2
Manipur, Rime * MCW Anton at
0.81
I
Pondicherry, AIDS Conbe
4
Pune
nr
0
0
0.37
0
Tamil Nadu, Coimbatore
0.12
0.38
Tamil Nadu, Salem
Ti?
0.63
Tirupab
0
0.05
0.97
0.8
0.1
_o_
0
£
0.1
V
0
7
0
0
Vellore
0.1
Calcutta
Chennai
New Delhi
Outside Major Urban Aren
Group
Area
S« workers
OOside Major Urban Aren
| 1985
1986
1987
1988
1989
0.8
0.7
0
Maharashtra, Mumbai
Area
0.5
0.7
0
0.01
0.01
0
1990
1991
1992
1993
1985
1986
1987
1988
1989
1990
Tintah
1991
0.9
3.14
3.11
0
0.5
142
4.94
24.23
6
21.2
46.8
23.71
Rajkot district
1.79 ;
Rati am
0
0
0
0
Vncodegama
Major Urban Aren
Group
[Area
Prisoners
Outside Major Urban Aren
Group
[Area
STD patients
Outeide Major Urban Aren
1995 1996 1997
n
34.9
18.5
0
0
1.94
14
15.3
28
25
35
z
29
8.5
12.5
19
1.4
1
0.89
8.76
13.2
21.11
33.93
26.6
50.99
T?
I 1986
1987
1988
1989
1990
1991
1992
1993 1994 1995 1996 1997
0
0
0
8.6
I 39.1
44.8
67.2
0.5
1.2
55
Manipur, Churachandpur
25.4
47.78
55.7
Manipur, Imphal
85.63
61.05
73.26
Nagaland, Dimapur
32
Triptn, Jazoui
0
Calcutta
1
Chennai
16.5
| 1985 | 1986
1987
1988
1989
1990
1991
1992
Bangalore
1993
1994
1995
1996 1997
0.5
0.4
Chennai
1985 | 1986
1987
1988
1989
1
1.4
1991
1992
15
1994
1995
0
0
£
1.33
0
0
Anctwa Pradnh, Hyderabad
4.69
4.44
Anrtwa Pradesh, Tirupathi
3.75
6.25
Anrtva Pradnh, Vnakhapatn
7.79
1990
1993
A & N Island, Csr Nicobar
A & N Island, Port Blair
0
Anam, GMCH
Chamfigarh, General Hospital
0
0
Goe, Vasco
0.79
0 49
1996 1997
2.54
16.4
Gujrat, Ahmedabad
6.14
5.42
Gijrat, Baroda
13.63
9.58
UNAIDS/WHO Epidemiological Fact Sheet
76.7
1.99
Thirunelveii
Major Urban Aren
1995 • 1996 1997
5
Mianbai
Manipur State
1994
3.7
3
Calcutta
[Area
18.5
0
Ujjian
Injecting cfrug users Outside Major Urban Aren
4.3
0
1
Surat
Group
0.69
2.38
1992 1993 1994
31.6
Pune district
Major Urban Aren
0.5
2 25
33.73
Madurai
Vstlore
0.3
2.5
25.9
Bhiwadi
Tiruchirapalty
0.6
| 2.17 i 1.35 | 1.49 | 1.22 |
Manipur, Rime ♦ JNH STD Clin |
Pisw
0.25
0.75
1.91
Triptra, MCH Clinic
Blood donors
4.18
3.97
Rothak dsbict
Group
0.5
3.8
Pune disbict (ANCII)
4T
3.4
0.15
Nagaland, Kohima
Major Urban Aren
1996 1997
6.5
47
14,2
June 1998
India
Annex: HIV Surveillance data by site
Group
I 1985 | 1986
Area
1987
1988
1989
1990
1991
1993
1994
1995
Oqrat, Jamnagar
13.8
7.89
3.7
4.5
Gujrat, Sirat
18.87
22.8
15.9
20.6
Himachal Pradeeh, Simla
0
0.62
T"
Karnataka Medical College
1.95
1992
Karnataka, Bangalore
7.34
6.92
Karnataka, Hubii
20.5
16.5
Karnataka, Mangalore
2.26
Karnataka, Manipal
1.56
Madhya Pradeeh, Bhopal
0
Madurai
4.2
29.2
6
6
15
Maharashtra, Nagpir
3
14
11
Manipir, Imphal
3.9
8.17
Mizoram, Atzwai
3.92
Nagaland, Kohima
3
Orissa, Cuttack
Tot"
8
18
33
Rajasthan, Jaipur
1.35
Tamil Nadu Madurai
6.37
Tirupati
TsT
1.13
9.02
0
Vellore
0.4
0.8
0.6
16
18
'
2.4
U I 5.3
Chennai
Tamil Nadu, Channai
Outaida Major Urban Araaa
1985
1986
1987
6.1
R
Maharashtra, Mumbai
Area
1988 1989 1990
1991
2.66
1992 1993
36
31
31
3.78
4.35
T
Area
Truck drivtra
Outaida Major Urban Araaa
6.16
Tamil Nadu, Partmdirai
3
1986
1987
1988 1989 1990
1991 1992 1993 1994 1995 1996 1997
3.38
Himachal Pradaah
1.87
Jaipur
1.6
Jammu
1.82
Kaahmir Stata
Patiala District
1
3.13
Pirjab
3.08
Tami Nadu Stata
2.7
Tamil Nadu Salam
Major Urban Araaa
2.55
UltAaria
5.2
Tamil Nadu, Chennai
3.8
2.86 I 6.19
Tamil Nadu Tiructirapalli
Delhi
11.85
Tse'
1985
Amriiaar District
33
1994 1995 1996 1997
Manipur, TB Clinic
Tamil Nadu, Tampram
Group
10
0.9
Tripisa, GB Hospital
TB pati anta
11.2
34
Pune
Group
10
Maharashtra, Airangabad
Pondcherry, AIDS Centre
Major Urban Araaa
1996 1997
4
4.98
2.05
8.2
1
Notes:
UNAIDS/WHO Epidemiological Fact Sheet
June 1998
Bangladesh
Epidemiological Fact Sheet
on HIV/AIDS
and sexually
transmitted
diseases
*
I
UNAIDS
UNICEF • UNDP • UNFPA
UNESCO-WHO ■WORLD BANK
World Health
Organization
2- Bangladesh
Country information
Population pyramid, 1997
UNAIDS/WHO Working Group
on Global HIV/AIDS and STD
Surveillance
75-79
60-64
&c
sss
45-49
■KiSSfc-SttSSSS::
30-34
15-19
0-4
WOO
Gender
SMALE BFEMALE~|
Indicators
Year Estimate Source
Total Population (thousands)
1997
122.013
UNPOP
Population Aged 15-49 (thousands)
1997
61,360
UNPOP
Annual Population Growth
% of Population Urbanized
1996
19
UNPOP
1980-1996
5
UNPOP
1995
240
World Bank
1985-1995
2
World Bank
Human Development Index Rank (HO)
144
UNDP
Real GDP Per Capita Rank - HDI Rank
0
UNDP
Gender Related Development Index Rank
128
UNDP
Gender Empowerment Measure Rank
76
UNDP
Human Poverty Index Value (HPI)
48.3
UNDP
Average Annual Growth Rate of Urban Population
Net Migration Rate
GNP Per Capita (USS)
GNP Per Capita Average Annual Growth Rate
% Population Economic Active
1996
46
ILO
Unemployment Rate
1996
3
ILO
Global surveillance of HIV/AIDS and
sexually transmitted diseases (STDs) is a
joint effort of WHO and UNAIDS. The
UNAIDS/WHO Working Group on Global
HIV/AIDS and STD Surveillance, initiated in
November 1996, guides respective
activities. The primary objective of the
working group is to strengthen national,
regional and global structures and networks
for improved monitoring and surveillance of
HIV/AIDS and STDs. For this purpose, the
working group collaborates closely with
national AIDS programmes and a number of
national and international experts and
institutions. The goal of this collaboration is
to compile the best information available
and to improve the quality of data needed
for informed decision-making and planning
at national, regional and global levels. The
Epidemiological Fact Sheets are a first
output of this close and fruitful collaboration
across the globe.
Followng a senes of consultations, the
working group and its partners established e
framework standardizing the collection of
data deemed important for a thorough
understanding of the current status and
trends of the epidemic, as well as patterns
of risk and vulnerability in the population.
Within this framework, the Fact Sheets
collate the most recent country-specific data
on HIV/AIDS prevalence and incidence,
together wth information on behaviours
(e g. casual sex and condom use) which
can spur or stem the transmission of HIV.
The data include prevention indicators
developed by WHO’s Global Programme on
AIDS, which aim to measure trends in
knowledge of AIDS, relevant behaviours,
and a host of other factors influencing the
epidemic. Additional indicators - for
example, on care and support - will be
included when available.
>>
Total Adult Literacy Rate
Adult Male Literacy Rate
Adult Female Literacy Rate
Male Secondary School Enrollment Ratio
1990-1995
25
UNESCO
Female Secondary School Enrollment Ratio
1990-1995
13
UNESCO
Crude Birth Rate (births per 1.000 pop.)
1996
27
UNPOP
Crude Death Rate (deaths per 1.000 pop.)
1996
10
UNPOP
Maternal Mortality Rate (per 100.000 live births)
1990
850
WHO/UNICEF
Life Expectancy at Birth
1996
57
UNPOP
Total Fertility Rate
Infant Mortality Rate (per 1,000 live births)
1996
83
UNICEFAJNPOP
Under Five Mortality Rate (per 1,000 live births)
1996
112
UNICEF/UNPOP
% Population Access to Safe Water
% Population Access to Adequate Sanitation
Contact address
UNAIDS/WHO Working Group on Global HIV/AIDS and STD Surveillance
20, Avenue Appia
CH -1211 Geneva 27
Switzerland
Fax +41-22-791-4878
e-mail: Surveillance@UNAIDS.org
http 7/www. who. ch/emc/d i seases/h iv
http 7/www. unaids.org
UNAIDS/WHO Epidemiological Fact Sheet
Not unexpectedly, information on all of the
agreed-upon indicators was not available
for many countries in 1997. However, the
fact sheets do contain a wealth of
information which allows identification of
strengths in currently existing programmes
and compansons between countries and
regions. The fact sheets may also be
instrumental in identifying potential
partners when planning and implementing
improved systems.
The fact sheets can be only as good as
information made available to the
UNAIDS/WHO Working Group on Global
HIV/AIDS and STD Surveillance.
Therefore, the working group would like to
encourage all programme managers as
well as national and international experts
to communicate additional information to
the working group whenever such
information becomes available. The
working group also welcomes any
suggestions for additional indicators or
information proven to be useful in national
or international decision making and
planning.
June 1998
4
Bangladesh - 3
Estimated number of people living with HIV/AIDS
In 1997 and during the first quarter of 1998, UNAIDS and WHO worked closely with national governments and research
institutions to recalculate current estimates on people living with HIV/AIDS. These calculations are based on the previously
published estimates for 1994 (WER 1995; 70:353-360) and recent trends in HIV/AIDS surveillance in various populations
Epimodel 2, a microcomputer programme originally developed by the WHO Global Programme on AIDS, was used to
calculate the new estimates on prevalence and incidence of AIDS and AIDS deaths, as well as the number of children
infected through mother-to-child transmission of HIV, taking into account age-specific fertility rates. An additional
spreadsheet model was used to calculate the number of children whose mothers had died of AIDS.
The current estimates do not claim to be an exact count of infections. Rather, they use a methodology that has thus far
proved accurate in producing estimates which give a good indication of the magnitude of the epidemic in individual
countries. However, these estimates are constantly being revised as countries improve their surveillance systems and
collect more information. This includes information about infection levels in different populations, and behaviours which
facilitate or impede infection.
Adults in this report are defined as women and men aged 15 to 49. This age range covers people in their most sexually
active years. While the risk of HIV infection obviously continues beyond the age of 50, the vast majority of those who
engage in substantial risk behaviours are likely to be infected by this age. Since population structures differ greatly from
one country to another, especially for children and the upper adult ages, the restriction of the term adult to 15-to-49-yearoids has the advantage of making different populations more comparable. This age range was used as the denominator in
calculating adult HIV prevalence.
Estimated number of adults and children living with HIV/AIDS, end of 1997
These estimates include all people with HIV infection, whether or not they have developed
symptoms of AIDS, alive at the end of 1997
Adults and children
21000
Adults (15-49)
21000
3100
270
Women (15-49)
Children (0-15)
Adult rate (%)
0.03
Estimated number of AIDS cases
Estimated number of AIDS cases in adults and children that have occured since the
beginning of the epidemic:
Cumulative no. of AIDS cases
4900
Estimated number of deaths due to AIDS
Estimated number of adults and children who died of AIDS since the beginning of the epidemic:
Cumulative deaths
4200
Estimated number of adults and children who died of AIDS during 1997:
Deaths in 1997
1300
Estimated number of orphans
Estimated number of children who have lost their mother or both parents to AIDS (while
they were under age 15) since the beginning of the epidemic:
Cumulative orphans
810
Estimated number of children who have lost their mother or both parents to AIDS and who
were alive and under age 15 at the end of 1997:
Current living orphans
UNAIDS/WHO Epidemiological Fact Sheet
720
June 1998
4- Bangladesh
HIV Sentinel surveillance
This section contains information about HIV prevalence in different populations. The data reported in the tables below are
mainly based on the HIV data base maintained by the United States Bureau of the Census and are a compilation of data from
different sources, including national reports, scientific publications and abstracts. To provide for a simple overview of the
current situation and trends over time, summary data are given by population group, geographical area (Major Urban Areas
versus Outside Major Urban Areas), and year of survey. Studies conducted in the same year are aggregated and the median
prevalence rates (in percentages) are given for each of the categories. The maximum and minimum prevalence rates
observed, as well as the total number of surveys/sentinel sites, are provided with the median, to give the reader an overview
of the diversity of HIV-prevalence results in a given population within the country.
The differentiation between the two geographical areas Major Urban Areas and Outside Major Urban Areas is not based on
strict criteria, such as the number of inhabitants. For most countries, Major Urban Areas were considered to be the capital city
and - where applicable - other metropolitan areas with similar socio-economic patterns. This distinction assumes that capital
cities in many countries have specific characteristics related to the prevalence of higher risk behaviour and a concentration of
HIV infections. The term Outside Major Urban Areas considers that most sentinel sites are not located in strictly rural areas,
even if they are located in somewhat rural districts. Site/study-specific data on which the medians were calculated are printed
in an annex at the end of this fact sheet.
HIV prevalence in selected populations in percent
[Group
Area
Pregnant women
Major Urban Areas
Ill'll KrMl
IPk'Z-l
N.Sites
Minimum
Median
Maximum
Pregnant women
Outside Major Urban Areas
[Group
Area
Sex workers
Major Urban Areas
Sex workers
Outside Major Urban Areas
N_Sites
1
Minimum
0
Median
0
Maximum
0
IFEE1 IP‘4i
N_ Sites
i
Minimum
0.2
Median
0.2
Maximum
0.2
N.Sites
t
Minimum
o
Median
o
Maximum
[Group
Area
Injecting drug users
Outside Major Urban Areas
o
BPMii ibbiii
N.Sites
j
Minimum
q
Median
o
Maximum
KH1KEI5F1
q
[Group
Area
■■■
Military
Outside Major Urban Areas
N.Sites
j
iEaJ KQ K^i IB KB
Minimum
o
Median
q
Maximum
q
IESO KB
KIWI KIWI KIWI
[Group
Area
■■■ KB kb kb kb kb kb kb kb kiwi KIWI KIWI KIWI BWi HWi
STD patients
Major Urban Areas
N.Sites
Minimum
Median
Maximum
UNAIDS/WHO Epidemiological Fact Sheet
June 1998
♦
Bangladesh - 5
Assessment of epidemiological situation
Assessment of country
epidemiological situation
Regional maps
There is little information available on HIV
seroprevalence from Bangladesh. In 1988-89,
sero-surveillance was conducted among
several groups, sex workers, STD clinic
patients, IV drug users and antenatal clinic
attendees. No one was found positive.
Seroprevalence of HIV-1 for Pregnant Women
Middle South Asia
In 1996, 0.2 percent of sex workers tested in
Dhaka were HIV positive.
■ Aighatiiati^i’
r
Iran ''
There is no further information on HIV
prevalence in Bangladesh.
C«IN
.’•/ . .
Bhutan. -
IV«|lN.. ...•
••
■■■
India
Paiuanl Serapualim
.-'Eknngladexh
\
o
41.0
■
0.1 - 0.3
.. caoriba?.' Sri Lanka
*
1.0-4J
sn.Mo
$
1UU.TS.M
••'I. Moldluao
•seraprevaiferce ot mv-i Tor sex wai-Kara. a no
I.V. Drug Users in Wddle South Asia
b>u
i
Ml*
s-feeiizlilrrli
*
‘
ran mm
.>
■Xl-lf
••
:1
. "iw y.^S-IL«n<R
•xJ-SL
VjJrl.SF
ji r
UNAIDS/WHO Epidemiological Fact Sheet
June 1998
♦
6 - Bangladesh
Reported AIDS cases
AIDS cases by year of reporting
1979
1980
0
—0 | 00 | 0 J 0 n Po I 0
1981
Date of last report:
1982
1983
1984
1985
1986
1987
1988
1989
I 00 [ 0
1990
m
1991
1992
1993
I
0
0
1994
1995
1996
1997
1998
"^7
10
31 - Mar-1997
AIDS cases officially reported to WHO. Due to gaps in
diagnosis, underreporting, and reporting delays, officially
reported AIDS cases represent only a portion of all cases
in a country. Completeness of reporting varies
substantially from one country to another, from less than
10% in some countries with fewer resources to more than
80% in most industrialized countries (please also compare
with the section on estimates). Therefore, distribution by
age, sex and modes of transmission may not be
representative for all people living with AIDS in a given
country.
Total
Unknown
r n
AIDS cases by age and sex
Sex
Age
All
All
<1994 94/<95 1995
1996
1997 1998 Unkn. Total
0-14
15-24
25-49
50+
NS
Male
All
0-14
15-24
25-49
50+
AIDS cases by mode of transmission
NS
Female
Hetero. Heterosexual contacts.
Homo/Bi: Homosexual contacts between men
IDU: Injecting drug use. This transmission category also
includes cases in which other high-risk behaviours were
reported, in addition to injection of drugs.
Blood Blood and blood products.
Perinatal: Vertical transmission during pregnancy, birth or
breastfeeding.
NS: Not specified/unkncwn
All
0-14
15-24
25-49
50+
NS
NS
All
0-14
15-24
25-49
Sex
Trans, group
<94
94/<95 1995 1 996 1 997 1998 Unkn. Total
%
50+
NS
AD
Hetero
Homo/B
IDU
Blood
Perinatal
Other known
Unknown
Male
All
Hetero
Homo/H
IDU
Blood
Other known
Unknown
Female All
Hetero
IDU
Blood
Other known
Unknown
NS
All
Hetero
IDU
Blood
Perinatal
Other known
Unknown
UNAIDS/WHO Epidemiological Fact Sheet
June 1998
•/.
Bangladesh - 7
Curable STDs
Control and prevention of sexually transmitted diseases (STD) have been recognized as a major strategy in the prevention
of HIV infection and ultimately AIDS. Consequently, monitoring different components of STD control can also provide
information on HIV prevention within a country. One of the cornerstones of STD control is adequate management of patients
with symptomatic STDs. This includes diagnosis, treatment, and individual health education and counselling on disease
prevention and partner notification.
Estimated incidence and prevalence of curable STDs
Incidence
STDs
Year
Male Female
Prevalence
All
Year
Male Female
All
Chlamydia trach.
Gonorrhoea
Syphilis
Trichomonas
Comments
Source
STD Incidence, men
Prevention Indicator 9: Proportion of men aged 15-49 years who reported episodes of urethritis in the last 12 months.
Year
Area
Age
Rate
N=
n/a
n/a
Comments:
Sources:
STD Prevalence, women
Prevention Indicator 8: Proportion of pregnant women aged 15-24 years attending antenatal clinics whose blood has
been screened with positive serology for syphilis.
Year
Area
Age
Rate
N=
n/a
n/a
Comments:
Sources:
STD Case management (counselled)
Prevention Indicator 7: Proportion of people presenting with STD or for STD care in health facilities who received
basic advice on condoms and on partner notification.
Year
Area
Age
Rate
N=
n/a
n/a
Comments:
Sources:
STD Case management (treatments)
Prevention Indicator 6: Proportion of people presenting with STD in health facilities assessed and treated in an
appropriate way (according to national standards).
Year
Area
Age
Rate
N=
n/a
n/a
Comments:
Sources:
UNAIDS/WHO Epidemiological Fact Sheet
June 1998
8 - Bangladesh
Health service indicators
HIV-prevention strategies depend on the twin efforts of care and support for those living with HIV or AIDS, and targeted
prevention for all people at risk or vulnerable to the infection. These efforts may range from reaching out to vulnerable
communities through large-scale educational campaigns or interpersonal communication; provision of treatment for STDs;
distribution of condoms and needles; creating an enabling environment to reduce risky behaviour; voluntary testing and
counselling; home or institutional care for persons with symptomatic HIV infection; and preventing perinatal transmission and
transmission through infected needles or blood in health care settings. It is difficult to capture such a large range of activities
with one or just a few indicators. However, a set of well-established health care indicators - such as the percentage of a
population with access to health care services; the percentage of women covered by antenatal care; or the percentage of
immunized children - may help to identify general strengths and weaknesses of health systems. Specific indicators, such as
access to testing and blood screening for HIV, help to measure the capacity of health services to respond to HIV/AIDSrelated issues.
Access to health care
Indicators
Year
Estimate
Source
% of Pop. with access to health services - total
% of Pop. with access to health services - urban.
% of Pop. with access to health services - rural:
Contraceptive prevalence rate (%):
% of births attended by trained health personnel:
% of pregnant wcmen immunized against tetanus.
1995-1996
72
UNICEF
% fully immunized - Tuberculosis:
1995-1996
88
UNICEF
% fully immunized - DPT
1995-1996
66
UNICEF
% fully immunized - Polio:
1995-1996
66
UNICEF
% fully immunized - Measles:
1995-1996
59
UNICEF
Proportion of blood donations tested:
% of ANC clinics where HIV testing is available:
HIV/AIDS Hospital Occupancy Rate (Days)
Latex condoms are the only technology available that can prevent sexual transmission of HIV/STD. Persons needing
protection in situations that carry risk should have consistent access to high quality condoms. National AIDS Programmes
implement activities to increase both availability of and access to condoms. The two condom availability indicators below are
intended to highlight areas of strength and weakness at the beginning and at the end of the distribution system so that
programmatic resources can be directed appropriately to problem areas.
Condom availability (central level)
Prevention Indicator 2: Availability of condoms per capita in the country over the last 12 months (central level).
Year
Area
N
Rate
n/a
Comments:
Sources:
Condom availability (peripheral level)
Prevention Indicator 3: Proportion of people who can acquire a condom (peripheral level).
Year
Area
N
Rate
n/a
Comments:
Sources:
UNAIDS/WHO Epidemiological Fact Sheet
June 1998
Bangladesh - 9
♦
Knowledge and behaviour
Information on knowledge and behaviour related to HIV/AIDS is essential in identifying populations at risk for HIV infection It
is also critical in assessing changes over time as a result of prevention efforts. Guidelines and recommendations have been
published in the publication: "Evaluation of a National AIDS Programme: A methods package. 1. Prevention of HIV infection
WHO/GPA/TCO/SEF/94.1 Geneva, 1994".
Knowledge of HIV-related preventive practices
Prevention Indicator 1: Proportion of people citing at least two acceptable ways of protection from HIV infection.
Year
Area
n/a
Age group
Male
All
Female
15-19
n/a
20-24
n/a
25-49
n/a______________________________ 15-49
Comments:
Sources:
Reported non-regular sexual partnerships
Prevention Indicator 4: Proportion of sexually active people having at least one sex partner other than a regular
partner in the last 12 months.
Year
Area
n/a
n/a
n/a
n/a
Comments:
Sources:
Age group
15-19
20-24
25-49
15-49
Male
Female
All
Reported condom use in risk sex (gen pop)
Prevention Indicator 5: Proportion of people reporting the use of a condom during the most recent intercourse of risk.
Year
Area
Age group
n/a
15-19
n/a
20-24
n/a
25-49
n/a
Comments:
Sources:
15-49
UNAIDS/WHO Epidemiological Fact Sheet
Male
Female
All
June 1998
10- Bangladesh
*
Knowledge and behaviour
Ever use of condom
Percentage of people who ever used a condom.
Year
Area
Age group
1994
1994
1994
1994
1994
1994
1994
1994
1994
All
All
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
All
Total
Comments:
Sources:
All
All
All
All
All
All
Male
Female
All
6
11
17.7
16.7
15.5
13.4
8.9
5.7
13.9
Ever-mamed women
Demographic and Health Survey
Median age at first sexual intercourse
Median age of people at which they first had sexual intercourse.
Area
Year
Age group
n/a
20-24
n/a
n/a
25-49
45-49
Male
Female
All
Comments:
Sources:
Adolescent pregnancy
Percentage of teenagers 15-19 who are mothers or pregnant with their first child.
Year___________ Area___________Age group
1994
1994
1994
1994
1994
Comments
Sources:
15
16
17
18
19
Rate
10.6
23.4
38.7
45.1
59.2
N
615
566
463
539
382
DHS. 1994
UNAIDS/WHO Epidemiological Fact Sheet
June 1998
Bangladesh - 11
Sources_____________
Kamal’ M ■ E K3"01- 61 al- 1992. Status of AIDS/HIV Infection: Bangladesh. Institute of Epidemiology. Disease Control and Research, report.
Mian, M. A. H., M. A Kabir, K Begum, 1996, Comparative Analysis of Point Prevalence of the Different Types of STD in ICSWand FCSW XI
International Conference on AIDS, Vancouver, 7/7 14. Abstract Pub.B. 1048
UNAIDS/WHO Epidemiological Fact Sheet
June 1998
12- Bangladesh
Annex: HIV Surveillance data by site
1985 | 1986
Group
Area
Pregrart woman
Outside Major Urban Areas
Group
Area
Sax worker*
Outside Major Urban Areas
Notspedfied
Major Urban Areas
Dhaka
Group
Area
1987
1990
1991
1992 1993
1994
1995
1996 1997
1985 | 1986 1987 1988 1989 i 1990
1991
1992
1994 1995
1996 1997
1991
1992 1993 1994
1991
1992 i 1993 1994 1995 1996 1997
1991
1992 1 1993
Major Urban Areas
Injecting drug users Outside Major Urban Areas
1989
1993
M
__
| 1985 | 1986
Not apaafiad
1988
3
Notapadfiad
Major Urban Areas
H
Group
Area
| 1985 | 1986
Miiitiry
Outside Major Urban Areas
Group
Area
STD patients
Major Urban Areas
1987
1988 1989 1990
1987
1988 1989 i 1990
3
0.2
1995
|
1996 1997
0 I
Not specified
| 1985 | 1986
1987 1988 1989 i 1990
1994
1995
1996 1997
J
Notes:
UNAIDS/WHO Epidemiological Fact Sheet
June 1998
Sri Lanka
Epidemiological Fact Sheet
on HIV/AIDS
and sexually
transmitted
diseases
UNAIDS
UNICEF • UNDP • UNFPA
UNESCO • WHO • WOR1D BANK
World Health
Organization
2 - Sri Lanka
Country information
Population pyramid, 1997
UNAIDS/WHO Working Group
on Global HIV/AIDS and STD
Surveillance
75-79
60-64
DC
<
45-49
30-34
15-19
0-4
Gender
SMALE IS FEMALE I
Indicators
Year Estimate Source
Total Population (thousands)
1997
18,273
UNPOP
Population Aged 15-49 (thousands)
1997
10,025
UNPOP
Annual Population Growth
1980-1995
1.4
UNPOP
% of Population Urbanized
1996
22
UNPOP
1980-1996
2
UNPOP
1995
700
World Bank
1985-1995
3
World Bank
Average Annual Growth Rate of Urban Population
Net Migration Rate
GNP Per Capita (USS)
GNP Per Capita Average Annual Growth Rate
Human Development Index Rank (HDI)
91
UNDP
Real GDP Per Capita Rank - HDI Rank
9
UNDP
Gender Related Development Index Rank
70
UNDP
Gender Empowerment Measure Rank
70
UNDP
Human Poverty Index Value (HPI)
20.7
UNDP
40
ILO
% Population Economic Active
1996
Unemployment Rate
1996
11
ILO
Total Adult Literacy Rate
1995
90
UNESCO
Adult Male Literacy Rate
1995
93
UNESCO
Adult Female Literacy Rate
1995
87
UNESCO
Male Secondary School Enrollment Ratio
1990-1995
71
UNESCO
Female Secondary School Enrollment Ratio
1990-1995
79
UNESCO
Crude Birth Rate (births per 1.000 pop.)
1996
18
UNPOP
Crude Death Rate (deaths per 1.000 pop.)
1996
6
UNPOP
Maternal Mortality Rate (per 100.000 live births)
1990
140
WHO/UNICEF
Life Expectancy at Birth
1996
73
UNPOP
Total Fertility Rate
1995
2.4
UNPOP
Infant Mortality Rate (per 1.000 live births)
1996
17
UNICEF/UNPOP
Under Five Mortality Rate (per 1.000 live births)
1996
19
UNICEF/UNPOP
% Population Access to Safe Water
1990-1996
57
UNICEF
% Population Access to Adequate Sanitation
1990-1996
63
UNICEF
Contact address:
UNAIDS/WHO Working Group on Global HIV/AIDS and STD Surveillance
20. Avenue Appia
CH -1211 Geneva 27
Switzerland
Fax: +41-22-791-4878
e-mail: Surveillance@UNAIDS.org
http://www who.ch/emc/diseases/hiv
http://www unaids.org
UNAIDS/WHO Epidemiological Fact Sheet
Global surveillance of HIV/AIDS and
sexually transmitted diseases (STDs) is a
joint effort of WHO and UNAIDS. The
UNAIDS/WHO Working Group on Global
HIV/AIDS and STD Surveillance, initiated in
November 1996, guides respective
activities. The primary objective of the
working group is to strengthen national,
regional and global structures and networks
for improved monitoring and surveillance of
HIV/AIDS and STDs. For this purpose, the
working group collaborates closely with
national AIDS programmes and a number oi
national and international experts and
institutions. The goal of this collaboration is
to compile the best information available
and to improve the quality of data needed
for informed decision-making and planning
at national, regional and global levels. The
Epidemiological Fact Sheets are a first
output of this close and fruitful collaboration
across the globe.
Following a series of consultations, the
working group and its partners established e
framework standardizing the collection of
data deemed important for a thorough
understanding of the current status and
trends of the epidemic, as well as patterns
of risk and vulnerability in the population.
Within this framework, the Fact Sheets
collate the most recent country-specific data
on HIV/AIDS prevalence and incidence,
together with information on behaviours
(e.g. casual sex and condom use) which
can spur or stem the transmission of HIV.
The data include prevention indicators
developed by WHO's Global Programme on
AIDS, which aim to measure trends in
knowledge of AIDS, relevant behaviours,
and a host of other factors influencing the
epidemic. Additional indicators - for
example, on care and support -- will be
included when available.
Not unexpectedly, information on all of the
agreed-upon indicators was not available
for many countries in 1997 However, the
fact sheets do contain a wealth of
information which allows identification of
strengths in currently existing programmes
and compansons between countries and
regions. The fact sheets may also be
instrumental in identifying potential
partners when planning and implementing
improved systems.
The fact sheets can be only as good as
information made available to the
UNAIDS/WHO Working Group on Global
HIV/AIDS and STD Surveillance
Therefore, the working group would like to
encourage all programme managers as
well as national and international experts
to communicate additional information to
the working group whenever such
information becomes available. The
working group also welcomes any
suggestions for additional indicators or
information proven to be useful in national
or international decision making and
planning.
June 1998
A
Sri Lanka - 3
Estimated number of people living with HIV/AIDS
In 1997 and during the first quarter of 1998, UNAIDS and WHO worked closely with national governments and research
institutions to recalculate current estimates on people living with HIV/AIDS. These calculations are based on the previously
published estimates for 1994 (WER 1995; 70:353-360) and recent trends in HIV/AIDS surveillance in various populations
Epimodel 2, a microcomputer programme originally developed by the WHO Global Programme on AIDS, was used to
calculate the new estimates on prevalence and incidence of AIDS and AIDS deaths, as well as the number of children
infected through mother-to-child transmission of HIV, taking into account age-specific fertility rates. An additional
spreadsheet model was used to calculate the number of children whose mothers had died of AIDS.
The current estimates do not claim to be an exact count of infections. Rather, they use a methodology that has thus far
proved accurate in producing estimates which give a good indication of the magnitude of the epidemic in individual
countries. However, these estimates are constantly being revised as countries improve their surveillance systems and
collect more information. This includes information about infection levels in different populations, and behaviours which
facilitate or impede infection.
Adults in this report are defined as women and men aged 15 to 49. This age range covers people in their most sexually
active years. While the risk of HIV infection obviously continues beyond the age of 50, the vast majority of those who
engage in substantial risk behaviours are likely to be infected by this age. Since population structures differ greatly from
one country to another, especially for children and the upper adult ages, the restriction of the term adult to 15-to-49-yearolds has the advantage of making different populations more comparable. This age range was used as the denominator in
calculating adult HIV prevalence.
Estimated number of adults and children living with HIV/AIDS, end of 1997
These estimates include all people with HIV infection, whether or not they have developed
symptoms of AIDS, alive at the end of 1997
Adults and children
6900
Adults (15-49)
6700
2000
190
Women (15-49)
Children (0-15)
Adult rate (%)
0.07
Estimated number of AIDS cases
Estimated number of AIDS cases in adults and children that have occured since the
beginning of the epidemic:
Cumulative no. of AIDS cases
1900
Estimated number of deaths due to AIDS
Estimated number of adults and children who died of AIDS since the beginning of the epidemic:
Cumulative deaths
1700
Estimated number of adults and children who died of AIDS during 1997:
Deaths in 1997
400
Estimated number of orphans
Estimated number of children who have lost their mother or both parents to AIDS (while
they were under age 15) since the beginning of the epidemic:
Cumulative orphans
450
Estimated number of children who have lost their mother or both parents to AIDS and who
were alive and under age 15 at the end of 1997:
Current living orphans
UNAIDS/WHO Epidemiological Fact Sheet
390
June 1998
4- Sri Lanka
HIV Sentinel surveillance
This section contains information about HIV prevalence in different populations. The data reported in the tables below are
mainly based on the HIV data base maintained by the United States Bureau of the Census and are a compilation of data from
different sources, including national reports, scientific publications and abstracts. To provide for a simple overview of the
current situation and trends over time, summary data are given by population group, geographical area (Major Urban Areas
versus Outside Major Urban Areas), and year of survey. Studies conducted in the same year are aggregated and the median
prevalence rates (in percentages) are given for each of the categories. The maximum and minimum prevalence rates
observed, as well as the total number of surveys/sentinel sites, are provided with the median, to give the reader an overview
of the diversity of HIV-prevalence results in a given population within the country.
The differentiation between the two geographical areas Major Urban Areas and Outside Major Urban Areas is not based on
strict criteria, such as the number of inhabitants. For most countries, Major Urban Areas were considered to be the capital city
and - where applicable - other metropolitan areas with similar socio-economic patterns. This distinction assumes that capital
cities in many countries have specific characteristics related to the prevalence of higher risk behaviour and a concentration of
HIV infections. The term Outside Major Urban Areas considers that most sentinel sites are not located in strictly rural areas,
even if they are located in somewhat rural districts. Site/study-specific data on which the medians were calculated are printed
in an annex at the end of this fact sheet.
HIV prevalence in selected populations in percent
Group
Area
Pregnant women
Major Urban Areas
Pregnant women
Outside Major Urban Areas
KkltU MUtoM
1PI-M1 Btofl BkMii
N_ Sites
1
1
1
1
Minimum
0
0
0
0
Median
0
0
0
0
Maximum
0
0
0
0
6
0
0
0
N.Sites
1
3
1
5
Minimum
0
0
0
0
Median
0
0
0
0
Maximum
0
0
0
0
[Group
Area
MHHi BUM!
Sex workers
Major Urban Areas
N_ Sites
1
1
1
Minimum
0
0
0.5
0
0
Median
0
0
0.5
0
0
Maximum
0
0
0.5
0
0
4
5
Sex wort ers
Outside Major Urban Areas
[Group
Area
Mritary
Outside Major Urban Areas
[Group
Area
Pnsoners
Major Urban Areas
Prisoners
Outside Major Urban Areas
lEMl fl^ll
llPM-l
IPWCIieeii ■EKWil BfcSa
N_ Sites
Minimum
0
0
0
Median
0
0
0
Maximum
0
0.53
| BPKEI liiRBI
N.Sites
3
Minimum
0
Median
0
Maximum
0
KRHfll ■ultra
N_ Sites
Minimum
0
Median
0
Maximum
0
N.Sites
3
Minimum
0
Median
0
Maximum
0
BklTi 1PI&1 fl#! tEM) tW-'H BkrZI Bkfoi
Area
■■■I
STD patients
Major Urban Areas
N_ Sites
t
1
t
1
1
1
1
Minimum
o
0
o
0
0
0
0
Median
0
0
0
0
0
0
0
Maximum
0
0
0
0
0
0
0
Outside Major Urban Areas
1
■PBU BPTrl
iK’El
IK.'.I lEKl Ippjil
[Group
STD patients
1
1
0
0
0
1
0
0
0
N.Stes
5
6
Minimum
0
0
Median
0
0
Maximum
0.43
0 88
UNAIDS/WHO Epidemiological Fact Sheet
June 1998
Sri Lanka - 5
Assessment of epidemiological situation
Assessment of country
epidemiological situation
HIV testing among women attending antenatal
care clinics was conducted in Sri Lanka since
1988. Up to 1996 no evidence for HIV
infection in this population was found. Single
HIV infections have been found in female sex
workers and male STD patients in Kurunegala
in 1995 and 1996 and in 1993 in Colombo.
As of December 1997, a total of 77 AIDS
cases had been reported to WHO
Regional maps
Seroprevalence of HIV-1 for Pregnant Women
Middle South Asia
•Aiflhj
Iran '■
•:
'■/ .
ia,r
Bhutan
“KflartK-'1
-
«.-■
C«|N
India
u>cu«su>: p.1'
.-'EMnglIliad exh
Raiuanl Serapualivw
<1.0
0
■$
0.1 - 0.3
1.0-4.3
s n. a o
.. vslorbcr SH Lanka
*
IlMU.W.tf
™n +
Maldluee
seroprevaifeftce ot mv-i tor sex watKer^nd
I.V. Drug Jaers In Middle South Asia
i>n txtfi ■
bMi
frllA
Sh-i ■
/• "E-aiizlilrrh
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••
. *iw YJ2'ILan<4
•SJ-IL
Vsirtall
■
?
UNAIDS/WHO Epidemiological Fact Sheet
KJ
Jal* ♦
June 1998
6 - Sri Lanka
Reported AIDS cases
AIDS cases by year of reporting
1979
1980
1981
1982
1983
1984
1985
1986
1987
"I i 0 I 0 P0 pj0 [ 00 : 0 | 2 |
Date of last report:
1988
1989
1990
1991
1992
3
■^7
Sex
Age
AJI
AJI
■^7 2
Male
Female
Hetero: Heterosexual contacts.
Homo/Bi: Homosexual contacts between men.
IDU: Injecting drug use. This transmission category also
includes cases in which other high-risk behaviours were
reported, in addition to injection of drugs.
Blood Blood and blood products
Perinatal Vertical transmission during pregnancy, birth or
breastfeeding.
NS: Not specified/unknown.
AJ
Male
94/<95 1995 1996 1997 1998 Unkn. Total
11
1998
1997
1996
8 I
I
Total
77
Unknown
I
I
Hetero
Homo/Bi
6
IDU
Blood
0
Perinatal
Other known
0
Unknown
3
1
0
1
AJI
9
3
Hetero
Homo/Bi
6
IDU
0
0
2
0
0
0
0
2
0
0
2
0
1
IDU
0
Blood
0
Other known
0
Unknown
2
AJI
Hetero
IDU
Blood
Pennatai
Other known
Unknown
0
0
1
0
0
0
0
0
0
1
0
0
0
3
11
0-14
1
15-24
1
25-49
77
100%
0
1
2
2.6%
0
0
49
8
7
64
50+
4
3
0
7
9%
NS
3
0
0
3
4%
AJI
47
59
100%
1
0
1
1 7%
15-24
0
0
0
0%
25-49
40
9
0
0
6
3
0-14
3
49
83%
10%
1.3%
83%
50+
3
3
0
6
NS
3
0
0
3
5%
All
11
2
T
18
100%
0-14
0
0
1
I
5 6%
0
0
1
5.6%
2
4
15
83%
0
0
1
5.6%
25-49
9
50*
%
%
1997 1998 Unkn. Total
8
15-24
NS
1996
sF
NS
0
0
0
0
AJI
0
0
0
0
0-14
0
0
0
0
15-24
0
0
0
0
25-49
0
0
0
0
50+
1
0
0
0
NS
0
0
0
0
1
4
4
0
0
0
0
0
<1994 94/<95 1995
8
6
0
0
0
ii
Female All
Hetero
NS
<94
ah
Blood
Other known
Unknown
1995
14
AIDS cases by age and sex
AIDS cases by mode of transmission
Trani, group
1994
31-Dec-1997
AIDS cases officially reported to WHO. Due to gaps in
diagnosis, underreporting, and reporting delays, officially
reported AIDS cases represent only a portion of all cases
in a country. Completeness of reporting varies
substantially from one country to another, from less than
10% in some countries with fewer resources to more than
80% in most industrialized countries (please also compare
with the section on estimates). Therefore, distribution by
age, sex and modes of transmission may not be
representative for all people living with AIDS in a given
country.
Sex
1993
4
0
AIDS cases through 1995 not classified by transmission
category. Reports by age and sex for 1995 include
cumulative cases through 1995.
UNAIDS/WHO Epidemiological Fact Sheet
June 1998
Sri Lanka -1
Curable STDs
Control and prevention of sexually transmitted diseases (STD) have been recognized as a major strategy in the prevention
of HIV infection and ultimately AIDS. Consequently, monitoring different components of STD control can also provide
information on HIV prevention within a country. One of the cornerstones of STD control is adequate management of patients
with symptomatic STDs. This includes diagnosis, treatment, and individual health education and counselling on disease
prevention and partner notification.
Estimated incidence and prevalence of curable STDs
Incidence
STDs
Year
Male Female
Prevalence
All
Year
Male
Female
All
Chlamydia trach.
Gonorrhoea
Syphilis
Trichomonas
Comments
Source
STD Incidence, men
Prevention Indicator 9: Proportion of men aged 15-49 years who reported episodes of urethritis in the last 12 months.
Year
Area
Age
Rate
1997
All
15-49
2
N=
Comments: Total in 2 districts (1 urban, 1 rural)
Sources:
Preliminary results from PPI survey Awaiting confirmation.
STD Prevalence, women
Prevention Indicator 8: Proportion
of pregnant women aged 15-24 years attending antenatal clinics whose blood has
n/a
been screened with positive
n/aserology for syphilis.
Year
Area
Age
Rate
N=
Comments:
Sources:
STD Case management (counselled)
Prevention Indicator 7: Proportion of people presenting with STD or for STD care in health facilities who received
basic advice on condoms and on partner notification.
Year
Area
Age
1997
All
All
Rate
N=
Comments: Health facility survey not yet conducted
Sources:
STD Case management (treatments)
Prevention Indicator 6: Proportion of people presenting with STD in health facilities assessed and treated in an
appropriate way (according to national standards).
Year
Area
Age
1997
All
All
1997
All
All
Rate
N=
Comments: Not available. Health Facility survey not yet conducted.
Sources:
UNAIDS/WHO Epidemiological Fact Sheet
June 1998
8 - Sri Lanka
Health service indicators
HIV-prevention strategies depend on the twin efforts of care and support for those living with HIV or AIDS, and targeted
prevention for all people at risk or vulnerable to the infection. These efforts may range from reaching out to vulnerable
communities through large-scale educational campaigns or interpersonal communication; provision of treatment for STDs;
distribution of condoms and needles; creating an enabling environment to reduce risky behaviour; voluntary testing and
counselling; home or institutional care for persons with symptomatic HIV infection; and preventing perinatal transmission and
transmission through infected needles or blood in health care settings. It is difficult to capture such a large range of activities
with one or just a few indicators. However, a set of well-established health care indicators -- such as the percentage of a
population with access to health care services; the percentage of women covered by antenatal care; or the percentage of
immunized children - may help to identify general strengths and weaknesses of health systems. Specific indicators, such as
access to testing and blood screening for HIV, help to measure the capacity of health services to respond to HIV/AIDSrelated issues.
Access to health care
Indicators
Year
Estimate
Source
Contraceptive prevalence rate (%):
1990-1996
66
UNPOP
% of births attended by trained health personnel
1990-1996
94
UNICEF
% of pregnant women immunized against tetanus.
1995-1996
81
UNICEF
% fully immunized - Tuberculosis
1995-1996
88
UNICEF
% fully immunized - DPT
1995-1996
90
UNICEF
% fully immunized - Polio:
1995-1996
91
UNICEF
% fully immunized - Measles:
1995-1996
86
UNICEF
% of Pop. with access to health services - total:
% of Pop. with access to health services - urban:
% of Pop. with access to health services - rural:
Proportion of blood donations tested
99
% of ANC clinics where HIV testing is available.
HIV/AIDS Hospital Occupancy Rate (Days):
Latex condoms are the only technology available that can prevent sexual transmission of HIV/STD. Persons needing
protection in situations that carry risk should have consistent access to high quality condoms. National AIDS Programmes
implement activities to increase both availability of and access to condoms. The two condom availability indicators below are
intended to highlight areas of strength and weakness at the beginning and at the end of the distribution system so that
programmatic resources can be directed appropriately to problem areas.
Condom availability (central level)
Prevention Indicator 2: Availability of condoms per capita in the country over the last 12 months (central level).
Year
Area
1997
All
Comments:
Sources:
N
Rate
1
Based on data received from suppliers and estimated population 15-49 years. 1997 rate will be
available when PPI survey results are completed.
MOH, 1996
Condom availability (peripheral level)
Prevention Indicator 3: Proportion of people who can acquire a condom (peripheral level).
Year
Area
N
Rate
1997
Comments
Sources:
1997 PPI survey results awaited
1997
UNAIDS/WHO Epidemiological Fact Sheet
June 1998
Sri Lanka - 9
Knowledge and behaviour
Information on knowledge and behaviour related to HIV/AIDS is essential in identifying populations at risk for HIV infection. It
is also critical in assessing changes over time as a result of prevention efforts. Guidelines and recommendations have been
published in the publication: “Evaluation of a National AIDS Programme: A methods package. 1. Prevention of HIV infection
WHO/GPA/TCO/SEF/94.1 Geneva, 1994“.
Knowledge of HIV-related preventive practices
Prevention Indicator 1: Proportion of people citing at least two acceptable ways of protection from HIV infection.
Year
~997
Area
All
Age group
15-49
Male
Female
All
Comments. 1997 PPI survey results awaited.
Sources:
Reported non-regular sexual partnerships
Prevention Indicator 4: Proportion of sexually active people having at least one sex partner other than a regular
partner in the last 12 months.
Year
1990
1993
1993
1993
1993
Area
Age group
Male
Female
All
15-49
7.4
3.6
All
15-19
20
0
All
20-24
10.5
8.2
5.4
2.6
All
25-39
All
40-49
All
5.1
3.3
Comments: 1997 PPI survey results awaited.
Sources.
KABP/Behavioural Studies - GPA. 1993
Reported condom use in risk sex (gen pop)
Prevention Indicator 5: Proportion of people reporting the use of a condom during the most recent intercourse of risk.
Year
Area
Age group
1997
15-49
n/a
15-19
n/a
20-24
n/a
25-49
Male
Female
All
n/a_____________________________ 15-49
Comments: ■'997 PPI survey results awaited.
Sources:
1997
o
UNAIDSM/HO Epidemiological Fact Sheet
June 1998
10- Sri Lanka
Knowledge and behaviour
Ever use of condom
Percentage of people who ever used a condom.
Year
Area
Age group
Male
Female
All
Male
Female
All
15-19
15-49
20-24
25-49
n/a
n/a
n/a
n/a
Comments:
Sources:
Median age at first sexual intercourse
Median age of people at which they first had sexual intercourse.
Year
Area
Age group
n/a
20-24
n/a
n/a
25-49
45-49
Comments:
Sources:
Adolescent pregnancy
Percentage of teenagers 15-19 who are mothers or pregnant with their first child.
Area
Year
Rate
Age group
n/a
n/a
n/a
n/a
15
15-17
16
17
n/a
n/a
18
18-19
n/a
19
N
Comments:
Sources:
Estimated number of IDU
Estimated number of injecting drug users.
Year
Area
Age group
Male
Female
All
n/a
Comments:
Sources:
n/a
UNAIDS/WHO Epidemiological Fact Sheet
June 1998
Sri Lanka - 11
Sources
Brown, T , P Xenos, 1994, AIDS in Asia: The Gathering Storm, Analysis from the East West Center, no. 16, August.
Samarakoon, S., 1993, STD among Female Prostitutes Attending the Central Venereal Diseases Clinic (CVDC), Colombo, Sri Lanka, IX
International Conference on AIDS. Berlin, 6/6 11, Poster PC Cl 4 2891
NSACP Colombo 30 May 1996. Report on HIV Sentinel Surveillance 1996, Sri Lanka.
NSACP Colombo. Report on HIV Sentinel Surveillance 1995, Sri Lanka.
World Health Organization, 1991, HIV Sentinel Surveillance in Sn Lanka, World Health Organization Documents.
World Health Organization, 1993, Report on Sentinel Surveillance - First Round -1993, WHO HIV Surveillance Report, May 10, Sri Lanka.
UNAIDS/WHO Epidemiological Fact Sheet
June 1998
12 - Sri Lanka
Annex: HIV Surveillance data by site
[Group
Area
Pregnant woman
Outaida Major Urban Area*
| 1985 | 1986
1987
1988
1989
1990
1991
1992
1993
1994
Amradhaptfa
1995
1996
0
0
0
0
0
0
0
0
Baduiia
0
Galla
0
Kandy
0
0
Kurtsrogala
Notspodfiod
0
Ratnapura
Major Urban Aren
[Group
Area
Blood donors
Outside Major Urban Areas
Major Urban Areas
Group
Area
Sax workers
Outside Major Urban Areas
|
| 1985 | 1986
0
n
Colombo
1987
1988
1989
1990
0
1991
1992 I 1993
1994
0
0
0
0
1995
1996
Anwadhapwa
Baduiia
0
0
Galla
0
0
Kandy
0
0
Kurimegala
0
0
Ratnapraa
0
0
Colombo
0
0
1995
1996 1997
| 1985 | 1986
1987
1988
1989
1990
1991
1992
1993 1994
Anwadhapira
0
0
0
Gallo
Kandy
Major Urban Areas
1997
0
Baduiia
[Group
1997
0
0
0
0
0
Kurisregala
0.53
1
Ratnapraa
0
0
0
0
Colombo
0
1985 | 1986
Area
1987
1988
1989 ! 1990
0
1991
0.5
1992 I 1993
1994
1995 : 1996
1997
Injecting <tug twers Major Urban Areas
Group
Area
Military
Outside Major Urban Areas
| 1985 | 1986 1987
1988 1989 i 1990 1991
Gaflo
0
Kandy
0
Ratnapura
Group
Area
Prisoners
Outside Major Urban Areas
0
I 1985 | 1986
1987
1988
1989
Area
STD patients
Outside Major Urban Areas
1991
1992 1993 1994 1995 I 1996 1997
1991
1992 i 1993 1994 I 1995 1996 1997
I 0
Ratnapiaa
Group
1990
Gallo
Kandy
Major Urban Areas
1992 I 1993 I 1994 1995 1996 1997
0
Colombo
0
1985 | 1986
1987
1988
1989
1990
Anuradhapura
0
0
_o_
_0_
Baduiia
0
Gallo
Kandy
"o’
T
Kurtaregala
0.43
0.88
0
0
0
° i
Ratnapiaa
Major Urban Areas
[Group
[Area
TB patients
Outside Major Urban Areas
Colombo
0
1985 | 1986
0
0
0
0
0
1987
1988
1989
1990
1991
1992 1993 I 1994 1995 1996 1997
Anuradhapura
0
Badula
Major Urban Areas
[Group
Area
Truck drivers
Outside Major Urban Areas
0
0
Gallo
0
0
Kandy
0
0
Kurinegala
0
0
Ratnaptaa
0
0
Colombo
0
0
1995
1996
1985 | 1986 1987
1988
1989
1990
1991
1992 1993
1994
1997
Gallo
Notes:
UNAIDS/WHO Epidemiological Fact Sheet
June 1998
Nepal
Epidemiological Fact Sheet
on HIV/AIDS
and sexually
transmitted
diseases
>
UNAIDS
UNICEF • UNDP • UNFPA
UNESCO ■WHO»W«1D &ANK
*
World Health
Organization
2 - Nepal
Country information
UNAIDS/WHO Working Group
on Global HIV/AIDS and STD
Surveillance
Population pyramid, 1997
75-79
60-64
op
45-49
30-34
15-19
0-4
ssrflii
Gender
MALE H FEMALE I
Indicators
Year Estimate Source
Total Population (thousands)
1997
22.591
UNPOP
Population Aged 15-49 (thousands)
1997
10.404
UNPOP
Annual Population Growth
1980-1995
2.6
UNPOP
% of Population Urbanized
1996
14
UNPOP
1980-1996
6
UNPOP
1995
200
World Bank
1985-1995
2
World Bank
Human Development Index Rank (HDI)
154
UNDP
Real GDP Per Capita Rank - HDI Rank
-6
UNDP
Gender Related Development Index Rank
131
UNDP
46
ILO
Average Annual Growth Rate of Urban Population
Net Migration Rate
GNP Per Capita (USS)
GNP Per Capita Average Annual Growth Rate
Gender Empowerment Measure Rank
Human Poverty Index Value (HPI)
% Population Economic Active
Unemployment Rate
Total Adult Literacy Rate
1995
27.5
UNESCO
Adult Male Literacy Rate
1995
41
UNESCO
Adult Female Literacy Rate
1995
14
UNESCO
Male Secondary School Enrollment Ratio
1990-1995
46
UNESCO
Female Secondary School Enrollment Ratio
1990-1995
23
UNESCO
Crude Birth Rate (births per 1.000 pop.)
1996
37
UNPOP
Crude Death Rate (deaths per 1.000 pop.)
1996
12
UNPOP
Maternal Mortality Rate (per 100.000 live births)
1990
1500
WHO/UNICEF
Life Expectancy at Birth
1996
56
UNPOP
Total Fertility Rate
1995
5.2
UNPOP
Infant Mortality Rate (per 1,000 live births)
1996
82
UNICEF/UNPOP
Under Five Mortality Rate (per 1.000 live births)
1996
116
UNICEF/UNPOP
% Population Access to Safe Water
1990-1996
63
UNICEF
% Population Access to Adequate Sanitation
1990-1996
18
UNICEF
Contact address:
UNAIDSM/HO Working Group on Global HIV/AIDS and STD Surveillance
20, Avenue Appia
CH -1211 Geneva 27
Switzerland
Fax: +41-22-791-4878
e-mail: Surveillance@UNAIDS.org
http://www.who.ch/emc/diseases/hiv
http://www.unaids.org
UNAIDS/WHO Epidemiological Fact Sheet
Global surveillance of HIV/AIDS and
sexually transmitted diseases (STDs) is a
joint effort of WHO and UNAIDS. The
UNAIDSA/VHO Working Group on Global
HIV/AIDS and STD Surveillance, initiated in
November 1996, guides respective
activities. The primary objective of the
working group is to strengthen national,
regional and global structures and networks
for improved monitoring and surveillance of
HIV/AIDS and STDs. For this purpose, the
working group collaborates closely with
national AIDS programmes and a number of
national and international experts and
institutions. The goal of this collaboration is
to compile the best information available
and to improve the quality of data needed
for informed decision-making and planning
at national, regional and global levels. The
Epidemiological Fact Sheets are a first
output of this close and fruitful collaboration
across the globe.
Following a series of consultations, the
working group and its partners established c
framework standardizing the collection of
data deemed important for a thorough
understanding of the current status and
trends of the epidemic, as well as patterns
of risk and vulnerability in the population.
Within this framework, the Fact Sheets
collate the most recent country-specific data
on HIV/AIDS prevalence and incidence,
together with information on behaviours
(e.g. casual sex and condom use) which
can spur or stem the transmission of HIV.
The data include prevention indicators
developed by WHO's Global Programme on
AIDS, which aim to measure trends in
knowledge of AIDS, relevant behaviours,
and a host of other factors influencing the
epidemic. Additional indicators - for
example, on care and support - will be
included when available
Not unexpectedly, information on all of the
agreed-upon indicators was not available
for many countries in 1997. However, the
fact sheets do contain a wealth of
information which allows identification of
strengths in currently existing programmes
and compansons between countries and
regions. The fact sheets may also be
instrumental in identifying potential
partners when planning and implementing
improved systems.
The fact sheets can be only as good as
information made available to the
UNAIDSM/HO Working Group on Global
HIV/AIDS and STD Surveillance.
Therefore, the working group would like to
encourage all programme managers as
well as national and international experts
to communicate additional information to
the working group whenever such
information becomes available. The
working group also welcomes any
suggestions for additional indicators or
information proven to be useful in national
or international decision making and
planning.
June 1998
a.
Nepal - 3
Estimated number of people living with HIV/AIDS
In 1997 and during the first quarter of 1998, UNAIDS and WHO worked closely with national governments and research
institutions to recalculate current estimates on people living with HIV/AIDS. These calculations are based on the previously
published estimates for 1994 (WER 1995; 70:353-360) and recent trends in HIV/AIDS surveillance in various populations
Epimodel 2, a microcomputer programme originally developed by the WHO Global Programme on AIDS, was used to
calculate the new estimates on prevalence and incidence of AIDS and AIDS deaths, as well as the number of children
infected through mother-to-child transmission of HIV, taking into account age-specific fertility rates. An additional
spreadsheet model was used to calculate the number of children whose mothers had died of AIDS.
The current estimates do not claim to be an exact count of infections. Rather, they use a methodology that has thus far
proved accurate in producing estimates which give a good indication of the magnitude of the epidemic in individual
countries. However, these estimates are constantly being revised as countries improve their surveillance systems and
collect more information. This includes information about infection levels in different populations, and behaviours which
facilitate or impede infection.
Adults in this report are defined as women and men aged 15 to 49. This age range covers people in their most sexually
active years. While the risk of HIV infection obviously continues beyond the age of 50, the vast majority of those who
engage in substantial risk behaviours are likely to be infected by this age. Since population structures differ greatly from
one country to another, especially for children and the upper adult ages, the restriction of the term adult to 15-to-49-yearolds has the advantage of making different populations more comparable. This age range was used as the denominator in
calculating adult HIV prevalence.
Estimated number of adults and children living with HIV/AIDS, end of 1997
These estimates include all people with HIV infection, whether or not they have developed
symptoms of AIDS, alive at the end of 1997
Adults and children
26000
Adults (15-49)
25000
10000
580
Women (15-49)
Children (0-15)
Adult rate (%)
0.24
Estimated number of AIDS cases
Estimated number of AIDS cases in adults and children that have occured since the
beginning of the epidemic:
Cumulative no. of AIDS cases
2100
Estimated number of deaths due to AIDS
Estimated number of adults and children who died of AIDS since the beginning of the epidemic:
Cumulative deaths
1700
Estimated number of adults and children who died of AIDS during 1997:
Deaths in 1997
840
Estimated number of orphans
Estimated number of children who have lost their mother or both parents to AIDS (while
they were under age 15) since the beginning of the epidemic:
Cumulative orphans
750
Estimated number of children who have lost their mother or both parents to AIDS and who
were alive and under age 15 at the end of 1997:
Current living orphans
UNAIDS/WHO Epidemiological Fact Sheet
710
June 1998
4- Nepal
HIV Sentinel surveillance
This section contains information about HIV prevalence in different populations. The data reported in the tables below are
mainly based on the HIV data base maintained by the United States Bureau of the Census and are a compilation of data from
different sources, including national reports, scientific publications and abstracts. To provide for a simple overview of the
current situation and trends over time, summary data are given by population group, geographical area (Major Urban Areas
versus Outside Major Urban Areas), and year of survey. Studies conducted in the same year are aggregated and the median
prevalence rates (in percentages) are given for each of the categories. The maximum and minimum prevalence rates
observed, as well as the total number of surveys/sentinel sites, are provided with the median, to give the reader an overview
of the diversity of HIV-prevalence results in a given population within the country.
The differentiation between the two geographical areas Major Urban Areas and Outside Major Urban Areas is not based on
strict criteria, such as the number of inhabitants. For most countries, Major Urban Areas were considered to be the capital city
and - where applicable - other metropolitan areas with similar socio-economic patterns. This distinction assumes that capital
cities in many countries have specific characteristics related to the prevalence of higher risk behaviour and a concentration of
HIV infections. The term Outside Major Urban Areas considers that most sentinel sites are not located in strictly rural areas,
even if they are located in somewhat rural districts. Site/study-specific data on which the medians were calculated are printed
in an annex at the end of this fact sheet.
HIV prevalence in selected populations in percent
I Group
Area
Pregnant women
Major Urban Areas
■uS BEH-I KRI&I BPMil
Hk'PM
N.Sites
Minimum
Median
Maximum
Pregnant women
Outside Major Urban Areas
N.Sites
1
Minimum
o
0
Median
0
0
Maximum
0
0
[Group
Area
■■■I
Sex worters
Major Urban Areas
N.Sites
rm
iffei eebi era in
Em ihti roi EErTl ebh
Minimum
0.9
Median
0.9
Maximum
Sex workers
Outside Major Urban Areas
[Group
Area
Injecting drug users
Major Urban Areas
[Group
Area
Prisoners
Outside Major Urban Areas
[Group
Area
STD patients
Major Urban Areas
0.9
N.Sites
i
Minimum
0.9
Median
0.9
1.3
Maximum
0.9
1.3
BkMl 1K&1
1.3
I EMI lEEII Itexi | EMI IEEEIIEM1MEMIBEM1
N.Sites
Minimum
1
1.6
o
0
Median
1.6
0
0
Maximum
1.6
0
0
i
Iptyl
N.Sites
1
Minimum
0
0.6
Median
0
0.6
Maximum
0
0.6
■£££1 Ik'BM
iHBM ItEEI fTffHI ITOI EKIi fpFfl f^J EEEE1
N.Sites
Minimum
Median
Maximum
STD patients
Outside Major Urban Areas
N.Sites
1
1
Minimum
0.1
0.18
Median
0.1
Maximum
0.1
UNAIDS/WHO Epidemiological Fact Sheet
1
1
1.01
0.65
1.42
0.18
1.01
0.65
1.42
0.18
1.01
0.85
1.42
June 1998
>
Nepal - 5
Assessment of epidemiological situation
Assessment of country
epidemiological situation
There is little current information available on
HIV prevalence in Nepal. HIV testing among
antenatal clinic attendees was conducted at 8
sentinel surveillance sites including Katmandu
in 1991 and 1992. At that time, no evidence of
HIV infection was found among the antenatal
clinic attendees tested.
In 1993, HIV testing of sex workers in
Katmandu Valley found 0.9 percent of women
tested were HIV positive. In 1991 and 1992,
HIV testing of sex workers in 8 sentinel
surveillance sites including Katmandu found
0.9 and 1.3 percent of the sex workers tested
respectively to be positive.
Regional maps
Seroprevalence of HIV-1 for Pregnant Women
Middle South Asia
Iran ''
;
S,
■?
BlMilan. -
;•
c«in
India
Paiuiiil Serapusliv*
.-'BjingladeMh
In Katmandu, 1.6 percent of IV drug users
tested in 1991 were HIV positive. In 1993 and
1994, no evidence of the virus was found
among IV drug users tested at that time.
<1.0
0
0.1 - 0.3
$
. taoriba? Sri Lanka
Among male STD clinic patients, 0.1 percent
tested in 1989 were HIV positive. HIV
prevalence among male STD clinic patients
tested at various sites increased from 0.2
percent in 1992 to one percent in 1997
1.0-4J
IttU-lS.tf
In 1990, one percent of prisoners tested
positive for HIV infection.
seroptevaierce at mv-i tor sex wancersand
l.V. Drug users In Middle5o*Jlh Asia
tK] i
: -- ■ PjU'jai i
MU
\4
.
iLim,
.> -kiAJ LbtiJi
r>A VWrtr-c
AJ.|£ <
1A.-.I
••
■xJ - S L
' VMrl.U
Jai*
UNAIDS/WHO Epidemiological Fact Sheet
June 1998
e
6 - Nepal
Reported AIDS cases
AIDS cases by year of reporting
Eil
1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990
0 I 6 | 0 ' 0 | 00 | 00 I 00 I 0 ' 0 i 2 I 0 ’ 2
Date of last report:
1991
T
1992 1993 1994
—5 | 10 | 11
1995
1996
15
1997
1998
98 I
Total
Unknown
| 183 I
7-Jan-1998
AIDS cases officially reported to WHO. Due to gaps in
diagnosis, underreporting, and reporting delays, officially
reported AIDS cases represent only a portion of all cases
in a country. Completeness of reporting varies
substantially from one country to another, from less than
10% in some countries with fewer resources to more than
80% in most industrialized countries (please also compare
with the section on estimates). Therefore, distribution by
age, sex and modes of transmission may not be
representative for all people living with AIDS in a given
country.
AIDS cases by age and sex
Sex
Age
All
All
<1994 94J<95 1995
1996
1997 1998 Unkn. Total
0-14
15-29
30-49
50+
NS
Male
All
0-14
15-29
30-49
50+
AIDS cases by mode of transmission
NS
Female
Hetero: Heterosexual contacts.
Homo/Bi: Homosexual contacts between men.
IDU: Injecting drug use. This transmission category also
includes cases in which other high-risk behaviours were
reported, in addition to injection of drugs.
Blood: Blood and blood products.
Perinatal: Vertical transmission during pregnancy, birth or
breastfeeding.
NS: Not specified/unknown
All
0-14
15-29
30-49
50+
NS
MS
All
0-14
15-29
3049
<94 94/<95 1995 1996 1997 1 998 Unkn. Total %
Sox
Trans, group
AJ
Afl
50
37
98
183 100%
Hetero
Homo/Bi
48
0
37
0
96
0
181 99%
0 0%
IDU
Blood
2
0
0
0
0
0
0
0
Pennatai
Other known
Unknown
0
0
0
0
All
20
16
78
Hetero
19
16
78
Homo/Bi
0
0
0
113
113
0
IDU
1
0
0
Blood
Other known
Unknown
0
0
0
0
0
0
0
Male
0
0
2
0
0
1%
0%
0%
0
0
0%
0
0
0%
0
30
29
21
18
21
18
68
68
IDU
Blood
i
0
0
0
0
0
0
Other known
Unknown
0
0
0
0
0
0
0
0
AJI
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Hetero
IDU
Blood
Pennatai
Other known
Unknown
0
NS
0
0
0
Female All
Hetero
NS
50*
1995 data reflect cumulative cases through 1995.
UNAIDS/WHO Epidemiological Fact Sheet
June 1998
%
Nepal - 7
Curable STDs
Control and prevention of sexually transmitted diseases (STD) have been recognized as a major strategy in the prevention
of HIV infection and ultimately AIDS. Consequently, monitoring different components of STD control can also provide
information on HIV prevention within a country. One of the cornerstones of STD control is adequate management of patients
with symptomatic STDs. This includes diagnosis, treatment, and individual health education and counselling on disease
prevention and partner notification.
Estimated incidence and prevalence of curable STDs
Incidence
STDs
Year
Male Female
Prevalence
All
Year
Male
Female
All
Chlamydia trach.
Gonorrhoea
Syphilis
Trichomonas
Comments
*
Source
A total of 13.250 new cases of STD was reported to Health
Management Information System. DHS in the fiscal year
1996Z97. Majority of the diagnosis was made on the basis of
syndromic approach
NCASC and DHS/P&FAD. HMIS section.
STD Incidence, men
Prevention Indicator 9: Proportion of men aged 15-49 years who reported episodes of urethritis in the last 12 months.
Year
Area
Age
n/a
All
All
Rate
N=
Comments:
Sources:
STD Prevatence, women
Prevention Indicator 8: Proportion of pregnant women aged 15-24 years attending antenatal clinics whose blood has
been screened with positive serology for syphilis.
Year
Area
Age
Rate
N=
1997
All
15-24
1.3
1802
Comments: 13% tested VDRL + TPHA. TPHA for the same sample population was found to be 4.7%. (O f the samples
22.5% were above 25 years of age)
Sources:
NCASC
STD Case management (counselled)
Prevention Indicator 7: Proportion of people presenting with STD or for STD care in health facilities who received
basic advice on condoms and on partner notification.
Year
Area
Age
Rate
1997
All
All
70
N=
Comments: The data comes from compilation of reports from PHC.
Sources:
NCASC
STD Case management (treatments)
Prevention Indicator 6: Proportion of people presenting with STD in health facilities assessed and treated in an
appropriate way (according to national standards).
Year
Area
Age
Rate
1997
All
All
80
1997
All
All
80
N=
Comments: In the PHC. syndromic management Is practiced. However at the Health Post and sub-Health Post level
appropnate drug availability is a major constraint in STD case management.
Sources:
NCASC
UNAIDS/WHO Epidemiological Fact Sheet
June 1998
8 - Nepal
Health service indicators
HIV-prevention strategies depend on the twin efforts of care and support for those living with HIV or AIDS, and targeted
prevention for all people at risk or vulnerable to the infection. These efforts may range from reaching out to vulnerable
communities through large-scale educational campaigns or interpersonal communication; provision of treatment for STDs;
distribution of condoms and needles; creating an enabling environment to reduce risky behaviour; voluntary testing and
counselling; home or institutional care for persons with symptomatic HIV infection; and preventing perinatal transmission and
transmission through infected needles or blood in health care settings. It is difficult to capture such a large range of activities
with one or just a few indicators. However, a set of well-established health care indicators -- such as the percentage of a
population with access to health care services; the percentage of women covered by antenatal care; or the percentage of
immunized children -- may help to identify general strengths and weaknesses of health systems. Specific indicators, such as
access to testing and blood screening for HIV, help to measure the capacity of health services to respond to HIV/AIDSrelated issues.
Access to health care
Indicators
Year
Estimate
Contraceptive prevalence rate (%):
1990-1996
23
UNPOP
% of births attended by trained health personnel
1990-1996
7
UNICEF
% of pregnant women immunized against tetanus.
1995-1996
11
UNICEF
% fully immunized - Tuberculosis:
1995-1996
73
UNICEF
% fully immunized - DPT
1995-1996
51
UNICEF
% fully immunized - Polio:
1995-1996
48
UNICEF
% fully immunized - Measles:
1995-1996
45
UNICEF
Source
% of Pop. with access to health services - total:
% of Pop. with access to health services - urban:
% of Pop. with access to health services - rural:
Proportion of blood donations tested:
% of ANC clinics where HIV testing is available:
HIV/AIDS Hospital Occupancy Rate (Days):
Latex condoms are the only technology available that can prevent sexual transmission of HIV/STD. Persons needing
protection in situations that carry risk should have consistent access to high quality condoms. National AIDS Programmes
implement activities to increase both availability of and access to condoms. The two condom availability indicators below are
intended to highlight areas of strength and weakness at the beginning and at the end of the distribution system so that
programmatic resources can be directed appropriately to problem areas.
Condom availability (central level)
Prevention Indicator 2: Availability of condoms per capita in the country over the last 12 months (central level).
Year
Area
1997
All
Comments:
Sources:
N
Rate
2___
The Numerator reflects only condoms imported by Ministry of Health/DHS/LMD and does not include
commercial distributors.
MOH/DHS/LMD. 1997
Condom availability (peripheral level)
Prevention Indicator 3: Proportion of people who can acquire a condom (peripheral level).
Year
Area
1997
All
Comments:
Sources:
N
Rate
80
Every village having sub health post and NGO. Family Planning workers (TBA) distributing condoms, it
is assumed that the availability is more than 80%.
NCASC, 1997
UNAIDS/WHO Epidemiological Fact Sheet
June 1998
Nepal - 9
Knowledge and behaviour
Information on knowledge and behaviour related to HIV/AIDS is essential in identifying populations at risk for HIV infection. It
is also critical in assessing changes over time as a result of prevention efforts. Guidelines and recommendations have been
published in the publication: "Evaluation of a National AIDS Programme: A methods package. 1 Prevention of HIV infection
WHO/GPA/TCO/SEF/94.1 Geneva, 1994".
Knowledge of HIV-related preventive practices
Prevention Indicator 1: Proportion of people citing at least two acceptable ways of protection from HIV infection.
Year
Area
Age group
1995
1995
1995
All
All
All
15-19
20-24
25-49
Male
All
Female
34.7
33.5
30
Comments: Rate in table is proportion that mentioned the use of condoms as a way to avoid HIV/AIDS. Among 15-49
ever-mamed women who had heard of AIDS 30.9% mentioned “use of condoms": 52.6% mentioned "have
only 1 sexual partner" (n=2263).
Sources:
Family Health Survey. MOH/DHS
Reported non-regular sexual partnerships
Prevention Indicator 4: Proportion of sexually active people having at least one sex partner other than a regular
partner in the last 12 months.
Year
Area
Age group
n/a
n/a
20-24
n/a
25-49
n/a
Comments.
Sources:
15-49
Male
Female
All
15-19
Reported condom use in risk sex (gen pop)
Prevention Indicator 5: Proportion of people reporting the use of a condom during the most recent intercourse of risk.
Year
Area
Age group
n/a
15-19
n/a
20-24
n/a
25-49
Male
Female
All
n/a_____________________________ 15-49_________________________
Comments:
Sources:
UNAIDS/WHO Epidemiological Fact Sheet
June 1998
10 - Nepal
Knowledge and behaviour
Ever use of condom
Percentage of people who ever used a condom.
Year
Area
Age group
1996
All
15-19
1996
All
20-24
1996
1996
1996
1996
1996
1996
All
25-29
5.5
8.5
8.8
All
30-34
6.5
All
35-39
5.5
All
40-44
3
All
45-49
1.6
All
Total
6.2
Comments:
Sources:
Male
Female
All
Ever-mamed women
Demographic and Health Survey
Median age at first sexual intercourse
Median age of people at which they first had sexual intercourse.
Year
Area
n/a
n/a
n/a
Age group
Male
Female
All
20-24
25-49
45-49
Comments:
Sources
Adolescent pregnancy
Percentage of teenagers 15-19 who are mothers or pregnant with their first child.
Year___________ Area__________ Age group_______
1996
All
15
Rate
3.2
1996
1996
1996
1996
11.8
22.8
All
All
All
All
All
15-17
16
17
18
19
Area
AiF
Age group
1996
Comments:
Sources:
36
50.7
N
485
1382
469
428
449
399
DHS/1996
Estimated number of IDU
Estimated number of injecting drug users.
Year
1997
Comments:
Sources:
AH
Male
Female
__ All
20000
NCASC. 1997
UNAIDSM/HO Epidemiological Fact Sheet
June 1998
Nepal - 11
Sources
Bhatta, P , S. Thapa. S. Neupane, et al. 1994, Commercial Sex Workers in Kathmandu Valley: Profile and Prevalence of Sexually Transmitted
Diseases, Journal of the Nepal Medical Association, vol. 32, no. 111, pp. 191 203
Gurubacharya, V. L, 1990, Nepal, AIDS in Asia and the Pacific Conference, Canberra, Australia, 8/5 8, p. 102.
Li. P C., E. K Yeoh, 1992, Current Epidemiological Trends of HIV Infection in Asia, AIDS Clinical Review, pp 1 23.
X. Sh™SuH N^^veXhrSn^Za,'0^■ 1988'
Te™ P'an
,he Preven,l°n and COn,rol Of AIDS
Nepal' Minretry Of Health’
A. S^Rana. S. H. Maharjan, et al., 1995, Declining Risk for HIV among Injecting Drug Users in Kathmandu, Nepal: The Impact of a Harm
Reduction Programme, AIDS, vol. 9, no. 9, pp. 1067 1070.
B. K, J. Baker, S. Thapa, 1994, HIV/AIDS in Nepal. An Update, Journal of the Nepal Medical Association, vol. 32, no. Ill, pp. 204 213.
World Health Organization, 1992, Project Summary, AIDS Prevention and Control Project/Nepal, October, Document.
♦
UNAIDS/WHO Epidemiological Fact Sheet
June 1598
"Pis S'i-s
05824
12 - Nepal
Annex: HIV Surveillance data by site
1
| 1985 | 1986
|Group
Area
Pragnant woman
Oiiside Major Urbin Arm
Group
[Area
Sax workare
Oilside Major Urban Areas
Eight sites
Major Urban Areas
Kathmandu Valley
Group
[Area
Priaonars
1988 1989
1987
1988 1989
STD patients
Outside Major Urban Areas
[ 1985 | 1986
1987
1988
1988
0
Various sites
0
1994
1995 1996 1997
1994
1995 1996 1997
1994
1995
1996 1997
|
1992
1993
1989
1990
I 0-9
1989 ' 1990
1993
1992
1991
|
|
0
|
0
1991
1992
1993
1994
1995
1996 1997
1991
1992
1993
1994
1995
1996 1997
PL
I 0.18 | 1.01
0.65
__
0.6 |
[ 1985 | 1986 1987
Not stated
1991
1-6
4 towns
1
1992 1993
i
I
1987
Notapadfiad
[Area
1990
Kathmandu
Oilsida Major Urban Araaa
1991
0.9 I 1.3 I
| 1985 | 1986
[Area
Group
1990
0
[ 1985 | 1986
Injacting <tug uaara Major Urban Araaa
Group
1987
Ei^itaitM
1988
1989 1990
0.1
1.42
Notes:
UNAIDS/WHO Epidemiological Fact Sheet
June 1998
U4
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T .
LU
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%
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"lL1 KUJ
■A notAI oaoa
XXMWALrtTt
' HIV&AI
ipsa?
A GUIDE FOR JOURNALISTS
st
1
ft'r-sb I Panic about setting ittheh _ I panic about RePoPr/^iro M Lt
HIV o-nd fl|bs
INFORMATION / ADVICE / CONTACTS
No one would deny'that reporting on HIV and AIDS can be difficult. This
guide is designed to help journalists tackle what is a complex and
controversial topic.
o
The virus, and the fatal syndrome which it causes, are still not fully
understood, even by the experts. Medical knowledge and opinion is
1
constantly changing, which may lead to confusion for the public.
■
When "experts" disagree, public fears, myths and bigotry often come to the
fore. Such powerful emotions make good copy, but much of the resulting
media coverage has not helped the public to understand HIV and AIDS.
Below we answer some of the most common questions that people ask
about HIV and AIDS.
llSaiii
rip
■A
■■■■
o ■
HIV stands for Human Immunodeficiency
Virus. HIV can damage the body's defence
system so that it cannot fight certain
infections. When a person is infected with
HIV the virus can be found in their blood,
semen or vaginal fluids and breast milk.
A person with HIV is said to be HIV anti
body positive, seropositive, body positive,
or, more commonly, HIV positive - that is,
they have tested positive for the presence
of antibodies to HIV or for the virus itself in
their blood. (Babies may be born with
their mothers' antibodies in their blood
which later disappear: see How is HIV
passed on?).
j
j
n
/V -
What is the difference
between HIV and AIDS?
..
C/i
Once people have HIV it remains in their
body for the rest of their lives and can be
transmitted to other people, i.e. they
remain infectious for the rest of their lives.
People with HIV may have no symptoms at
all for a prolonged period, but eventually
experience a range of medical conditions.
AIDS stands for Acquired Immune
Deficiency Syndrome. It describes the
.condition where the body's defence system
has been broken down by HIV and can no
longer fight certain infections. A person is
said to have AIDS when.they are affected
by certain otherwise rare illnesses which
occur as a result of immunodeficiency,
such as some cancers and pneumonias.
The cause of illness or death among people
with HIV is not the virus itself, but these
other illnesses to which HIV has made the
person vulnerable. A person with AIDS
may recover fully or partially from some of
these illnesses, but eventually succumbs to
one or more of them.
So far as is known, almost all people with
HIV will eventually develop AIDS, but how
long this takes varies from person to
person. Currently the average time from
infection to the development of AIDS in
the UK is between eight an‘d ten years.
Many people still confuse HIV infection
with AIDS. It is therefore important that
journalists make a clear distinction
between the two.
Is there more than one
kind of virus?
Yes. HIV-2, which is much less common
than HIV-T, was discovered in Senegal in
1985 and is found mainly in West Africa.
The progress to AIDS may be slower with
HIV-2 infection. It may be possible for
people to be dually infected with HIV-1
and HIV-2.
As with other viruses such as influenza,
HIV mutates constantly, so different strains
of the virus are found in different parts of
the world.
How is HIV passed on?
HIV is passed on from person to person
through intimate contact with infected
blood, semen, vaginal fluids or breast milk.
There are three main ways: first, by
unprotected sexual intercourse (anal or
vaginal) with a person with HIV; second,
through innoculation with or transfusion of
infected blood, which in the UK is
normally through drug users sharing
contaminated injecting equipment,
including syringes and needles; and third,
from an infected mother to her baby, either
in the womb, during birth or through breast
feeding.
Not everyone who comes into contact with
HIV will contract the virus. For example, • >
3
j
I
babies born to HIV positive mothers have
their mothers' antibodies to HIV in their
blood, but may not necessarily be infected
with HIV.
However, it can take only one exposure to
the virus to become infected.
HIV is a fragile virus which can only
survive for a short time in the
environment (exactly how long depends
on the conditions). It is not contagious, so
it is NOT passed on through everyday
social contact with someone who has HIV
infection (including AIDS itself). For
example, the virus cannot be passed on by
touching, shaking hands or hugging, nor
by sneezing and coughing, and cannot be
caught from insect bites. It is perfectly
safe to share objects used by an infected
person such as cups, cutlery, glasses, food,
clothes, towels, toilet seats and
doorknobs, and facilities such as
swimming pools.
However, people with HIV or AIDS should
not share toothbrushes or razors because
there is a very small risk that these will be
contaminated with blbod, and in any case
this contravenes basic rules of hygiene.
Are blood transfusions
safe now?
Since 1985 blood donated in the United
Kingdom has been screened for antibodies
to HIV, so the risk of being infected is
almost negligible. There is a very small
risk from donors who have been infected
shortly before giving blood, as they may
not have yet developed antibodies to the
virus (this is called a "window period"),
and for this reason donors are asked not to
give blood if they may be at risk of
infection. Blood plasma products, such as
Factor 8 which is given to haemophiliacs,
are prepared from screened blood which
then goes through additional purifying
treatment.
It is now extremely unlikely that people
will become infected through blood
transfus.ions in most developed countries,
although it may still happen in some parts
of the world. People travelling abroad,
either for business or pleasure, who would
like more information can get a free leaflet
called "The Traveller's Guide to Health"
from their local post office (or phone free
on 0800 55^777 to order a copy).
What about donating
blood?
People donating blood in the United
Kingdom cannot become infected with
HIV because all equipment is sterile and is
only used only once.
Can people get HIV from
their doctors and dentists?
There have been no known cases of people
contracting HIV from their doctors or
dentists in the United Kingdom, and only
one case (involving a Florida dentist who
infected six patients) worldwide. The
General Medical and Dental Councils
advise all doctors and dentists who believe
that they may have been exposed to HIV to
seek medical advice and, if appropriate, to
have a test for HIV. This includes those
who have engaged in invasive medical or
surgical techniques in parts of the world
where no provision could be made for
adequate precautions to be taken against
the danger of infection.
The Department of Health's Expert
Advisory Group on AIDS has issued
guidance for HIV infected health care
workers. It slates that health care workers
with HIV should not perform invasive
surgical procedures in which injury to the
worker could result in blood contaminating
the patient's open tissues. A United
Kingdom Advisory Panel has been created
to provide specific occupational advice to
health care workers, personal physicians,
occupational physicians and professional
bodies where there is doubt about the need
to restrict a particular health care worker's
occupational activities. It would be wise
for journalists to check the exact and
current position with the Department of
Health. '
Routine HIV testing of health care
workers undertaking invasive procedures
is not considered justified. Such testing
would also be ineffective; HIV infection
can take three months or more to show up
in tests, so results would only show that
workers were not infected three months
before the test date.
What about
acupuncturists and
tattooists?
Any device that punctures the skin,
including tattooing and acupuncture,
needles and equipment for ear-piercing or
4
between cusiaows oi will use new,
disposable needles, removing the risk.
Similarly good barbers-will sterilise their
razors between customers to eliminate any
contamination by intecled blood.
Which groups of people
are most at risk from HIV?
Although gay men, injecting drug users
and haemophiliacs have been
disproportionately affected in the United.
Kingdom by the AIDS pandemic, it is
misleading and dangerous to talk about
high-risk groups. It is the way in which
people behave that puts them at risk from
HIV, not who they are. A more relevant
term is "high-risk behaviour".
If one partner is infected, unprotected anal
intercourse, whether between a man and a
woman or between two men, carries a
particularly high risk of transmitting HIV.
But unprotected vaginal intercourse also
carries a significant risk.
Current research suggests that other sex
ually transmitted diseases (STDs),
especially those which-cause ulceration,
facilitate transmission of HIV. It is possible
that there are other factors which increase
the risk of a person becoming infected with
HIV and also hasten the onset of AIDS, and
research is continuing into these "co
factors".
However, journalists should be extremely
wary of unsubstantiated claims about
research findings.
Are heterosexuals really at
risk?
YES. Worldwide the World Health
Organization estimates that 80“90 per
cent of people with HIV have contracted
the virus as a result of heterosexual
intercourse, that is, through sex between a
man and a woman. Although people who
have contracted the virus through
heterosexual sex make up a small
proportion of people known to be HIV
positive in the United Kingdom, they arc
currently the fastest-growing group. And it
is possible that many more heterosexuals
are unaware that they a.re HIV positive, as
most do not consider themselves to be at
risk and therefore do not come forward to
HIV appears lo he
more edMly
from a man to a woman than irom a
woman to a man. A survey of 16 studies of
heterosexual partners of people with HIV
worldwide found that 32 per cent of men's
partners and 25 per cent of women's
partners contracted the virus. However,
the risk of infection for partners of either
sex is still high.
Because the majority of people known to
be HIV positive in the United Kingdom
have been men (because the epidemic has
affected gay men and because almost all
haemophiliacs are male), less is known
about the effects of the virus on women.
What is certain is that women suffer from
related gynaecological conditions in
addition to other illnesses associated with
HIV and AIDS.
How does the "AIDS test"
work?
Despite many references to>an "AIDS
test" in the media, there is actually no
such thing. The test is for antibodies to
HIV.
<>■
This test looks for antibodies to HlV" in a
person's blood, or sometimes in their
saliva. (The saliva test is used mainly for
epidemiological surveys.)
It can take two to three months and
sometimes longer from the time of
infection for antibodies to show up in a
test, although a person will already be able
to pass on the virus. So if people think
they have been infected they should seek
advice, but may be asked to wait before
taking the test.
A positive result does not mean that a
person has AIDS, only that they have HIV.
The test cannot predict when or whether
they will go on to develop AIDS.
Tests can be carried out only under the
authorisation of a qualified medical
practitioner; home-testing kits are illegal,
unreliable and can be dangerous. It is very
important that anyone considering taking
the test should talk to a health adviser,
counsellor or doctor about the implications
before making a decision (this is one of the
reasons that home-testing kits are banned).
Test results and the fact that a test has been;
taken are confidential between the person
concerned and the medical staff treating
them. However, information about the test
be tested.
5
t
may appear on CPs' records, and could
then with the patient's permission be
passed on, tor example to insurance
companies. People can be tested in
complete confidentiality - and
anonymously if they wish - at health
authority-run STD clinics'(also known as
Special Clinics and Cenito-Urinary
Medicine Clinics).
What treatment is
available for HIV and
AIDS?
At the time of publication the most widely
available treatment for HIV-related illness
is zidovudine (AZT). Zidovudine may
increase the survival time of people who
already have AIDS and help decrease the
severity of HIV-related symptoms.
However, there are side-effects and some
of these can be severe, often forcing
people to stop taking zidovudine.
Prophylactic drugs arc also available for
certain illnesses associated with HIV.
Other drugs are being developed and
tested all the time, and it is hoped that one
of these (or a combination of drugs) will
prove effective against HIV.
Journalists should treat claims of new
treatments for HIV infection and AIDS
with extreme scepticism unless these have
been made by reputable and experienced
research workers.
How can people protect
themselves against HIV
and AIDS?
There is no vaccine available that will
prevent HIV infection, and because HIV, as
a virus, mutates easily, it will be difficult to
produce an effective vaccine against it.
Even if a vaccine can be made, it could
take a long time to prove that it is safe
enough to use.
As there is neither an effective vaccine
nor an effective cure available for HIV
infection, it is very important for
individuals to take precautions to stop the
virus spreading. Encouraging people to
practise "safer sex" makes an important
contribution to this.
Using a condom can help, to stop the virus
- and other sexually-transmitted diseases passing from one person to another. But
condoms are effective only if they are used
consistently and if manufacturers'
instructions are followed closely, and it is
6 .
important for journalists to stress this in
their stories.
For example, condoms should be put on
when a man has an erection but before any
genital contact is made, and should never '
be re-used. People should only use good
quality condoms (in the UK the BSI
"kitemark" means that they have been
properly tested), and for this reason it is
better to take condoms from the United
Kingdom when travelling abroad.
Anything containing oil, such as vaseline,
baby oil and some pessaries or
suppositories, can damage a condom and
make it fail. Only water-based lubricants
such as KY Jelly should be used with
x condoms, and if people are using oil to
give each other a massage they should use
a towel or tissue to wipe their hands
before touching a condom.
I
I
Journalists can also help to raise awareness
of the new female condom Femidom,
which may prove to be as effective as the
male condom and which heterosexual
couples may prefer to use. More work
needs to be done to evaluate jts efficacy
and acceptability.
Safer sex also includes alternatives to
penetrative sex such as mutual
masturbation, kissing, licking and body
rubbing. Sex toys can heighten sexual
enjoyment, but should not be shared. Oral
sex carries a theoretical risk of infection,
and for this reason using condoms or oral
shields (also known as dental dams) is
recommended.'
Injecting drug users should always use
their own needles and syringes, but if they
do share, can lessen the risk of infection by
cleaning equipment with bleach after each
use. Used needles and syringes should be
disposed of safely by putting them in a
rigid container with a lid. In many parts of
the country needle exchange schemes offer
free supplies of clean injecting equipment
and will safely dispose of used equipment.
Journalists covering stories about injecting
drug users should consider mentioning
what facilities are available for them
locally, as (his will also help to prevent the
spread of HIV.
I!'
'AIDS’ surgeon
will escape test
Dy NICHOLAS DUCKLEY
THE SURGEON said
to be infected with the. ll<llv
... infectious
.............. sec(rate .on
HIV virus
not have
. 1.7 will
.....................
* ■ ~ ^.ondary
\;<Hiuary diseases, Jitn
to takc^an APc
J
AIDS test XRunicns,
of- Queen
before
\b’eing allowed ^lary’s, said: “I do not
nrp-hn.n,
back to\vork._—_
th ink there is any risk
/Health
''chiefs to patients.’’
*revealcd yesterday
Mr Curran was last
/that they have no night still in hiding
power to force eye after claims he carried
specialist Peter Cur out 140 operations
ran, 45, to be screened while HIV positive.
for the killer disease.
• DOCTORS have no
| He has promised to right to test patients
) undergo ^necessary” for HIV without their
NACCURATE'^ checks in oAer consent, the British
tcTreturn to his duties Medical Association
at Queen Mary’s Hos ruled at its annual
pital, Sidcup, Kent. meeting ih Not
But these will conccn- tingham yesterday.
Journalists should also avoid describing
people with HIV or AIDS as "innocent", as
"victims" or as "sufferers", as these terms
are misleading and inaccurate.
®HIV does not discriminate. Anyone can
become infected, and to talk about
"innocence" implies that some people
with HIV and AIDS are guilty, which can
encourage prejudice and discrimination.
©Describing people as "victims" implies
helplessness and invites pity, which
many people with HIV qr AIDS who are
trying to fight the virus and to lead lives
as normal as possible find unhelpful and
insulting.
©People with AIDS are not necessarily ill
all the time, so to describe them as
"sufferers" is not appropriate.
Respect privacy
Clause 6 of the NUJ's Code of Conduct
says that, subject to the justification by
overriding considerations of the public
interest, a journalist should do nothing
which entails intrusion into private grief
and distress.
Supermarkets profit from rising
condom sales after Aids campaign
dom questions were written
down and answers wore num
bered so interviewees did not
have to use the word. Half of all
A ROUND 15 per cent of con- women replied that they had
A^idoms are now bought in never had sex with partners
supermarkets, compared with wearing condoms, but 83 per
10 per cent two years ago. Min- cent of both men and women /
tel, the market research com knew condoms formed a bar
pany. said in a report published rier against the Aids virus.
Condoms w'ere most popular
yesterday. Sales from vending
among 18-19 y&ar olds. By class,
machines are also increasing.
Total, sales are expected to they were most popular with
rise to 155 million this year, the lower middle class and least
nearly 20 per cent more than in popular with the very poor and
l^S^wheri^he Government pro- unemployed. A drop in mail
zmoted^^Shddhis as part of its order sales is seen as further
rrsafer sex” Campaign against proof that the embarrassment /
I nhejAidssvirul But the contra- factor is declining. “Only 3 per '
1 captive pill is still the most pop cent of people refused to
ular contraception, with 25 per answer the condom questions.''
1 /cent of women using it com- said Margaret Rooke-Matthews
tipared with 16 per cent who rely for Mintel. “That compares
with 10 per cent who refused to
on partners’ condoms.
3 Boots, which accounts for answer questions we asked
j nearly half of all condom sales, recently about funerals.”
has moved them from pharmaCCURATE0^** display. Mintel said Sales of condoms
1939 1991
i that manufacturers had
%
x
switched to discreet pastel
55
49
I coloured packs to attract
women customers. Some
reports suggest women may
: now be buying up to 40 per cent
of all condoms purchased.
Mintel interviewed 600 men
j and women In their own homes
James Erllchman, Consumer
Affairs Correspondent
8
The NUJ urges journalists to respect the
privacy of people living withJHIV and
AIDS, including the family and friends of
people infected with the virus. Identities
and addresses should not be revealed or
hinted at without permission, and
journalists should not pressurise people
living with HIV and AIDS into publicly
revealing their identities.
Information given to journalists in
confidence by individuals living with HIV
and AIDS should not under any
circumstances be passed on or made
accessible to other journalists, programme
makers or researchers. Journalists have a
responsibility to ensure that this
confidentiality is understood by colleagues
and by all those working with them.
Employment protection for people with
HIV or AIDS can be achieved through
negotiating specific clauses in contracts of
employment. These clauses can cither
form a separate policy on HIV and AIDS,
or be part of a more general policy to
protect all workers with life-threatening
illnesses. In cither case, a policy should
include at least the following clauses:
I
ioL
jJjj;
m
©People with HIV or AIDS will be treated
in the same way as people with any
other life-threatening illness, such as
cancer or heart’disease.
©The company recognises that an
employee who has HIV or AIDS does not
present a risk to other stall.
©The company and the union will work
together to educate all stall regarding the
true nature of, and risks relating to, HIV
and AIDS, and to combat ignorance and
I
hysteria.
XZ7
4
©There will be no discrimination in
recruitment against job applicants
internally or externally on the grounds
that the applicant has HIV or AIDS.
©No staff member or job applicant will be
required to take the HIV antibody test.
©Staff members who have HIV or AIDS
are not required to inform the company.
However, if it is known that a staff
member has HIV or AIDS confidentiality
will be maintained. - Any member of staff
who deliberately breaches this
confidentiality will be subject to
disciplinary action. Information about
grievance procedures will be fully
disseminated.
©Staff members who have or who are
thought to have HIV or AIDS will not be
victimised or discriminated against. Any
member of staff who discriminates
against a staff member with or who is
thought to have HIV or AIDS will be
w
.:1
w>'
1
I
1)
10
with pay.
©Staff members who have HIV or AIDS
may require medical treatment including
hospitalisation from time to time but still
be able to resume their normal life
between episodes ot illness. Both the
company and the union will endeavour
to ensure that such employees can
continue working for as long as they are
willing and able, through redistribution
of their workload, and/or by offering
them part-time working or flexible
working hours and/or by the
employment of freelance journalists.
©The company will install condom
machines (at a height accessible to
everybody including wheelchair users)
for the use of staff members.
©The company's policy on HIV and AIDS
will be fully disseminated and regularly
monitored by both the company and the
union.
©Appropriate training will be provided to
allow realistic and sensitive responses to
people with or who are perceived to
have HIV or AIDS or who are caring for
people with HIV or AIDS, including
training about confidentiality procedures.
©Special conditions and concerns may
arise outside the UK. All requests for
staff to work overseas will be supported
by appropriate information, advice,
insurance and necessary equipment.
EASAH, the Employers' Advisory Service
on AIDS & HIV, provides consultancy
services including needs assessment,
strategy and policy development or
review, evaluation and monitoring.
Contact Adam Christie or Steve Suckling
on 0274 521 511 (phone and fax) or via
PO Box 346, Bradford BD7 2DB.
subject to disciplinary action.
Information about grievance procedures
will be fully disseminated.
I
©Staff will not be dismissed or redeployed
to alternative employment because they
have HIV or AIDS unless they request it.
©Staff members with HIV infection or
AIDS will be given adequate leave and
time off with pay to receive medical care
and counselling.
O
©Staff members who are caring for people
with AIDS or HIV-related conditions will
be given adequate leave and time oft
I
i
i
I
7
Reporting on HIV and AIDS may be dilticult
sometimes, particularly as information is constantly
changing, but there is plenty of help available. Where
relevant the same organisations can also be
recommended Io the general public for further
information, advice and help.
Qi '.S Statutory organisations
'Z -v
SSMi
K
HEALTH EDUCATION AUTHORITY PRESS OFFICE
071 413 1987
The I leallh Education Authority is the statutory body
providing information to the public in England on issues
relating to sexual transmission of the virus.
HI Al TH PROMOTION.WALES 0222 752 222
/\ similar organisation to the above serving the
population of Wales.
HEALTH EDUCATION BOARD FOR SCOTLAND
031 447 8044
x
A similar organisation to the above serving the " x
population of Scotland.
A -f:.-
THE HEALTH PROMOTION AGENCY FOR
NORTHERN IRELAND 0232 31 1 514 (press
office)/0232 31 1 611 (switchboard)
A similar organisation to the above serving the
population of Northern Ireland.
HEALTH PROMOTION UNIT - REPUBLIC OF
IRELAND 010 3531 714. 711
A similar organisation to the above serving the
population of the Republic of Ireland.
..r,
DEPARTMENT OF HEALTH PRESS OFFICE
071 210 5223 - 5229
The Department of Health is the statutory body
providing information to the public relating to injecting
drug use and the transmission of HIV.
4
pIbI
BHR ■
is
DEPARTMENT OF HEALTH - NORTHERN IRELAND
0232 520 000
* 4
NATIONAL HIV PREVENTION INFORMATION
SERVICE 071 724 7993
A free national information service lor professionals on
HIV education and prevention. Will also assist the
media.
NATIONAL AIDS HELPLINE 0800 567 123
Provides free confidential information and advice for
the general public on HIV and AIDS 24 hours a day,
seven days a week. If you can only give out one
. contact number with your story, this should be it.
Advice is also available in:
Punjabi, Bengali, Hindi, Urdu, Gujarati 0800 282 445
Wednesday 6pm -10pm.
Cantonese 0800 282 446Tucsday Gpm -10pm.
Arabic 0800 282 447
Wednesday Gpm -10pm.
>
A Minicom service is available for people with hearing
difficulties on 0800 521 361 lOam-IOpm seven days a
week.
iglll •
Voluntary organisations
TERRENCE HIGGINS TRUST 071 B31 0330 (helpline
071 242 1010 12 noon-10pm, seven days a week)
Offers a wide range of services which are open to
everyone.
NATIONAL AIDS TRUST 071 972 2845
Promotes voluntary sector responses to HIV.
!
SCOTTISH AIDS MONITOR 031 555 4850
Provides a comprehensive range of care and prevention
services.
BODY POSITIVE 071 835 1045 (Helpline
071 373 9124 7-i0PM DAILY)
Self-help and support groups for people affected by HIV.
BLACKLINERS 071 738 7468 (helpline 071 738 5274
Monday - Friday 9am-5pm)
Provides emotional and practical support and housing to
black people of African, Asian and Caribbean origin
affected by HIV and AIDS.
BLACK HIV AND AIDS NETWORK (BHAN)
081 749 2828
(helpline 081 742 9223 9.30am-5.30pm
Monday-Friday)
Provides information, support and counselling to black
people with HIV and AIDS, together with education and
training.
HAEMOPHILIA SOCIETY 071 928 2020 (media
enquiries to the health network 0353 669 939)
Support and advice for people affected by haemophilia.
POSITIVELY WOMEN 071 490 SSOI tfielpline
071 490 2327 12-2pm Monday to Friday-for women
with HIV only)
.•
Provides a range of practical and emotional support
services to women living with HIV and AIDS.
.
MAINLINERS 071 737 3141/738 4656
Support, advice and help for drug users.
SCODA (STANDING CONFERENCE ON DRUG
ABUSE) 071 430 2341
Can provide an up-to-date national list of drug treatment^:
services and needle and syringe exchange facilities..
w
POSITIVE PARTNERS & POSITIVELY CHILDREN
071 738 7333 (head office)/071 250 1396 (North
London office)
Support, information and advice for children and adults
living with HIV and AIDS, their families and partners.
AIDS AHEAD 0270 250 736
Health education, information, counselling and
interpretation services for deaf people.
IMMUNITY LEGAL CENTRE 071 388 6776
Specialist legal and welfare rights advice centre for
people in the Greater London area who have legal
problems associated with HIV.
BRITISH MEDICAL ASSOCIATION 071 387 4499
Deals with ethical, social and public policy issues
relating to HIV and AIDS and the medical profession.
LONDQN LIGHTHOUSE 071 792 1200
Britain^sTirst major residential and support centre for
people living with HIV and AIDS.
UK NGO AIDS CONSORTIUM 071 401 8231
Consortium of development agencies whose
programmes are affected by HIV and AIDS.
There arc also many local organisations dealing with
HIV and AIDS, both statutory and voluntary, and
details can be obtained from regional and district
health authority press offices. Many of the national
organisations listed will also refer callers to local
\
representatives where they exist.
A
© Health Education Authority 1993
ISBN 1 85448 825 2
.4 Iff."
11
HIV & AIDS
AGUIDE FOR JOURNALISTS
No one would deny thal reporting on HIV and AIDS can be difficult.
When options seem to conflict, public fears, myths and bigotry often
come to the fore. Such powerful emotions make good copy, but much of
the resulting coverage has not helped tine public to understand HIV and
AIDS.
HIV and AIDS: a guide for journalists provides information, reporting
guidelines and useful contacts to help you tackle this complex and
controversial subject.
50p
ISBN 1-85448-825-2
Health Education Authority
Hamilton House Mabledon Place
London wcih vtx
9 781854 488251
Injecting drug use and HIV infection in Asia
Nick Crofts, Gary Reid and Paul Deany*
in collaboration with the Asian Harm Reduction Network
AIDS 1998, 12 (suppl B):S69-S78
Keywords: Injecting drug use, Asia, risk behaviours, HIV infection
Introduction
The importance of injecting drug use in the many
epidemics of HIV in Asia has been sporadically recognised,
but like injecting drug users (IDU) themselves it is often
marginalized. Although many discrete [1-3] and
interconnected [4-6] epidemics of HIV infection among
IDU in various parts of Asia have been well described,
their role as epicentres tor wider epidemics, and their
impact on whole communities, has undergone little formal
investigation. Accordingly, public health responses to the
specific issue of HIV among IDU in Asia have been slow
to emerge and, more generally, this issue is seen as
secondary to the reduction of drug demand and the
control of supply.
The record of success of demand and supply reduction
■ attempts in Asia is, however, as parlous as anywhere else
in the world, as measured by the rapidity with which
new populations ot IDU appear and with which HIV
spreads in these populations [7-12]. Here, we review the
ever-changing scene ot illicit (and sometimes licit) drug
production, trafficking and consumption in Asia, as a
background to the emergence and spread ot injecting as
a common route of administration and HIV infection as
an almost inevitable consequence.
Methodological note
The role of the various Asian countries in the production,
trafficking and use of illicit drugs is complex (Table 1).
Many aspects have never been formally studied, and by
their natures are intensely difficult to accurately describe
or measure. The review presented here comes from a
comprehensive literature review and consultation with
over 400 key informants in Asia and elsewhere carried
out by the Asian Harm Reduction Network under the
auspices of the United Nations Joint Programme on AIDS
Asia-Pacific Intercountry Teams Task Force on Drug Use
and HIV Vulnerability in late 1997. Opinions expressed,
however, are those of the authors.
Patterns of drug production^ trafficking and
use in Asia
The historical centre of opium production in the Golden
Triangle region ofAsia, Myanmar, continues to support a
thriving opium industry, producing over 80% of the opium
cultivated in southeast Asia, and increasingly turning to
heroin production [7,13-15]. Trafficking of opiates out
of Myanmar is continually finding new routes, along
which new populations of opium users spring up. The
traditional methods of opium and heroin use, that ot
smoking or inhaling vapours produced by heating the
opiate, often rapidly give way to heroin injection,probably
for reasons of cost-effectiveness. These transitions are
followed almost inevitably by explosive epidemics of HIV
infection [16-18]. Trafficking continues from Myanmar
through Thailand to Malaysia, Singapore and onwards;
major routes that have opened up over the last decade
include those across the southwest of China to Hong
Kong, through the northeast states of India, and across
Laos and Cambodia to Vietnam and beyond [7,19-21].
Heroin is increasingly replacing opium as the major drug
smoked or injected, although substantial populations still
inject so-called ‘blackwater opium’ in Vietnam and
Cambodia (left over after smoking, and dissolved in often
unsterile water) [20,22].These changes in the region have
involved new and younger populations in IDU, with
concomitant risk of HIV infection. Latterly, new waves
of heroin smoking are being seen among even younger
populations, with proportions moving from smoking to
injecting [23,24].
From the Epidemiology and Social Research Unit, The Macfarlane Burnet Centre for Medical Research, Fairfield, Victoria,
Australia and the ’Asian Harm Reduction Network, Fairfield, Victoria, Australia.
Requests for reprints to: Nick Crofts, Epidemiology and Social Research Unit, The Macfarlane Burnet Centre for Medical
Research, RO Box 254, Fairfield, Victoria 3078, Australia.
J
© Lippincott-Raven Publishers ISBN 0-41283-650-5 ISSN 1350-2840
S69
S70
AIDS 1998. \zol 12 (suppl B)
Table 1. Involvement or Asian countries in illicit drugs.
Major involvements
in drugs
Major drugs
involved
Production, refining,
trafficking, consumption
Opium, heroin,
China
Precursors, trafficking,
production, consumption
Opium, heroin,
amphetamines
Official: 56 000
unofficial: NA
Yunnan: 1 00 000
60 000-90 000
Thailand
Trafficking, consumption.
some producing/refining
Opium, heroin,
amphetamines
1.29 million total
?60%
Self administered
Vietnam
Trafficking, consumption
Opium, heroin
185 000-200 000
50 000 +
' Professional
injectors and self
administered
Ma lavs i a
Trafficking, consumption
Heroin, morphine,
amphetamines
50% heroin
Trafficking, some production.
refining, consumption
Opium, heroin,
NA
NA
Injecting occurs
Laos
Production, trafficking,
refining, consumption
Opium, blackwater
opium, heroin
NA
NA
Injecting occurs
(Hong Kong]
Trafficking, transhipment,
consumption, finance
Heroin,
30 000-40 000
mostly heroin
25 000-32 000
Self administered
amphetamines
Heroin, some
amphetamines
9000 in rehab,
>90% heroin
?
Most smoking
200 000-300 000
?
Most inject
self administered
Country
Mvnamar
Cambodia
Singapore
Trafficking, transhipment.
consumption, finance
Number of
drug users
Number
of IDU
Injecting
behaviours
300 000
Professional
injectors'
60 000
Self administered
amphetamines
257 000 amphetamines
Bangkok: 36 000
180 000-400 000
Professional
injectors' and self
administered
amphetamines
Taiwan
Trafficking, consumption
Amphetamines.
heroin
Philippines
Production, consumption
Marijuana,
amphetamines
2000
Cebu City
Most inject
self administered
Indonesia
Production, trafficking,
consumption
Ecstasy, marijuana,
heroin
30 000-40 000
Self administered
India
Production, trafficking,
consumption
'Brown sugar',
heroin, cannabis,
buprenorphine
3 million heroin
users
25 000-40 000
Manipur
Self administered
Nepal
Production, consumption
Brown sugar , heroin,
cannabis
25 000-40 000
2000
Kathmandu
Self administered
Bangladesh
Minor production,
consumption
Heroin, cannabis,
buprenorphine
?
?
Self administered
Sri Lanka
Production, trafficking,
consumption
Heroin, cannabis,
users
50 000 heroin
?
? Self administered
IDU, injecting drug users: NA, not available.
Amphetamines have been available in the region for some
years, but recently there has been an upsurge in
production, trafficking and consumption [25,26]. The
majority of the precursor chemicals (especially ephedrine)
are diverted from the pharmaceutical industry in China,
and shipped to Taiwan. Japan and the Philippines for
production ot amphetamines, consumed locally and for
export. Recently the production of amphetamines has
increased in Myanmar. Laos, Cambodia. Thailand and
Vietnam. From China and Myanmar the major production
is trafficked for consumption inThailand, and increasingly
onwards to other southeast Asian countries [7,17].
China has seen increasingly widespread drug use from
the early 1980s.coinciding with the economic'open door’
policy [27]. The highest concentrations of drug use are in
the southwest, on the border with the Golden Triangle,
especially in the provinces of Yunnan. Guangxi and
Sichuan along trafficking routes to Hong Kong and
Canton, but also spreading towards the northwest
(Xinjiang Province), northeast and to the interior [28,29].
Increasing amounts of heroin and other opiates from the
Golden Triangle are entering China, 90% originating from
Myanmar. There is increasing evidence of domestic
production and trafficking of opium and heroin in China
for the growing domestic market [7.15]. The more recent
and quite severe increase in drug trafficking and drug use
in various cities throughout the country is closelv
connected with internal migration, which is associated
with rapid economic development especially in the
Special Economic Zones and is estimated to be as high as
120 million people [27].
k>
HIV and IDU in Asia Crofts ef a/.
In general, Thailand, Malaysia and Vietnam are both
trafficking and consuming countries, although they also
have limited production and refining of drugs.Thailand’s
opium poppy cultivation has dimimshed significantly over
the years but importation from Myanmar continues to
rise for local consumption and for shipment to world
markets [7]. Recently, heroin has replaced opium as the
drug of choice among the northern hill tribes otThailand,
encouraging the establishment of drug trafficking
organizations within the country and the expansion of
their networks [30,31]. Heroin use is very widespread,
affecting most urban centres and rural and remote
communities. The production, trafficking and use of
methamphetamine is reported to be rising rapidly [24,32].
The use and trafficking of illicit drugs has increased in
Vietnam since the ‘Doi Moi’, or open door policy,
announced in 1986,makingVietnam an imponant country
in the global narcotics trade. Most of the heroin and opium
traffic originates inThailand, crossing either through China
or Laos before entermgVietnam. Opium is the most popular
illicit drug followed by pharmaceuticals such as pethidine,
morphine, and diazepam; the favoured route ot adminis
tration is by injecting.The use of heroin, which had largely
disappeared fromVietnam after 1975. has re-emerged since
the mid-1990s, increasingly involving younger populations
who smoke the drug, but also increasingly move to injecting.
In recent years, there have been reports ot use of
methamphetamine inVietnam [7.33].
I
Opium poppies are not grown in Malaysia, but because
of its proximity to the Golden Triangle there has long
been significant use of illicit drugs in Malaysian society.
Now, as historically, heroin enters Malaysia both overland
and by sea, usually from Thailand [7,8]. The movement
of populations from both sides of the border has grown
enormously, bringing with it an increase in the trafficking
of narcotics, mainly heroin and opium [34]. The most
popular illicit drugs used are heroin, followed by cannabis
and amphetamines.
Cambodia and Laos are increasingly involved in trafficking
of drugs from the Golden Triangle region, and consump
tion is concomitandy increasing in these two countries.
Cambodia is a leading transmitting and trafficking country,
situated in close proximity to one the worlds most prolific
opium growing regions. Although Cambodia is not a
traditional opium producer, there are reports of opium
cultivation and of amphetamine factories.Amphetarmnes
are available at Phnom Penh’s entertainment centres, and
heroin and opium are available at so-called ‘shop houses’
[7,20,35].
Hong Kong and Singapore have their own populations
of drug users, but their major importance is as transhipment points and financial centres for the drug market.
Hong Kong is a major centre for trafficking ot high and
increasing proporuons of the heroin originating from the
Golden Triangle region, having been imported through
China. Laos, Cambodia orVietnam. Hong Kong has also
become an important source and transhipment point for
ephedrine. There has been a recent significant rise in
heroin use amongst the youth, which maybe linked to
the rapid social changes that are taking place [7,23].
Similarly, Singapore does not cultivate, produce or process
narcotics, but is a leading regional shipping and financing
centre and is used by international traffickers to transit
narcotics and tor the laundering of drug proceeds. Since
the 1970s, heroin, mostly entering from Malaysia, has
remained the drug of choice and the leading drug problem
(E.Tan. personal communication. 1997) [7].
The Philippines is a major producer and exporter of
marijuana; heroin use is uncommon, but opioid
pharmaceuticals and amphetamine (or lshabu’) are
common. Since 1990, amphetamine use has been widely
detected inTaiwan, generally produced within the country;
but the closure ot illegal laboratories in recent years has
shifted many operations to the Chinese mainland. From
mid-1993, there appears to have been a shift from amphe
tamine to either heroin alone or a mixture of heroin and
amphetamine [7,22,36,37].
India remains an imponant producer of legal narcotics
(gum opium), pharmaceuticals such as buprenorphine and
propoxyphene, and some illicit narcotics, and a crossroad
for international trafficking. Following the prohibition
of cannabis and opium in 1985, the heroin based‘brown
sugar’ from Afghamstan appeared in many major urban
centres in India [7,38].This is the domestic drug of choice
except in the northeast states of Manipur and Nagaland
where injectable heroin is preferred [2,39). Although
Nepal is not a significant producer of illicit drugs, there
has been an increase in the number of heroin users, with
most heroin coming across the open border with India
[40]. Cannabis cultivation is substantial and the use of
cannabis has been culturally accepted for centuries
[7,39,41]. In much of northern India and Nepal, irregular,
costly or scarce supphes of heroin have led to the increas
ing injection of opioid pharmaceuticals.
Although its neighbours Myanmar and India are large
opium producers. Bangladesh is not a major producer of
narcotics, but heroin and buprenorphine are the most
frequently used drugs, imported from Myanmar and India,
respectively. In Sri Lanka, the leading drug problem is
heroin and the country has become a growing tranship
ment point of illicit drugs with increasingly reported
heroin seizures imported from Myanmar.The major drug
grown in the country is cannabis [7,39].
Populations involved in illicit drug use
Populations involved in the use of illicit drugs vary widely
throughout southeast Asia in their numbers, drugs used
S71
S72
AIDS 1 998, Vol 1 2 (suppl B)
and modes ot administration, but in relation to opiates
each generally is placed along the continuum ot move
ment trom opium smoking among older generations co
heroin or other opioid injecting among younger people.
New drugs (such as ecstasy) and the diffusion ot previously
restricted drugs (such as amphetamines and opioid
pharmaceuticals) are finding markets among new popu
lations ot young people, indicating further the diversifica
tion of drug markets.
in other larger urban centres, especially Chiang Mai and
Chonburi, and increasingly among rural populations,
especially hill tribes in the nonh and in southern provinces
in association with the fishing fleets [7.46). Heroin use is
found throughout the country, whereas amphetamine use
is so far generally located in the central and northern
regions ot the country. It has been estimated by TDRI
that there are up to 257 000 amphetamine users,currently
surpassing the number of heroin users [24.25].
Populations at risk ot HIV infection through IDU are
therefore being created continually in multiple ways in
many parts ot the region. Drug use and trafficking is
associated with mobile populations and across borders,
such as among ethnic minorities across the ThaiMyanmar. China-Myanmar andVietnam-China borders.
In addition, it is increasingly associated with internal and
external migrations and increased contact and openness
with the West in relation to economic development
[7.26,27].The Asian drug scene is rapidly becoming pan
ot the global drug scene.
It is estimated that there are 185 000-200 000 opiate users
in Vietnam. 135 000 of whom are thought to be opium
smokers, and more than 50 000 IDU, with 30 000 IDU
in Ho Chi Minh City and up to 6000 in Hanoi [33|.
These figures may underestimate the actual numbers.
Dealers who often act as professional’injectors are wide
spread; in Ho Chi Minh City alone there are an estimated
3000 [47]. Ot all IDU, 70% are under the age of 30 years,
and 95% are male [48|.
Heroin has become the major drug of choice in Myanmar,
primarily injected, although there is still much smoking
or inhaling ot heroin [26]. It was estimated in 1996 chat
there were up co 300 000 IDU nationwide, out of a total
population of 43 million [42). Most IDU (>90%) are
young men, the highest prevalences of IDU being in
border areas where there has been a traditional use of
opium, as a result ot socioeconomic development resulting
from cross-border trade and migration. Floating popula
tions ot workers arriving in mining towns have accelerated
initiation into the use ot illicit drugs, mainly heroin [26,42).
Such focal points enhance the dissemination of drug use
to the whole countrv.
In China, the official estimate of the number of registered’
drug users was 148 000 in 1992; by 1997 this had grown
co an estimated 560 000. ot whom a growing proportion
are IDU. In 1994, it was conservatively estimated that the
number ot IDU was at least 60 000. It was estimated in
1995 that there were up to 100 000 drug users in the
Province ot Yunnan, most of whom were believed to be
IDU. Outside Yunnan, IDU varies widely by region: 6090% of drug users inject in Guangxi, 20-30% in Guandong
and Sichuan and only 5% in Guizhou Province [27,28,43).
In 1993, the Thai Development and Research Institute
(TDRI) estimated that there were 1.29 million drug
‘addicts’ in the country, approximately 2.2% of the
population, and the Office ot the Narcotics Control Board
estimate there are 25 000 new cases each year [44]. Up
to 60% ot those entering treatment centres are IDU. In
1994, it was estimated that the number of IDU was
between 100 000 and 240 000 [45]. In 1991, it was estima
ted that there were 36 000 IDU in the Bangkok area;
Bangkok has higher levels chan other regions of the
country, but high rates ot IDU have also been reported
*
In 1996.it was estimated that there were 180 000-400 000
drug users in Malaysia, but the number of active IDU in
Malaysia, both dependent and non-dependent, is not really
known. In 1994.it was estimated that 50% of drug users
used heroin, of whom 15-20% inject. Large urban centres
like Kuala Lumpur and Penang have large populations of
IDU, but no state is free from IDU. It is estimated that
90% ot drug users are male and between the ages of 19
and 39 years, many unemployed [49,50].
A recent study in Cambodia found that although many
key informants claimed that a problem with illicit drugs
does not exist, others believed that there was an increased
availability and use ot drugs, as a result ot Cambodia's lax
drug laws, inadequate policing, the many socioeconomic
problems and an unregulated financial system. How
widespread the use ot illicit drugs is cannot be accurately
determined because no quantitative analysis yielding hard
data has been undertaken [7,20).
I
It has been estimated that there are currently 30 00040 000 active drug users in Hong Kong, the majority of
whom use heroin. In 1996. the number of ‘registered’
drug users was 12 342, of whom >80% were male, and
89% reported heroin as their mam drug, of whom most
injected. There is- a-1 trend
t
towards younger people using
drugs: in 1995,10% of the; new users of illicit drugs were
under 16 years old and 37% were 16-20 years old [23,5 1 ].
In 1996, there were approximately 9000 drug ‘addicts’
undergoing rehabilitation in Singapore’s treatment centres,
most (>90%) reporting heroin as their primary drug, but
there is no available estimate of the numbers of IDU in
Singapore (E. Tan, personal communication, 1997). It is
reported that therems an increasing trend towards IDU [52],
There are conflicting reports about the number of IDU
in the Philippines with one estimation of 2000 IDU in
4
HIV and IDU in Asia Crofts et al.
Cebu City alone, but another study in Manila finding
only one IDU out of 960 drug users. It is generally
perceived that IDU is minimal in the Philippines, but
there are some indications that it is more extensively
practised than currently officially recognized [7,53].
Police in Taiwan estimate the total illicit drug using
population as 200 000, whereas public health authorities
estimate around 300 000, of whom 100 000-150 000 are
heroin dependent. The propomon that is injecting is
unclear, but it is believed to be high and growing [54].
The use of illicit drugs in India is widespread. Nationwide
estimates of the number of drug users have not been made,
but it is estimated there are around 3 million heroin users
[39], plus large populations using pharmaceuticals. The
State of Manipur alone has an estimated 25 000-40 000
IDU out of a population of 1.8 million [2,40]. It has
been estimated that there are between 25 000 and 40 000
drug users in Nepal, of whom 10% are believed to be
IDU. In the capital Kathmandu, it is estimated there are
2000 IDU [41,42]. Estimates of the number of drug users
in Bangladesh are not available.There are estimated to be
up to 50 000 heroin users in Sri Lanka [7].
Risk practices and trends in behaviours
For both individuals and for populations of drug users in
most pans of Asia, the move from smoking or inhaling to
injecting of heroin, once established, is rarely seen to revert;
$uch transitions are far more common than transitions in
the reverse direction. The major influence on these
transitions would seem to be economic [43,48], but this
has not been deeply investigated. Among injecting popula
tions, the sharing and reuse of injecting equipment is
subject to many pressures, including scarcity and relative
cost ot equipment, social organization of drug use, and
custom [26.27,31,48).
*
Myanmar has a culture of ‘shooting galleries’ in which
professional injectors administer an illicit drug, generally
heroin, to the client, who could be located in many areas
ot the country, including mining areas, but are reportedly
rare in urban communities. Such establishments common
ly have one set of injection equipment; the IDU pays for
both the heroin and for its injection, and the use of bleach
or sterilization of equipment is rare [12,55]. A report from
a drug treatment centre in 1993 found that 83% of new
attendees shared their needles and other injecting para
phernalia [55]. The open sale of injecting equipment is
traught with problems because a person found in posses
sion ot a synnge and/or needle is liable to arrest. Prohibi
tion and cost of injecting equipment, as well as comrade
ship, tavour the sharing of injecting equipment [26,43].
In southwest China, heroin use is either by smoking in
cigarettes, inhaling or increasingly by injecting. In 1995, a
e
study in Yunnan Province reponed that IDU in the cities
favoured heroin mixed with diazepam, whereas those in
the remote areas preferred opium and pain killers [44],
There are reports that most IDU from the Lonchuan
county, southwest China, obtain used needles and plastic
tubing from waste disposal sites of local hospitals and
clinics. In 1992, a study in southwest China reported that
before 1987, <1% had been injecting heroin, but by 1992,
33% ot all drug users were administering their drugs by
injecting [56]. Throughout southern Yunnan IDU
continues to increase in popularity. Sharing of needles
and syringes has been reported to be common practice
in various regions of the country, with small but increasing
proportions of IDU cleaning their injecting equipment;
methods include either boiling the needles or washing
the needles in cold water [44]. In the county of Dehong,
Yunnan Province, more than 30% inject, with 70-100%
sharing needles and syringes [27].
The most popular route of administration of heroin in
Thailand is by injecting. There are conflicting reports in
urban settings on the extent to which IDU share injecting
equipment. It has been reponed that since HIV prevention
campaigns targeting IDU were launched, sharing of
injecting equipment has dropped markedly, but these data
are limited in scope and coverage [46], In the hill tribes
ofThailand, where the injecting ot heroin was introduced
much later than in the rest of the country, it was verv
common to share equipment, occasionally rinsing with
water but most often not [31], The boiling of injecting
equipment or cleaning needles with bleach appears not
to be widespread, resulting in the common use of inade
quate cleaning methods. Amphetamines, a relatively recent
introduction, are generally taken orally or smoked, but
there are reports of injecting [7,57].
‘Blackwater opium is commonly injected inVietnam.The
mixing ot opium with pharmaceutical products, such as
diazepam, is a common practice [21,33,58].Transitions
from smoking drugs to injecting are increasing [21,33].
Most IDU in urban settings visit what are commonly
termed‘shooting galleries’, where the dealer who usually
supplies the illicit drug also acts as the‘professional’ injector.
Up until the mid-1990s, there were many accounts of
using the same needle and other injecting paraphernalia
(the‘common pot’for the blackwater opium) for 10-100
clients in a day without any attempt at effective sterilization
[21.58] . In 1996, behavioural changes were detected in
some areas, and a study in Ho Chi Minh City found that
an increasing number of IDU no longer shared needles
and syringes. Attempts at cleaning needles and syringes
by both the ‘professional’ injector or by the majority of
IDU generally proved inadequate. The sharing of the
‘common pot’ containing the opium remains common
practice [21,46,58]. It is estimated that 50-80% of IDU
regularly share needles and syringes, with only a minority
using effective methods to clean their injecting equipment
[48.58] . In 1996, a study in Ho Chi Minh City reported
S73
«
S74
AIDS 1998, Vol 1 2 (suppl B)
that 51% ot IDU interviewed visited a ‘shooting gallery’
with 41% injecting at home. Outside urban areas in
Vietnam, opium is usually smoked and little injecting has
been detected to date, but there are repons of increasing
prevalence ot injecting in rural areas [47].
Most studies ot IDU in Malaysia have found that higher
percentages of drug users inject heroin rather than smoke
or snort it (some participants in these studies were unaware
ot any other method of administration). Traffickers travel
around villages selling heroin, often prepared in the
syringe, resulting in the one needle and synnge being
used many times across several villages [8]. A substantial
proportion ot IDU have shared their needles and svnnges,
with little effective cleaning beforehand. Needles and
syringes can be purchased from pharmacies, but carrying
a needle can be seen as incriminating evidence of drug
use and IDU may therefore be reluctant to procure clean
injecting equipment from a pharmacy [8,50].
In Cambodia, opium is both smoked and injected, and
heroin is injected.as in the Phnom Penh'shop houses', in
the cafes frequented by the semiskilled Vietnamese
labourers, and in certain nightclubs. Syringes and needles
are available at every authorized and unauthonz ed
drugstore, without prescription [20].
A study in a voluntary rehabilitation centre in Hong Kong
in 1990 and 1992, reponed that 84.8% of those surveyed
took drugs by injection, heroin being the preferred drug,
and nearly 70% claimed never to have shared injecting
equipment. A behavioural study over the period 19901995. reported that needle sharing was not common
practice amongst IDU who had attended methadone
clinics following counselling [59]. In 1996, the predomi
nant illicit drug used continued to be heroin, and 60.6%
ot registered heroin users were known to favour injecting.
In contrast, among newly reported cases heroin was still
the most popular drug, but inhalation was the preferred
route (46.7%) with injection preferred by onlv 19.6%.
Transitions to injecting seem to take place once users
have developed a habit past initial experimentation [23].
In 1995, a survey among ‘street addicts’ indicated that
38.5% ot IDU shared needles regularly or had just ceased
co do so in the previous 3 months. A methadone clinic
study in the mid-1990s reported that of those who had
ever shared their needles, 80% had done so in the initial
period of their drug addiction [60]. Needles and syringes
are easy to obtain at most pharmacies without a
prescription, but despite this a study in 1996 reponed
instances ot needle sharing as a result of a perceived lack
ot availability of clean syringes [61].
The typical heroin user in Singapore inhales, with heroin
injecting reported to be rare. There is no information
available as to whether IDU share needles or engage in
any harm reduction practices, such as the use of bleach to
clean injecting equipment. Needles and syringes are
widely available without prescription (E.Tan and R. Chan,
personal communication, 1997).
In the Philippines, the little available information suggests
commonly injected drugs include morphine, analgesics
and muscle relaxants, with needles and syringes purchased
trom drugstores, obtained without prescription. Sharing
ot needles occurs and results from a lack of money, an
inability to gain access to clean equipment and
camaraderie among friends [36,62]. A needle exchange
program began in Cebu City in 1996, undenook surveys
ot its clients, and found trends towards safer drug taking
practices (C. Aquino, personal communication. 1997).
In Taiwan, most beginners mix heroin with tobacco in
cigarettes, but following a period ot smoking or inhalation
that might last weeks or months, they begin injecting
heroin. In an analysis ot clinical characteristics of heroin
dependent persons admitted for detoxification in Taipei
City Psychiatric Centre during the mid-1990s, 100
patients (35.3%) smoked mixed heroin and cigarettes as
the only route, while the other 186 patients (64.7%)
injected.The Department of Health has placed no controls
on syringes and needles, which can be purchased, without
prescription, throughout the country [37].
In India, brown sugar heroin has generally been
administered by inhalation, but there has been a recent
trend towards injecting, particularly in the cities of
Mumbai (Bombay) and Chennai (Madras) [63]. iMore
recently, the injecting of buprenorphine is gaining
popularity among former heroin users [7,39],The sharing
ot injecting equipment and inadequate cleaning
techniques of needles and syringes is common [40.64].
In Nepal, it has been reported that injecting mav be
increasing. Injecting within a group is common practice,
but the sharing ot injecting equipment is less prevalent in
the capital Kathmandu following the establishment of a
needle exchange program [7,41,42]. In Bangladesh, heroin
is reported to be injected and a similar trend is seen with
buprenorphine, with the sharing of injecting equipment
reponed to be frequent in Dhaka [39,65]. Heroin users
in Sri Lanka are reported to mainly administer the drug;
by inhalation [39].
HIV transmission
There have been several comprehensive reviews of HIV
prevalence among IDU in Asian countries [4-6],
The prevalences of HIV infection among IDU in
southeast Asia are among the highest that have been
reported in the world; tew signs exist ot any major decrease
ot this epidemic. IDU are widespread, participate in highrisk sharing ot injecting equipment with multiple partners,
are mobile and mix with other injectors in the region,
and have a high prevalence rate ot HIV infection.therefore
<
HIV and IDU in Asia Crofts et al.
♦
Table 2. HIV and injecting drug use in Asian countries.
Surveillance cumulative HIV infections
Reported
*
Surveys of HIV prevalence in IDU
Country
HIV risk behaviours
Year
Estimated
n
%IDU
Year
Location
Prevalence Ref.
Myanmar
>80% sharing
1993
500 000
7500
73%
Myanmar
Kachin State
N. Shan State
56.5%
93%
82%
China
70-100% sharing
1996
200 000
5157
Yunnan
Xinjiang
57.4%
60%
60%
Thailand
40% still
sharing
1997 900 000
NA
(Reported 43 000 AIDS cases)
Vietnam
50-80% sharing
1997
1995
1994
1994
1996
1997
1997
1997
1995
1995
1995
1997
3000580 000
6700
37%
70%
Ruili, Yunnan
76%
Longchuan, Yunnan 57.6%
Yiling City, Xinjiang 70%
Baishi City, Guangxi 77.2%
Bangkok
33%
Chiangmai Province 37.6%
Songkhla Province
46.5%
HCMC
Lang Son, N.Province97%
(68|
Hanoi
2%
Khanh Hoa
68%
[68|
Quang Ninh
90-100% f
76%
1996
1992
entering DRC
Kota Bharu
NA
NA
80+% sharing
1997
50 000
Cambodia
Laos
NA
NA
1997
1997
1997
1997
155 000
7705
NA
240
2000-3000 855
0.03%
NA
1.9%
NA, but believed to be low
NA
631
2.2%
NA, but believed to be low
1997
1997
1997
1997
5000
18 000
200 000
1491
916
3.3%
0.3%
NA
NA
Hong Kong
30% sharing
Singapore
Most smoking
little sharing
Taiwan
Reported sharing
Philippines
Reported sharing
Indonesia
Sharing common
India
Sharing common
Nepal
Outside of
1995 NA
Kathmandu sharing is common
Bangladesh
? Sharing common
NA
Sri Lanka
NA
NA
558
3-5 million 7034
331
[68|
1997
1996
1997
1997
Malaysia
21 863
37.4%
[66]
(42|
[42]
[67]
[67]
[67]
[67]
[44|
2.7%
40%
30%
[8|
[691
Manipur
Chennai (Madras)
55.7 %
15-20%
Kathmandu
0%
[70|
[381
|40|
low
low
NA, but believed to be low
1995
1997
1995
NA
NA
•Poshyachinda V, Perngparn U, Danthamronkul V, personal communication, 1998; ’Kraus S, personal communication, 1997; Country Pro
gramme Advisor, Joint United Nations Programme on HIV/AIDS, Vietnam. NA, not available; HCMC, Ho Chi Minh City; DRC, drug rehabili
tation centres.
increasing the likelihood of sharing injecting equipment
with an HIV-positive partner [4,6].Thus, this marginalized
group of people often act as core groups and a major
vector for the regional spread of HIV infection.
Various parts of southeast Asia have seen the most rapid
diffusion of HIV infection among injecting drug users
found anywhere in the world (Table 2).Within a period
of approximately 12 months, many areas reached a
prevalence of HIV infection among IDU of 40% or
greater. In Myanmar recently, the HIV prevalence among
IDU in Kachin State was 93% and in the Northern Shan
State 82% (17,26). Ruili county in the Province ofYunnan,
China, has some of the highest rates of reported HIV
infection in the country, above 70% [27]. Ho Chi Minh
City has the highest reported number of HIV infections
in Vietnam, making up 93% of all reported cases in the
city [48]. In Bangkok, recent prevalence of HIV among
IDU has stabilized to under 40% but has yet to show
signs of decreasing significantly. In India, the HIV infection
prevalence amongst IDU in the State of Manipur has
been reported in past years as above 70%.
Discussion
What is immediately apparent from a review of the
situation in Asia regarding the association of IDU and
HIV infection is the dynamic nature of the patterns
observed. New drugs are constantly appearing [7], and
new populations are becoming involved in risky drug
use practices, thus enhancing HIV transmission. Truly
S75
S76
AIDS 1998, Vol 12 (suppl B)
explosive epidemics of HIV follow rapidlv on the heels
of the involvement of these new populations in injecting,
providing core groups bom which secondary transmission
may occur. Moves from the smoking of opium to the
injecting of heroin, new trafficking routes, the involvement
of mobile populations such as the Thai fishing fleet and
truck drivers travelling nonh from the Golden Triangle,
internal migration associated with economic development
and continuing armed conflict, are all involved in
maintaining this dynamism [12,26,27,31]. Countries such
as Thailand. Myanmar.Vietnam and Malaysia have all been
host to large epidemics of HIV among IDU. most of
which continue unabated. Other countries in the region,
such as Laos and Cambodia, have not yet seen this pheno
menon, but would seem to have all the preconditions for
rapid shifts in administration route and subsequent HIV
outbreaks [20,35]. Indonesian government authorities are
very sensitive towards open dialogue on drug use issues,
but recent anecdotal accounts indicate that there may be
an estimated j0 000—40 000 IDU in the country (G. Loth,
personal communication. 1997).
One newly emerging pattern is the wider use of
amphetamines, their mixed use with heroin, and their
impact on sexual risk behaviour for HIV prevalence. The
coincidence ot increased amphetamine availability in
Thailand with decreased availability and increased price
of marijuana may be just that, but this is a pattern that has
been observed elsewhere. In many parts of Asia, as
elsewhere, involvement of ethnic or other minorities in
production, trafficking and consumption of illicit drugs
[26.27] is one factor in the relative neglect that aspect of
the epidemic has received in terms of response.
The methodological problems associated with monitoring
both the use ot particular drugs, especially those that are
illicit, and the spread ot HIV in association with that drug
use are formidable in any setting. In many parts of Asia,
these problems can be insurmountable with currently
available resources and adverse social and legal contexts.
As can be seen from this review of current knowledge,
the result is that there are many gaps in our understanding
ot both patterns of drug use and of HIV transmission
among drug users. To the degree to which the profile of
the threat to the health of countries inAsia from epidemics
ot HIV among IDU can be raised, the importance of
improving data on and the understanding of these patterns
and their determinants will also be raised. Both are
necessary underpinnings of successful prevention pro
grams at the national and regional scale.
HIV-related disease. Both mitigate against both an
improved understanding ot the extent and nature of the
HIV epidemic, and a humane and effective response to it
[71].
The paradigm case of Mampur (where trafficking routes
tor heroin out of the Golden Triangle sprang up in the
1980s; where consequent epidemics of IDU, with
continued recruitment ot young people, have been
occurring since the early 1980s; where HIV has been
spreading at an explosive rate since at least 1989, and
continues to spread at the same rates; where the initial
response was confined to crackdowns and incarceration;
where now there are epidemics ofAIDS and tuberculosis,
as well as ot HIV and hepatitis C, well beyond the capacitv
ot the medical system or indeed the society to cope; and
where latterly some very brave people running small and
underfunded programmes in the face of enormous
difficulties have won support trom a very brave
government to take meaningful action) stands as exemplar
for the situation in Asia.
------ Its
—lessons
-------- a must be learnt, and
soon [2].
As well as in countries of southeast and south Asia, the
preconditions for epidemics of IDU and HIV exist in
western and central Asia. Lessons learnt trom southeast
Asia should be applied there as rapidly as possible and on
a scale commensurate with the size ot the potential
epidemic.
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♦
*■
T .
THE LANCET
/I
HIV series
k
ki
Prevention of HIV infection in developing countries
Doris d'Cruz-Grote
The HIV/AIDS epidemic continues to spread rapidly In developing countries. Heterosexual transmission accounts for
almost three-quarters of Infections. Current strategies have been effective In the prevention of HIV spread within
certain groups but they have had limited Impact on the general spread of the epidemic. There is a need to complement
these strategies with approaches that will Influence the social and environmental determinants of risk to enable those
vulnerable to Infection to protect themselves.
w
♦
The HIV epidemic continues to spread at a rate of over
6000 new infections per day,1 the most rapid increases
being observed in southern and central Africa and in
South Asia (table and figure).2 As many as 50% of all new
infections are in women aged 14-24 years. By the year
2000, according to WHO forecasts, 30—40 million new
infections will have occurred, 90% in developing
countries?
Heterosexual transmission is rising and mother-to-child
transmission is also increasingly important. Significant
levels of HIV infection have been detected among
injecting drug users in countries in South and South-East
Asia and in Latin America. We know that injecting drug
users have a pivotal role in the spread of infection to
the
non-drug-using
heterosexual
population.^
Documentation of seropositivity among blood donors in
India* and Thailand underlines the importance of donor
selection and the rational use of blood transfusions.1 Since
heterosexual transmission of HIV accounts for 70-80% of
the cases in developing countries,’ prevention of AIDS is
and will remain linked to sexual behaviour and to the
factors that affect such bevhaviour in various settings and
cultures. In this review I will discuss the prevention of
heterosexual transmission in developing countries.
Current programmes against heterosexual transmission
of HIV are mass-awareness campaigns for the general
public and interventions combined with supportive
services targeted at specific groups. These programmes
have been effective in the prevention of HIV spread within
these groups*"* but have not resulted in sustainedbehaviour change and have fried to prevent the general
spread of HIV/sexually transmitted diseases (STDs) in
developing countries.13-10 Most prevention programmes
concentrate on influencing individual behaviour and do
not take into consideration ±e social, economic, and
structural determinants of risk that act as barriers to the
adoption of preventive behaviour.
Australia. Europa, and North America
Latin Amenta and Cambean
Africa
Asia
Globai total
MM-im
MtimatedHIV
2000
rrofactadWV
pmiiinut
>12 million
>1-5 million
>8-5 million
>3 million
14-15 million
1 million
>2 million
>9 million
9 million
20 million
•Total number of HIV-infected adults currently alNe. f Total number of HIV-infected
adults m trie year 2000.
Table: WHO estimated and projected HIV prevalence In adults
by “macro" region, July, 1995
why and how and with what specific goals interventions
should be undertaken. There is some evidence that mass
education campaigns in certain countries—eg, Mexico,
Tanzania, and the Central African Republic—have
increased public knowledge of AIDS but there is bantfy
acy evidence of impect oh behavioura) change.l>,<
Targeted Interventions
Interventions consisting of three interrelated strategies—
reduction of number of partners, promotion of condom
use, and control of STDs—targeted at populations at risk
have resulted in increased condom use within these
groups, as has been seen in sex workers in Calcutta,
India,17 Mexico,and Zimbabwe7 and in long-distance
lorry (truck) drivers in Tanzania.1* However, there is
800n
Africa
---------- Asia
•
600-
Latin America
—Developed countries
■8
I 4003
Masn-awamMss campaigns
Natkmat mass-awareneta campei^is have been
implemented in many parts of sub-Saharan Africa,
Mexico,1’ and countries such as Thailand* and India* but
very few of these have been rigorously- planned or
evaluated at the national level. In many cases, to be seen
to be doing something as quickly as possible to halt the
epidemic was deemed more important than investigating
o
jC
200-
O-f-i
1980
Lancet 1996: 34«: 1071-74
OervtnusttrasM 18,10829 Bacfln, Oenmny
(Ms D d'Cruz-Orote)
Vol 348 • October 19, 1996
2000
Year
Figure: WHO eetimated and projected annual adidt AIDS
Inddencea by “macro" rw^on
1071
TH£ LANCET
ample evidence to show that thw thtw-pr
rf strategy fs
population most vulnerable so uffecooe and who do not
have the means to protect themselves-5AI>'12
Reduction in number of sexual partners
Most women in need of prevention are not sex workers
but women with one partner—their husband. For them
monogamy is an irrelevant strategy. Studies indicate that
50-80% of all infected women in Africa have only one
sexual partner," and at 1991 infection rates an estimated
1500 monogamous women were being infected each day.20
In India, 30-50% of HIV-seropositive persons are women,
most of whom have been infected via heterosexual
transmission and many of whom do not belong to highnsk groups.21
For a large subset of women who are not monogamous,
having multiple partners is a means of survival. With few
marketable skills, women may have to use sex as a means
of earning a living for themselves and their children.512-17’22
In Bombay, poor, widowed, divorced, or abandoned
women reported having sex with slum landlords in return
for access to resources or guarantees of physical security.2’
This observation clearly illustrates that when a woman is
economically powerless to negotiate her basic needs, or is
subject to domestic violence and abuse, encouraging her
to negotiate safer sex is unrealistic. Thus the strategy of
part iier reduction is relevant only if women are frrr to
control when and with whom they have ser.
The same principle applies to adolescents and young
people living in economically and socially underpriveleged
environments or in broken families. For them, selling
sexual services is a means of survival not only for
themselves but also often for the whole family.24 Without a
supporting network and access to education and to health
services, even when they know the preventive measures
they should take, they are in no position to regulate their
behaviour. Likewise, single-gender labour migrant groups
and long-distance truck drivers, temporarily displaced into
the all-male community of work camps and hotels away
from the tight control of their home communities, are
particularly vulnerable to HIV/STD infection as the result
of multiple partner sharing. Having no access to affordable
health care and sexual health promotion programmes at
their points of destination, they are not able to overcome
the obstacles to risk of infection.”
Condom use promotion
Massive efforts to increase condom use are still impaired
in some countries by high cost, poor quality, limited
availability, and lack of accessibility.
Even when
condoms are available, mens’ decision to use them may be
hampered by cultural misconceptions and social
inhibitions. Women cannot control the use of male
condoms when they cannot discuss sex freely, and they
also fear being labelled promiscuous. Socially, women are
under pressure to engage in sex without condoms because
of the importance of fertility and of having children for the
stability of marital unions and the social and economic
security that this supposedly brings.
STD control
1 control programmes were initially among the most
ne^cctcd
111 health-sector activities and the least
utilised largely because of the stigma attached to such
services.There is still a tendency to regard STD
control more as an individual’s problem than as a public
health concern. In many countries, STD control
programmes focus on commercial sex workers and male
clients and are coercive in nature.1WJO In the Philippines,
for example, a sanitation code stipulates that girls are
permitted to work as “hospitality girls” only after being
issued with special identification cards. If found positive
for STDs at their compulsory 2-weekly check-ups, they
have their identification cards removed until ±ey have
completed treatment, and those found HIV positive have
their cards removed permanently. Without the necessary
counselling and support services, most of the HIV-positive
sex workers move to other areas.50 Actions of this nature
can be counterproductive to AIDS prevention since they
force prostitution “underground” and increase the
chances of the virus spreading.
Targeting only sex workers and their clients for STD
treatment means ignoring ±e long-term reproductive
health of men and women. It is hard to ignore data
indicating that the rates of STDs are high not only in
adults but also and more so in sexually active youth. In
Thailand, two-thirds of patients diagnosed with an STD
in medical clinics are under the age of 25, and in Uganda
STDs are most common in 15-19-year-olds.”
-Reproductive tract infecoona lead to considerable
mortality and morbidity in women but have remained one
of the most neglected of all health issues. Bang and Bang52
conducted a study in two villages in Maharashtra, India,
reported in 1989, which showed that 92% of the 650
women examined had reproductive tract infections and
only 7-8% of these women had ever sought of received
treatment for these diseases. This neglect has been further
highlighted by the results of a more recent study in rural
Nigeria on reproductive tract infections and abortions
among adolescents. Almost half (43-6MD the adolescents
less than 17 years of age reported themselves to be sexually
active, 40-4% had a confirmed reproductive tract
infection, and 19'4% had an STD *
I
I
Tailoring provention to developing countries
All the evidence shows that urxegiea winch have proved
effective for certain at-risk groups, are not merring the
needs of those meet vuinerwWe to
—namrly,
women, youth, single-gender migrant groups, and other
marginalised segments of the population living under
economic and social deprivation. One of the underlying *
reasons is that much of the early work on preveaaon
attempted to standardise responses and ignored the
contextual factors and the role of gender in sexual
behaviour. M’*oa2’M Behaviour change has become,
synonymous with HIV preventiou and its theories are
being applied indiscriminately to monogamous wives, adolescents not yet sexually active, and populadoua who
have no access co services.1
How can we reduce the vulnerability of women, youth,
and other marginalised groups to infection and strengthen
their skills for protection?
«■
Provision of sexual health education
All individuals should have access to correct, objective,
and complete information not only on HIV/AIDS but also
on sexual and reproductive health. Young people are
achieving physical maturity earlier, continuing rheir
education longer, and marrying later. Consequently,
1072
Vol 348 • October 19, 1996
T
i
♦
*
*
f
I
targeting ab«tn)«« n tfrr'primary goat of HIV
prevmooa ia- enrexhstfc, as is implementing HIV/STD
prevention in schools with no mention of sex. Recent
studies show that comprehensive sexual health education,
when implemented before adolescents become sexually
active, is effective in encouraging young people to delay
sexual activity and to practise safer sex when they are
sexually active^"*Women’s groups repeatedly emphasise the need for
women to be informed about their reproductive system if
they are to protect themselves from sexually transmined
infection. They have found that participatory community
organising approaches and collective action by women, as
used in the Calabar Project in Nigeria,u have proved
effective not only in encouraging women to voice their
anxieties, problems, and needs but also for developing
strategies and messages that are appropriate and
acceptable.
Focus on women alone is not sufficient.
Comnumity-organiaing approaches also offer potential for
addressing sexual health concerns of men such as long
distance lorry drivers, members of armed forces, and men
involved in the sex industry.‘’‘uaa, Likewise, youtir
organisations and clubs, which already exist in some
communities, have proved useful in providing social
support for young girls and in providing space for both
girls and boys to discuss their anxieties, become conscious
of gender issues, and articulate their needs for
prevention.2*3’
Well-designed sexual health information programmes
are also necessary to counter underlying prejudices that
lead to stigmatisation and discrimination of people living
with AIDS/HTV’7 and for advocacy to convince decision
makers to make HIV/AIDS a priority issue.
Provision of relevant services
Unlew STD aervkw provwkm w reoriented to meet the
leeg-cerm sexual needs of men and women, prevention of
HIV/AIDS will have little chance of success. AIDS has
shown that solutions to health problems cannot be found
by setting up narrow neatly defined programmes such as
family planning, HIV prevention, and STD control.
Integrated sexual health services should be Signed to
provide informed contraceptive choices, counselling
services, good follow-up care, services for safe abortion,
and facilities for the diagnosis and treatment of STDs and
reproductive tract infections not only for adults but also
for youths.’’113*3’ To achieve these goals there must be
improve mcjits in health infrastructura and additional
supphea of drugs and condoms. Staff should be trained to
provide ongoing preventive counselling for those who are
HTV negative, and medical assistance, social support, and
advice on prevention for people living with AIDS and their
families.2*37
Studies on sociocultural and programmatic barriers to
seeking health care and decision-making are necessary to
make services more accessible and responsive to users’
needs.2’34 Above all, strong pofetical commitment is
imperative to ensure ready access to information, health
care, and condom promotion and distribution if
interventions are to be successful and sustained.‘•lttJ*3*
Creation of supportive social and economic
environments
Information about HIV, availability of condoms, and
provision of STD services cannot by themselves lead to
improvcmena in sexual health and HIV prevention if
Vol 348 • October 19, 1996
prevailing social, economic, and cultural constraints
hinder those most in need of these services from using
them. These constraints are especially important when
one considers women’s low economic and social status.22
One example of the efforts being made to improve
women’s socioeconomic sums within an existing AIDS
programme comes from Zambia. Zambian women fish
traders are frequently forced to provide sex in addition to
cash to buy fish from fishermen. As a way to protect these
women from this form of sexual exploitation, the National
AIDS Programme, in coDaboration with a women’s group
and the Zambian Cooperative Federation, have formed an
economic cooperative that conducts coUective bargaining
for fish as well as giving credit to women fish traders.M
Another important initiative has been implemented in
Nigeria. This project, which promotes health, including
HIV/STD prevention, through a functional literacy
programme and intersectoral coUaboration, has improved
the health of the women and their children and has
strengthened their capacity for income-generation through
the provision of loans.* Experience gained in empowering
women to exercise control over their lives in other areas__
eg, family planning—can have implications for HTV/AIDS
prevention. In Bangladesh, through the credit programme
of the Grameen Bank, rural women have become
economically empowered to exercise greater control over
their sexual behaviour as indicated by their increased rates
of contraceptive use.* Although these examples focus on
women, HIV prevention for both men and women will be
more effective through such economic enabling
approaches?
However, these are only short-term solutions. There
will be little progress in improving the economic status of
women and in promoting gender equity unless policy
revisions are undertaken to enable access to education for
all, and in particular access to education, skills training,
and employment opportunities for women?1*22 For both
men and women, rhe evidence emphasises the singular
importance of education as a means of gaining access to
work and, earning money, and of improving family welfare
and health status and hence of enhancing their capacity to
protect themselves from HIV/STDs.*1 Simultaneously, the
sexual vulnerability of women must be addressed. There is
growing concern about the link between aexual violence r*nd HIV transmission- Sexual abuse of girls and forced
sexual intercourse have never been addressed adequately.4^
The culture of silence surrounding incest, sexual abuse,
and sexual coercion must be broken. Communities must
question cultural and traditional practices that put girls at
risk and that sanction double standards which allow men
multiple sexual partners and prevent women from
protecting themselves.
There has to be political commitment to put AIDS and
sexuality on the agendas of development programmes by
integrating HIV prevention and promotion of sexual
health into development programmes and by allocating
resources to restructure health services. Development
policies are needed to stem the flood of labour migration
by increasing economic opportunities within the countries.
The strengths and contribution of community-based and
non-govemmental organisations in the fight against AIDS
and in the support of people living with AIDS must be
recognised. Not only should these organisations, which
address micro and macro socio-economic factors, receive
more resources, but also they should be involved in policy
development.
1073
1300
AIDS 1995, Vol 9 No 12
prehensive sexually transmitted disease (STD) treatment
can result in decreased HIV incidence even in the ab
sence of any significant behaviour change [16]. This is
further evidence of the preventive effect of a structural
intervention, albeit a physical one which relies on en
hanced service delivery. While continuing to recognize
the role of individual decision-making, all structuri in
terventions acknowledge that meaningful reduction of
HIV transmission can still occur even though the range
of an individual s action may be too limited in certain
contexts to allow for sufficient behaviour change.
Focusing on social and environmental determinants is
not so much an innovative approach as it is a confirma
tion of recommendations already espoused by the World
Health Organization and other health agencies. The
principles guiding disease prevention and health promo
tion were developed in the 1986 Ottawa Charter [17],
Five steps were identified in the charter: apart from the
necessity of developing skills, attention is also focused on
introducing appropriate health legislation, creating sup
portive environments, strengthening community-based
action and reorienting health services. These steps place
health within a broader social agenda. They also place at
tempts to motivate individual action in the wider context
of attempts to modify conditions of risk-taking [18,19]
The term ‘enabling’ is not new to public health. En
abling factors have been described previously to refer to
those factors that make a desired change in behaviour
possible [20], so that planning for a health education
programme should include motivating people to action
and also removing barriers that people might encounter.
Others have suggested that, to be successful, health ed
ucation must include an initial focus on the policy and
normative environment in which a programme will de
velop, as a supportive environment can facilitate, and a
hostile environment impede, effectiveness [21,22]. In the
context of AIDS, enabling has been used to refer to the
vulnerability of populations, for example, the obstacles
that women encounter in reducing risk of HIV and the
corresponding need to address these obstacles [23].
Although health behaviour theory does recognize the
influence of social and environmental factors on individ
ual behaviour [24,25], this recognition is rarely carried
into intervention strategies [26-28]. One source of dif
ficulty is that non-individual risk factors are essentially
of a structural nature and, therefore, not perceived to be
easily modifiable [28-30]. Another possible explanation
is that HIV transmission relates to sex and drug use,
both areas generally subject to taboo. The relationship
between such behavioun and social and environmental
factors has also never been well understood and is not
easily explored. In addition, the discourse of decision
makers in AIDS is largely a biomedical one [27,31] to
which only the more ‘scientific’ models and evaluation
designs, more easily measuring change in individuals
than in communities, appear credible. Thus, community
and societal-level changes, being difficult to quantify and
measure, are relegated to the realm of the non-scientific.
In our discussion of enabling approaches, we specifi
cally exclude attempts to alter prevailing social norms
about risk behaviours and HIV prevention. While these
approaches are in themselves very important, they are
somewhat different from the present concern. Their ef
fect on behaviour is through individuals perceptions, and
the choices individuals make about behaviour. Social
norms also have a role in shaping the national discourse
about prevention and are therefore important in creating
a supportive environment in which prevention can take
place. Nevertheless, in this review, we limit our concerns
to those structural interventions which directly remove
barriers to behaviour change or erect barriers to per
sistent risk-taking. Two categories of determinants, and
hence two types of enabling approaches, are examined in
this review: economic and policy. The assignment of a
specific factor to either of the two categories, however,
can be somewhat arbitrary given that they are interre
lated.
*
*
Economic constraints and behaviour
change
Health research has shown that populations of lower so
cioeconomic status are also those at a higher risk of mor
bidity and mortality resulting from health-related prob
lems [19]. Poverty has been associated with increased
risk for a wide variety of both infectious and chronic
diseases, and also with limited access to health care [29].
This finding equally applies to AIDS, as the disease has,
in recent years, come to affect disproportionately poorer
communities [30,32,33]. Thus, not only are poorer rural
and urban communities least able to bear the economic
consequences of AIDS once the epidemic is established,
they are initially at heightened risk of infection. Recog
nition of links like these between poverty and bad health
outcomes is one of the factors that drives development
programmes worldwide.
Even for those who are not poor, however, an eco
nomic dimension to risk behaviours may exist. In the
history of public health, numerous attempts have been
made to limit or discourage risky behaviour or, con
versely, to encourage healthier behaviours through the
use of economic incentives. Favourable insurance rates
for automobile drivers with safe driving records or for
individuals who do not smoke, drink immoderately, or
who exercise regularly are economic incentives used by
insurance companies to reinforce certain low-risk be
haviours. Elevated prices on harmfill products have also
been tried, as in the case of taxation on liquor in many
countries or, more specifically, on tobacco products in
Canada. Evidence from that country indicates that, for
some groups like adolescents, smoking may be a price
sensitive behaviour that can be decreased through in
creased taxation (Fig. 1) [34]. Similar experience has
been reported from Brazil, where the elimination of a
tax on imported condoms greatly reduced the price to
e
Enabling approaches Tawil ef al.
consumers and is believed to have contributed to a sub
stantial increase in condom sales (L. Rodrigues, personal
communication, 1995). Affordable pricing is one of the
elements of social marketing programmes for condoms
and other commodities as well.
50
45
40
35
I
J 30
I
i
* 20
15
teen smoking
10
0.5
5
0
1979
1982
198S
1988
1991
Fig. 1. Effect of cigarette prices on smoking among Canadian
teenagers, 1979-1991 (34).
In recent years, AIDS research has increasingly focused
attention on the vulnerability of women in sexual rela
tionships [30,35,36], particularly when considering the
constraints on women to propose or negotiate risk re
duction practices with their partners [37,38]. One ex
planation advanced is prevailing social norms on gender
roles, which encourage men but not women to make
decisions about sexual matters [38]. Yet this vulnerability
may also be a result of economic factors, such as women s
limited access to resources and their subsequent financial
dependence on their partners.
Economic factors, such as the need for some to leave
their families, seek shelter in new settings, and live apart
from regular partners for extended periods, heighten the
probability of casual sex and the risk of HIV transmission
among men and women alike. Seasonal migrant workers,
truck drivers and soldiers are some of the predominantly
male occupational categories associated with increased
risk of HIV [39,40].
Patterns of drug use may also be associated with eco
nomic factors. Although drug use is commonly viewed
as a consequence of psychopathology and influenced by
peer norms, the conditions that affect initiation, mode of
administration and access to treatment facilities may be
shaped by economic considerations [18,33]. For exam
ple, injecting drug use can become more common than
other modes of administration when it is perceived to be
a less expensive way to get ‘high’ [41].
In no case is the evidence for the economic determinants
of risk behaviour clearer than it is for sex work. Evi
dence from all regions of the world suggest that the over
whelming motive behind the exchange of sexual services
for the provider is economic opportunity [33,42,43].
Whereas this is often a desperate survival strategy for
some, it can sometimes be a lucrative alternative to exist-
ing employment opportunities for others [44], In Thai
land, for example, some female sex workers are able to
generate incomes 25 times greater than textile workers
[43]. In one case in Northern Thailand, the existence of
training programmes and subsequent employment in the
textile industry, at substantially lower wage, are not suf
ficient by themselves to stem the flow of young women
into sex work; programme staff must also persuade family
members that sex work is less acceptable employment for
young girls in the age of AIDS than it once was [45].
The absence of employment opportunities to generate
incomes of comparable magnitude or of educational op
portunities that might lead to such employment, is why
some may chose to remain in sex work [33,43].
Those involved in exchanging sex for money often have
limited power to negotiate safer sex practices with clients
[46]. Some of the more immediate factors explaining
this include: (1) price of sexual encounter (those who
earn less usually need more clients, limiting their ability
to refuse services and exposing them to greater risk);
(2) price of condoms (the price of condoms relative to
earnings can influence the frequency of use); (3) earn
ings provided to third parties (many of those involved
in sex work have to pay brokers, brothel or bar owners,
and, in some cases, their regular panners a proportion of
their earnings); (4) access to other sources of income (the
absence of an alternative source of income could deter
mine the number of clients which, in turn, influences
the negotiating capacity) [42].
What are the possibilities of modifying economic de
terminants to reduce the risk of HIV? For sex work, a
range of approaches has been proposed in the literature
[28], of which relatively few have been attempted and
even fewer have been evaluated. Most aim to reduce
risk-taking by alleviating economic pressures on those
entering or already involved in sex work [45]. A dis
tinction can be made between approaches designed to
intervene within the sex work context and those that
intervene to prevent or reduce dependency on sex work
(Table 1). All the options in the first column necessitate
collective action to alter work conditions. This is pos
sible when gatekeepers’ at sites, such as bar owners and
leading figures among sex workers, support such efforts.
Examples of such collective action exist from Nigeria
[47], Mexico [48] and Zimbabwe [49], all of which have
demonstrated increased condom use. The options pre
sented in the second column apply to all groups who are
economically vulnerable to HIV infection. Approaches
to increase the economic role and power of women as a
means of increasing their ability to exercise control over
their lives, including over their reproductive and sexual
behaviour, have been tried in a number of places. Ex
amples of such approaches exist from India [50], Zambia
[51] and Bangladesh [52]. In Zambia, women fish traders
are frequently forced to provide sex in addition to cash to
obtain fish from fishermen. These women are now being
encouraged to participate in economic cooperatives that
conduct collective bargaining for fish, as a way to protect
1301
1302
AIDS 1995, Vol 9 No 12
themselves from sexual exploitation [51]. In Bangladesh,
rural women participating in a revolving loan scheme
have been found to be economically empowered and to
exercise greater control over their sexual behaviour as
shown by their elevated rate of contraception use (Table
2) [52]. Although requiring a community interest and
collective bargaining effort, such measures may initially
involve considerable input from external sources.
Table 1. Examples of economic approaches to HIV prevention in
sex-work settings.
Interventions
Within sex-work settings
Enforce condom use in all client contacts
Integrate the cost of condoms into the price of sexual encounter
(or in the rent paid by clients for rooms)
Raise prices for sexual encounter
In communities where sex work exists
Improve young women's level of literacy and education
Identify alternative income sources or provide
vocational training
Develop money management and savings skills
Establish economic cooperatives
Facilitate access to accommodation
Table 2. The effect of women's empowerment on contraception use,
Grameen Bank, Bangladesh, 1992 [52).
Economic and
social influences
on contraceptive use
Empowered*
Not empowered
Coptributes substantially to family support
Contributes little or nothing
Living in Grameen Bank villages
Living in comparison villages
% of married women
aged < 50 years
using contraceptives
65
45
60
44
54
43
•Defined according to the following measures: mobility and visi
bility, economic security, status and decision-making power in the
household, ability to interact in public spheres, and participation in
non-family groups.
However, even in those societies where they clearly have
a central economic role, women may continue to have
limited negotiation power in sexual decision-making.
Culturally propagated conceptions of gender roles defin
ing men as the decision-makers often override other
considerations and will continue to offer a barrier to
significant HIV risk reduction for women [30,53]. Eco
nomic approaches such as those outlined above should be
considered in conjunction with approaches that attempt
to alter prevailing social norms. Whereas the examples
here have primarily focused on women, HIV preven
tion for both sexes could benefit from such economic
enabling approaches.
National policy, local practices and HIV
prevention
As stated previously, standard health promotion practice
has long recognized the importance for a supportive pol
icy environment in which a prevention agenda can be
pursued. National policies that recognize and condone
the desirable outcome of disease prevention and health
promotion are indeed an imporunt first step. Through
out the history of public health, however, policy has
also been directly employed to promote health. Policies
mandating preventive actions such as childhood immu
nizations, seat belt use, motorcycle helmet laws, and flu
oridation of water are examples of one type of approach.
Proscriptive policies prohibiting specific health-threaten
ing actions such as the sale of alcohol or tobacco to mi
nors, the use of tobacco products in public settings or the
sale of controlled substances for non-medical purposes,
are examples of another use of structural interventions in
the pursuit of public health. Similar applications for HIV
prevention are much rarer but do exist. In this section,
we examine the need for, and the use of, policy for HIV
prevention, both as regulation at the national level and
as consensus at the local level.
Restrictive legislation may act as a barrier to the adop
tion of preventive measures. Because of this, policy re
forms have been advocated, particularly in countries
where the urgency to prevent HIV has been recognized.
The threat posed by the AIDS epidemic, for example,
has led to calls for the decriminalization of prostitution
[54] and less repressive laws concerning drug use [55,56].
In many countries, debate continues about legislation to
allow distribution of condoms in schools or condoms
and needles in prisons. Arguments have been made that
such policy changes will facilitate HIV prevention efforts
and provide greater access to health and other services.
The difficulties of changing established policy are im
mense and it is evident that such changes are unlikely
to occur in many countries. Furthermore, it may be
too simplistic to believe that tolerant legislation always
creates the best environment for HIV prevention and
intolerant ones the worst [57]. Effective HIV preven
tion for sex work have been achieved in some countries
despite the illegality of prostitution [44], Even among
advocates for groups vulnerable to HIV, consensus does
not exist on the appropriate policy reforms; for exam
ple, will decriminalization of prostitution ease or en
hance exploitation of those involved [54]? Furthermore,
some apparently tolerant societies find difficulty in tak
ing actions that may impinge on individual rights and
choices. This is especially true when the HIV preven
tion agenda has become intertwined with broader social
agenda and issues of individuals’ rights. For a long time,
cities like San Francisco and Amsterdam debated closing
gay bath houses, as does Toronto now. On one hand, it
was argued that such an action would reduce possibilities
*
Enabling approaches Tawil et al.
♦
w
of unprotected multiple partner sex. Opponents argued,
however, that bath houses offered a good opportunity
for HIV prevention and that closing them would simply
drive the behaviour underground, away from the reach
of public health [58]. Similar actions have been more
easily taken in other public-health domains, where the
perceived benefit for the common good has been be
lieved to supersede the potential limiutions to the rights
of individuals. Although none dealt with such a personal
issue as sexual behaviour, the addition of fluoride to wa
ter, the requirement that passengers in cars wear seat belts
and the proscription on smoking in public places are
all public-health regulations that engendered controversy
when they were first introduced but are now accepted.
Policies and their enforcement can vary between com
munities [18]. Unlike the experience of countries such
as The Netherlands where policy on HIV prevention
has been fairly liberal, decision makers in most countries
remain cautious. Often, national policy has been tailored
to the local needs [59]. Harm reduction, for example, has
a goal of reducing the negative consequences of drug
use, including HIV infection. The provision of clean
injecting equipment to drug users, as well as informa
tion on how to continue to inject more safely, is one
of these controversial approaches that are often pursued
at the local level despite prohibitive national policy [60].
Unable to reach national consensus, the introduction of
needle-exchange programmes was left to local decision
makers.
Accepting the priority of HIV prevention over that of
drug-use control is essential in adopting an integrated
approach to HIV risk reduction. Evidence has shown
that early action to make sterile injection equipment
available is one of the key factors in maintaining stable
low seroprevalence of HIV among injecting drug users
[61]. Examples from several countries demonstrate the
possibility of adopting such an integrated policy, where
public health and law enforcement work together flexi
bly to meet both the needs of drug control and HIV
prevention [62]. An experiment in tolerant policy on
drug use in Zurich is a case in point. Designed at least
in part with HIV prevention in mind, the policy created
a zone of tolerance for drug use in the centre of the
city, bringing the risk behaviour into the open where
needle distribution and HIV prevention could be pro
moted. The policy may have in fact been successful in
preventing HIV transmission but it had the unforeseen
consequence of attracting large numbers of drug users
from other cities and countries [63]. For that reason, the
policy has now been discontinued and has been replaced
in part by an expansion of an existing medically-super
vised prescription heroin experiment [64].
In the area of prostitution, an example of the adoption
of national regulation exists. Brothel owners in Thailand
have been encouraged to implement the ‘condom-only
brothel’ policy [65]. This policy regulates the behaviour
of all clients visiting commercial sex establishments by
mandating condom use. This has been one of the fac-
tors believed to be responsible for substantial increases in
condom use in commercial sex and substantial decreases
in STD seen in recent years (Fig. 2) [66].
«JOOOO
I 00
400000
0 90
JSOOOO
0 10
300000
0 7Q
0 (0
250000
0 SO
200000
0 40
i 50000
0 30
100000
0 20
50000
0 10
0
0 00
1
1
1
!
I
i
i
i
i
Fig. 2. Reported sexually transmitted disease (STD) cases (to
tal and male) and estimated condom use in commercial sex
Thailand 1985-1993 [66].
Aside from national policy, attempts have also been made
in specific communities to modify contexts which en
courage risky sexual practices. In many African coun
tries, initiation rites and funeral ceremonies may include
multiple partner sex [67—69]. Most efforts to address this
have targeted local officials and opinion leaders. Both
in Zambia and Uganda, HIV prevention depended on
religious leaders and village elders taking action to mod
ify sexual practices associated with funeral ceremonies.
Culturally acceptable alternatives to these risky practices
were found and promoted [70]. Another approach is the
development of alternative social venues for homosexual
men, as was tried in American city, offering activities
through which it was possible for men to meet without
the sexual overtones of the gay bar [71], Objections by
a local politician to the use of government funds for
this project led to its early discontinuation. In another
example from Hong Kong, a ‘safe sex’ brothel was estab
lished to serve the needs of the local expatriate business
community. This brothel, managed by social workers,
reputedly provided its services without risk of STD or
HIV before questions raised in the local press led to its
closure [72]. In Viet Nam, many drug users get their
heroin injected by ‘community injectors’ [41]. As nu
merous persons are injected with the same equipment,
the potential for rapid transmission is clear. However,
these same community injectors can also promote safer
injecting practices.
Modifications of local practices, such as those listed
above, can be promising avenues for HIV prevention.
Together with national policy change, these structural
interventions are a powerful addition to, not a replace
ment for, the more standard HIV/AIDS prevention ap
proaches recommended. As we have seen in some of
the examples, however, careful preparation and consen
sus building are necessary to assure the implementation
and continuation of these approaches.
1303
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AIDS 1995, Vol 9 No 12
Conclusion
To date, AIDS prevention efforts around the world can
be characterized as being too little, too late and too nar
row. While countries are being exhorted and assisted to
move quickly and with intensity on HIV prevention, the
range of actions proposed is still narrow. As yet, AIDS
prevenrion efforts have had limited experience with ef
forts that aim to modify the context of risk-taking or
to go beyond debates on how to reinforce prevention
efforts. It is, therefore, urgent to broaden the range of
prevention options through innovative approaches ad
dressing the context of risk.
How can this be interpreted into practical recommen
dations? On the broader level, international agencies are
pursuing a policy of integrating HIV prevention into
development programmes and allocating resources to re
structure health services [73]. This is part of a long-term
strategy which aims to reduce the potential for HIV
transmission as well as to decrease the general health,
social and economic burden of the epidemic. On the
community level, there are some examples of initiatives
undertaken by non-governmental or governmental or
ganizations to support education, occupational training
or other activities for those who are potentially vulner
able to HIV. Questions persist on the impact of these
efforts on the AIDS epidemic, however. The discrep
ancy between the rapid pace of the AIDS epidemic and
the much slower pace of the fundamental social change
and development proposed casts doubt on whether these
approaches can be effective quickly enough.
It is evident that no single approach for behaviour
change, no matter how carefully or elaborately designed,
will fit all individuals or population groups. However,
a selection of intervention approaches tailored to spe
cific determinants of risk can be developed [28]. The
introduction of enabling approaches in HIV prevention
is necessary. In all cases, this will involve lobbying for po
litical support and policy changes. Long-term approaches
will be essential to curb the further development of the
epidemic [30], but, more immediately, possibilities do
exist to promote a more pragmatic approach to address
ing the determinants of HIV risk.
Yet challenges exist in pursuing a prevention strategy
that includes enabling approaches. First is the challenge
of undersunding situations where risk occurs. It is es
sential to focus on the structures that may impede or
facilitate risk avoidance, not just the individual deter
minants of risk behavioun. Second is the challenge of
thinking more broadly and creatively about the inter
vention options that this understanding suggests might
be needed. Third is the need to consult more widely
than among the traditional providers of HIV preven
tion. Useful alliances with those outside public health,
in particular in the domain of development, can pro
vide new input into intervention strategies. Fourth is
the need to consider how enabling approaches can work
with, not replace, behavioural interventions that focus
on the individual. The final challenge relates to evalu
ation, including the need to demonstrate the feasibility
of enabling approaches through flexible evaluation de
signs. Some AIDS researchers argue that existing be
havioural interventions have not been adequately eval
uated [74,75]. Evaluation is likely to be even more diffi
cult with enabling approaches, as standard evaluation de
signs might not be particularly useful. A comprehensive
description of the situation and understanding of how
the intervention works [76], paired with secondary in
dicators of behaviour change, are essential starting points
in the evaluation of enabling approaches.
In practice, numerous intervention programmes have de
veloped strategies involving improved access to condoms
or the provision of adequate health services, particularly
STD care, which are in themselves enabling of preven
tion and behaviour change. However, only a few have
developed an enabling approach as the principle preven
tion strategy, despite the considerable evidence on the
obstructive or facilitative role of social and environmental
determinants. The development of such interventions is
likely to require going beyond the realm of health edu
cation and intervention development as it has been cus
tomarily defined for HIV prevention. As we have shown,
such attempts are common in other areas of public health
and in keeping with the comprehensive definition of
health promotion. The time to think creatively and more
broadly about HIV prevention, to focus attention on the
context of risk, and to draw on examples from other
areas of public health is upon us.
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<9>
♦
Viewpoint
Fighting AIDS or responding to the epidemic: can public health
find its way?
Thjs materiai may be protected by
Copyright Law (Title 17, U.S. Code)
Josef Decosas
*
“AIDS is first of all a (...] issue”. The sentence is found in
scores of documents drafted by national and international
organisations. The word in parentheses tells us much about
the author and contributes little to the understanding of the
syndrome or its spread. For the health educator searching
for messages to alter attitudes and behaviour, infection with
human immunodeficiency virus (HIV) is above all an
individual and behavioural issue; for the social and
economic planner it is a social issue; for the gay or feminist
activist it is a human rights issue; for the public health
specialist it is a health issue; and for the international
bureaucrat it is a multisectoral issue. This last definition has
the advantage of being almost unassailable because nobody
really knows what it means outside the boardroom, where
terms like this have their own reality.
A complex issue, by definition, has many different facets.
There is no reason why HIV should differ from any other
aspect of the human condition. Cardiovascular disease is a
social issue; war and unemployment are health problems;
and hydroelectric power generation raises questions about
human rights. We seem to be perfectly content to live with
this complexity, so why is there a compulsion to define
exactly what kind of issue AIDS is?
The answer to this question lies in the peculiar nature by
which HIV entered our collective conscience. When the
world first heard about HIV, when “global mobilisation”
began, AIDS was an abstract concept to all but a few groups
who had already experienced death and sickness in their
midst. Even now, over a decade into the epidemic, this is the
prevailing situation in a large part of the world. The idea
that HIV was a microbial invader that had to be fought with
a single-minded and not too complex machinery was a
choice few of us questioned because abstract problems lend
themselves to simplistic solutions. Why introduce
complexity where no complexity is experienced? Thus the
“global fight against AIDS” was born, modelled on the
tried although not always successful recipe of disease
eradication, and borrowing the jargon of war to inject it
with passion.
The same documents that declare AIDS to be one issue
or another bemoan the problem of the war on HIV in their
first paragraphs: “In the absence of an effective vaccine or
cure . . .”. In other words, a traditional war was being
planned, but there were no traditional weapons. The search
for the magic intervention began. Was it to be health
education, abbreviated as I EC (for information, education,
communication) to give it a high-technology flair? Low
interest credit for women? Condom social marketing?
Community development? Peer education among
prostitutes? Sexually transmitted disease (STD) control?
GTZ Regional AIDS Programme for West and Central Africa, PO Box
9698, Kotoka International Airport, Accra, Ghana
(Josef Decosas mo)
Vol 343 • May 7,1994
Female education? Whatever the intervention, it had to
show results and it had to be cost-effective. The
representatives of the financing agencies demanded as
much.
A successful war demands an army of loyal soldiers, and
the public health professionals and their institutions
quickly fell into line. They become instant health education
experts, condom marketers, community developers, and, of
course, cost-effectiveness analysts. Some even became
quite good at it. But where was the discipline of public
health? It seems that it moved to Cuba, where, as
Scheper-Hughes tells us, the war on AIDS is being won
with the traditional public health methods.1 But then, the
Cuban success is not quite credible, and the response is
neither feasible nor acceptable anywhefe else.
Every war has its victims. The victim of the war on AIDS
is the discipline of public health. While our institutions are
desperately searching for the recipe to “stop AIDS” as
quickly and cheaply as possible, our attention is being
averted from what we know best. Is it really so important
that all doctors demonstrate the use of a condom to their
patients? Do we really need to spend so much time and
effort to find the conclusive proof that treatment of sexually
transmitted infections slows the spread of AIDS? Do we
need a high-powered public health professional to
coordinate the activities of prostitute collectives and boy
scout troops? Surely we have enough on our hands.
The countries in which I work are facing a potentially
devastating epidemic of tuberculosis. We have decades of
experience on how to respond to such a threat. Why is this
not the central preoccupation of the public health
specialists working in AIDS? HIV has finally brought the
long-hidden epidemic of sexually transmitted infections
out of the closet. We know about the tremendous toll of
suffering and disability associated with STDs, so why are
we spending so much time trying to convince ourselves and
others that STDs facilitate HIV transmission? Surely the
fact that there is a serious neglected public health problem
should be sufficient for us to move into action. We have
known for decades that the health care services in Africa are
woefully inadequate and we can now observe them being
stretched to another limit because of AIDS. This is
sufficient cause to rethink the methods of delivering
medical care on this continent. Why are we even discussing
the cost-effectiveness of screening blood for transfusion? Is
it important that contaminated blood contributes little to
the spread of HI V? Is that an acceptable reason to transmit a
preventable infection?
The HIV pandenic has given new steam to the
tuberculosis and STD treatment programmes and has led
to new initiatives in providing care for the sick. It has
generated improvements in the safety of transfused blood.
But these are orphan activities. They have to be justified in
terms of their effectiveness to stop AIDS and they are
constantly threatened with cuts if they are not found to be
1145
1
H
i ’
I
I
I ■
THE LANCET
cost-effective. All too frequently they are tossed into the
salad of a project which includes anything from puppet
theatre to demographic modelling.
Of course, we need public education campaigns. We need
economic and demographic impact analyses. We need
human rights conferences. We need puppet theatre, and we
need condom marketing. These activities are all
appropriate public responses to the HIV epidemic. They
are as appropriate and as necessary as tuberculosis and STD
treatment services. But how can one possibly measure the
effects of these diverse activities on a single cost
effectiveness scale? This can only be done if “stopping
AIDS” is the focus. One becomes a consumate watcher of
minute trends, a neurotic seeker of minimal effects.
Programmes are being evaluated to death and turned upside
down regularly to concur with current fashions of what is
more effective at preventing HIV infection. Technical
agencies become political lobbies for the activities they have
staked for themselves.
The concept of a war on AIDS with its goal to stop HIV is
seriously flawed and should be discarded. Most regions in
the world have a well-established epidemic of HIV. This
epidemic requires a social response ranging from a review of
legislation to a rethinking of the national industrial
devlopment plans. It also urgently requires new
programmes, new approaches, and some radical reforms in
health care and in public health. These needs are unrelated
to the goal of stopping the epidemic. They are the needs of
adapting our public and private lives to the fact that we live
in the times of HI V. The role of public health in responding
to this fact should be to take HIV into consideration in the
practice of public health. For me and for most readers of
The Lancet, AIDS is and will always remain a health issue.
But that is due to our choice of profession. Our biggest
potential contribution to the global response to AIDS is to
practise this profession well.
References
1 Scheper-Hughes N. AIDS, public health, and human rights in Cuba.
Lancet 1993; 342: 965-67.
r
BOOKSHELF
Genetic factors in drug therapy
David A Price Evans. Cambridge: Cambridge University Press. 1993. Pp 657.
£120/$175. ISBN 0-52141296X.
Most physicians can recall patients
who claim a poor relationship with
drugs. “I’m peculiar when it comes to
drugs, they all give me side-effects” is
the response to the suggestion that we
try an alternative agent. In most cases
the reason has more to do with anxiety
or suspicion about drug treatment
than the pharmacology of the drugs
concerned. For some patients, how
ever, there may be a biochemical or
immunological explanation, related to
a difference in drug metabolism or
tissue response. Pharmacogenetics is
the study of genetic factors that contri
bute to inter-individual variability in
drug response and our current under
standing of the subject is summarised
in Price Evans’ book.
The book begins with chapters on
genetic factors influencing drug “bio
transformation”. Several metabolic
processes concerned with drug
metabolism have now been shown to
exhibit genetic polymorphism, di
viding the population into extensive/
rapid or poor/slow metabolisers of
certain chemicals. The consequences
of being a poor metaboiiser depend
upon the drug, particularly the steep
ness of the dose-response curve and
the proximity of plasma concentra
tions required for therapeutic effect to
those that produce toxicity. For some
drugs the consequences are dramatic.
Examples are prolonged apnoea in
1146
patients lacking cholinesterase and
marked .reduction in blood pressure
and collapse in a poor metaboiiser of
the hypotensive agent debrisoquine.
For other drugs exposure to high
plasma concentrations is well toler
ated. Conversely, if the effect of the
drug depends upon conversion to an
active metabolite, a poor metaboiiser
may be undertreated by a standard
dose. Debate over the value of routine
screening for poor metabolisers of
relevant drugs receives full considera
tion here. The conclusion is that there
are few if any indications. Such a
practice does not substitute for
tailoring the dose to the individual
according to clinical response and in
some cases by measuring plasma con
centrations.
The chapters on variation in
response to drugs include discussions
of glucose-6-phosphate dehydro
genase deficiency, hepatic porphyrias,
malignant hyperthermia, and chlorpropamide-alcohol flushing. The
author comments that progress in our
understanding of the genetic basis of
drug metabolism has been more rapid
than in the genetic basis of variation in
drug response. He predicts that this
may be redressed as more receptors are
cloned and the functional implications
of structural polymorphisms defined.
An example of this is the recent linking
of malignant hyperthermia with
mutations in the ryanodine receptor
gene.
An interesting aspect of the study of
genetic factors influencing drug
metabolism and response is the poten
tial insight this may provide into the
aetiology of disease. For example, the
metabolic pathways that deal with the
clearance of drugs are also involved in
the metabolism of environmental tox
ins. Not surprisingly, the disease pro
cess most commonly studied to date is
cancer. Associations between cancer
(bronchial, bladder, gastrointestinal,
breast, lymphoma) and “seven pharmacogenetic polymorphic enzyme
systems’’ have been sought but the
results are conflicting. The author
argues that in some cases the disease
process may have influenced the phe
notyping test employed and suggests
that genotyping of individuals in
cluded in such studies may help
resolve the situation. The promise of
this approach remains to be realised.
Genetic factors in drug therapy con
tains historical detail as well as recent
developments and provides addresses
of centres of expertise, presumably for
further information or consultation in
managing particular patients. There
are some annoying errors, such as the
partial transposition of table 16.3 with
25.2, but these should not dissuade
those new to the subject as well as more
experienced pharmacogeneticists from
dipping in.
4
M R Wilkins
Department of Clinical Pharmacology. Royal
Postgraduate Medical School. Hammersmith Hospital.
London W12 ONN. UK
Vol 343 * May 7, 1994
4
An Ecological Perspective on Health
Promotion Programs
Kenneth R. McLeroy, PhD
Daniel Bibeau, PhD
Allan Steckler, DrPH
Karen Glanz, PhD, MPH
During the past 20 years there has been a dramatic increase in societal interest in
preventing disability and death in the United States by changing individual behaviors
linked to the risk of contracting chronic diseases. This renewed interest in health pro
motion and disease prevention has not been without its critics. Some critics have
accused proponents of life-style interventions of promoting a victim-blaming ideology
by neglecting the importance of social influences on health and disease.
This article proposes an ecological model for health promotion which focuses atten
tion on both individual and social environmental factors as targets for health promo
tion interventions. It addresses the importance of interventions directed at changing
interpersonal, organizational, community, and public policy, factors which support
and maintain unhealthy behaviors. The model assumes that appropriate changes in the
social environment will produce changes in individuals, and that the support of individ
uals in the population is essential for implementing environmental changes.
INTRODUCTION
*
During the past 20 years, there has been a dramatic increase in public, private, and
professional interest in preventing disability and death in the United States through
changes in individual behaviors, such as smoking cessation, weight reduction, increased
exercise, dietary change, injury prevention, protected sexual activity, and participation
in screening and control programs. While much of this interest in health promotion
and disease prevention has been stimulated by the epidemiologic transition from infec-
Kenneth R. McLeroy and Daniel Bibeau are with the Department of Public Health
Education, University of North Carolina, Greensboro.
Allan Steckler is with the Department of Health Behavior and Health Education,
University of North Carolina, Chapel Hill.
Karen Glanz is with the Department of Health Education, Temple University, Phila
delphia.
Address reprint requests to Kenneth R. McLeroy, PhD, Department of Public
Health Education, Room 49, McNutt Building, University of North Carolina at Greens
boro, Greensboro, NC 27412.
>
a
Health Education Quarterly
© 1988 by SOPHE. Published by John Wiley & Sons, Inc.
Vol. 15(4): 351-377 (Winter 1988)
CCC 0195-8402/88/040351-27 S04.00
352
Health Education Quarterly (Winter 1988)
tious to chronic diseases as leading causes of death, the aging of the population, rapid
ly escalating health care costs, and epidemiologic findings linking individual behaviors
to increased risk of morbidity and mortality.1 more recent development, such as the
AIDS epidemic, have also contributed.
Within the private sector, this interest in health promotion has led to the extensive
development and implementation of health promotion programs in the worksite,2 in
creases in the marketing of “healthy” foods,3 and increased societal interest in fit
ness.4 In the public sector this interest has led to national campaigns to control hyper
tension5 and cholesterol,6 the establishment of the Office of Disease Prevention and
Health Promotion within the Public Health Service and the Center for Health Promo
tion and Education within the Centers for Disease Control, the development and
implementation of community-wide health promotion programs by both governmental
agencies and private foundations,7 and the establishment and monitoring of the 1990
Objectives for the Nation in health promotion.8 Within the professions, interest in
health promotion led to the publication of the Lalonde Report in Canada.9 John
Knowles’ work on “The Responsibility of the Individual”10 and the Surgeon General’s
Report11 on Health Promotion/Disease Prevention in the United States, and “Health
Promotion: A Discussion Document on the Concept and Principles” in Europe.12
More recently, journals have appeared which are devoted exclusively to articles on
health promotion programs and activities (Note 1); existing journals both within and
outside of traditional public health disciplines have devoted theme issues to health
promotion topics (Notes 2 and 3); international conferences on health promotion have
been held (Note 4); and health education training programs have begun to focus more
extensively on health promotion topics and issues.
However. The increased interest in health promotion has not been without its
critics. Proponents of individually-oriented behavior change strategies have been ac
cused of supporting a victim-blaming ideology which
serves as a legitimization for the retrenchment from rights and entitlements; in relation
to the social causation of disease it functions as a colossal masquerade. The complexi
ties of social causation are only beginning to be explored. The ideology of individual
responsibility, however, inhibits that understanding and substitutes instead an unreal
istic behavioral model. It both ignores what is known about human behavior and min
imizes the importance of evidence about the environmental assault on health. It
instructs people to be individually responsible at a time when they are becoming less
capable as individuals of controlling their total health environment. Although environ
mental factors are often recognized as “also relevant,” the implication is that little can
be done about an ineluctable, technological, and industrial society .... What must be
questioned is both the effectiveness and the political uses of a focus on life-styles and
on changing individual behavior without changing social structure and processes (page
256).13
In discussing the life-style theory of disease. Tesh notes that “the life-style hypothesis
approaches disease as though ill health is the result of personal failure. It dismisses
with a wave of a hand most environmental toxins and it ignores the crucial connection
between individual behavior and social norms and rewards. It is. in fact, a victim-blam
ing approach to disease” (page 379).14 While both of these authors recognize that a
life-style approach to disease prevention may yield marginal improvements in health,
they suggest that prevention strategies that focus on individual behavior changes
McLeroy, Bibeau et al.: Ecological Perspective on Health
353
should remain secondary to environmental approaches, including changes in the physi
cal and social environment (Note 5).
In responding to some of the health promotion critics. Green15-16 notes that few
health promotion programs take an exclusively health behavior focus, and that pro
grams which focus on system change must ultimately be concerned with both the be
havior and health of individuals. Moreover, system-change approaches ultimately rely
on the consent of the governed in a democratic and pluralistic society, and must detd
with the issue of conflicting values. This suggests that the major chaUenge of systemchange approaches is implementing the changes.17
Green’s position is partially supported by data from the National Survey of Work
site Health Promotion Activities in which it was reported that of the 27% of worksites
offering stress management activities. “82.2% said they provided information to em
ployees. while the same percent mentioned introducing organizational changes to in
tervene with stress-producing activities (page 20).”18 Also, as Diana Chapman Walsh
has noted, employee and union support are critical to introducing systems approaches
to smoking control in the worksite.19
However Green’s response fads to recognize that the language we use. and the
models we adopt for health promotion programming, may still inadvertently serve to
ditect °ur attention toward certain types of interventions and away from others20
Specifically, the use of terms such as “life-style.” and “health behavior” may focus
attention on changing individuals, rather than changing the social and physical envi
ronment which serves to maintain and reinforce unhealthy behaviors. Green articulatea this focus in an earlier article.21
=se~:=s£s=s~
planntng the interventions have been made largely by psychologists. The result is that
the behavioral change interventions have tended to emphasize the individual, and have
been most useful in patient education. This concentration of behavioral science applitu onS|‘S SOrnetIineS at,the expense of action °n needed change in organizational, insti
tutional. environmental, and economic conditions shaping behavior (page 217).
Thus there is still the risk of a paradigm emerging for health promotion activities
wh'ch neglects the social causation of disease by its emphasis on individuals and individual choices.
The role of life-style and individual choices in determining health status may also
be misunderstood or misapplied by the general public. In a recent talk, the Surgeon
eneral. C. Everett Koop, noted the public retribution against cigarette smokers.
FU , ,.nVerS’ teena8ers wh° become pregnant, drug addicts, and wife beaters, and the
possibility that such retribution would spread to AIDS victims.23 The Circle K Corpo
ration, as announced in a recent letter to employees, has dropped health insurance
coverage for conditions it defines as “personal lifestyle decisions,” including AIDS,
alcoholism, and drug use.24 Thus, even if professionals working in the health promo
tion arena are successful in incorporating environmental influences into their interven
tions, the language used to describe health promotion activities may. inadvertently be
misused to support a victim-blaming ideology.
The extent to which health promotion focuses on individuals and individual choices
and ignores the social and organizational context of health-related behaviors may also
a
354
Health Education Quarterly (Winter 1988)
affect the extent to which we are able to reach specific groups in society. For example
Minkler has discussed the problems of developing health promotion programs to
[ea2C6h chS elderly In long-term care settings, and in reaching the poor, inner city elder
ly. Similar problems are inherent in reaching groups in society who are at greatest
risk for behaviorally related health care problems, such as the poor, intravenous drug
users, delinquent adolescents, and the socially isolated.
ECOLOGICAL MODELS
One conceptual framework which serves to direct attention to both behavior and
its individual and environmental determinants is an ecological perspective, such as that
proposed by Urie Brofenbrenner.27*28 In Brofenbrenner’s model, behavior is viewed as
being affected by, and effecting, multiple levels of influence. Specifically. Brofenbrenner divides environmental influences on behavior into the micro-, meso-, exo-, and
macrosystem levels of influence. The microsystem refers to face-to-face influences in
specific settings, such as interactions within one’s immediate family, informal social
networks, or work groups. The mesosystem refers to the interrelations among the vari
ous settings in which the individual is involved. These may include family, school, peer
groups, and church. The mesosystem is the system of microsystems. The exosystem
refers to forces within the larger social system in which the individual is embedded.
Examples might include unemployment rates which effect economic stability. The
macrosystem refers to cultural beliefs and values that influence both the microsystem
and the macrosystem. Examples would include cultural beliefs about smoking, such as
that promoted by the Marlboro man, or the importance of selected foods in establish
ing cultural identity, such as black-eyed peas and collard greens on New Year’s day.
Not only do each of these subsystems affect behavior, but the subsystems themselves
may change as their members are replaced or altered. Thus, an ecological perspective
implies reciprocal causation between the individual and the environment, sometimes
referred to as a transactional model (Note 6).29,30
By combining a theory of individual development with Brofenbrenner’s ecological
model. Belsky31 has developed a framework to account for individual, family, social,
and cultural influences in child abuse. Brofenbrenner’s ecological model has also been
used as a framework for viewing Type A behavior.32 and identifying potential system
level interventions. While not explicitly linked to Brofenbrenner’s model. Winett33 has
used an ecological model for assessing health life-styles. Also. Jackson34 has developed
a behavioral-environmental model of health problems that has been applied to health
promotion issues. Seidman has applied an ecological model using levels of analysis to
the problems confronting community psychology,35 and Kersell and Milsum36 have
used an ecological approach to integrate individual and environmental factors in study
ing behavior.
A public health model which can be viewed as an ecological or systems model is the
host-agent-environment model.37?38 Whereas most appropriately used with infectious
diseases-because of the usual presence of a single agent-the host-agent-environment
model indicates that population changes in infectious disease rates may be caused by
changes in the host, the agent, or the environment. For example, populations may
develop resistance to specific infectious diseases, thus lowering the infection rate. The
4
McLeroy, Bibeau et al.: Ecological Perspective on Health
*
355
agent may become more or less virulent;; or the environment may affect the distribution or importance of specific vectors.
The importance of ecological models in the social sciences is that they view behav
ior as eing affected by, and affecting the social environment. Many of the models
like Brofenbrenner’s-also divide the social environment into analytic levels that can
be used to focus attention on different levels and types of social influences and to
dev elop appropriate interventions. Thus, ecological models are systems models, but
they differ from traditional systems models by viewing patterned behavior-of individ
uals or aggregates-as the outcomes of interest (Note 7).
One of the problems with many ecological models of social behavior is that they
ack sufficient specificity to guide conceptualization of a specific problem or to iden
tify appropriate interventions. For example, the host-agent-environment model, by
collapsing the physical and social environment into a single source of influences is
difficult to apply in identifying appropriate interventions of many current health
problems, particularly those related to health promotion. Moreover, the host-agentenvironment model was originally used with a focus on morbidity or mortality as out
comes. and behavior as a contributing host characteristic, rather than viewing behavior
as an outcome of interest.
&
AN ECOLOGICAL MODEL FOR HEALTH PROMOTION
A variation on Broffenbrenner’s model-which is used as the conceptual framework
R°i ,LhjS3,Lhe^e issue
Health Education Quarterly-also borrows from the work of
s y, and Steuart. In this model, patterned behavior is the outcome of interest
and behavior is viewed as being determined by the following.
*
(1) intrapersonal factors-characteristics of the individual such as knowledge
attitudes behavior, self-concept. skiUs. etc. This includes the developmental
history of the individual.
(2) interpersonal processes and primary groups-formal and informal social net
work and social support systems, including the family, work group, and friendship networks.
(3) institutional factors-social institutions with organizational characteristics, and
formal (and informal) rules and regulations for operation.
(4) community factors-relationships among organizations, institutions, and informal networks within defined boundaries.
(5) public policy-local, state, and national laws and policies.
♦
An implicit assumption of these levels of analysis is that health promotion interven
tions are based on our beliefs, understandings, and theories of the determinants of beaVI.Or' “J1 11131 these flve levels of analysis reflect the range of strategies currently
available for health promotion programming. Other levels of analysis could be emp oyed as understanding of the causes and potential interventions to modify health
related behavior change.
The following discussion will review some of the processes operating at each of
these levels of analysis, how they affect health related behaviors, and potential health
promotion interventions that may be employed at each level of analysis.
356
Health Education Quarterly (Winter 1988)
Intrapersonal Factors
J iT6 nOte?' many °f 1116 behavior change models used in health promotion
ave been borrowed or adapted from psychology.21 Psychological models which have
been used to explain health related behavior or in program development include- ZTe'^hh
h and atrtitUde ChangS m°delS- SUCh aS 1116 hea"th belief moi
and the Fishbein theory of reasoned action;41 social learning theory■42-43 con
cepts of control, including locus of control. 44 and the psychology ofconuol-45 mod
of stress ,„dcop.„g;<‘ attrlbutto„ ,teories..r p„sonailty throttes.suchas
modds"' a„"d
d I
, P'r“ni,",y;<’ '"odels “f
making;50 developmental
models, and models which incorporate incentives, borrowed from social learning
theory or operant conditioning.51-52
s
tA??? psychol,oglcal theories are aPPUed to specific health problems or health relaed behaviors, the resultmg models may incorporate physiological processes and/or
interpersonal influences. Models of smoking acquisition and maintenance, for example
may include concepts of nicotine metabolism and excretion,53 and the role of family
3S r° 6 m°delS °r S0Cial mfluences in the acquisition of smoking behavior by
Our interventions may also incorporate techniques to modify the nature and extent
of social influences. For example, many adolescent smoking prevention programs in
corporate peer pressure resistance training (or social inoculation) and information
about parental influences; and smoking cessation programs and weight loss programs
may incorporate social support mechanisms. However, even when programs incorpo
rate social influences as part of the intervention-such as in peer counseling programs
the purpose is to change individuals, rather than to modify the social environ
ment. Adolescents are trained to resist interpersonal influences related to smoking,
rather than attempung to modify the norms and values that adolescents’ cliques net
works or families have about smoking. These interventions may reflect the implicit
assumption that the proximal causes of behavior and/or mechanisms for producing
behavioral changes lie within the individual, rather than in the social environment.
nterventions at the intrapersonal level, then, use a variety of intervention strategies
or levels of intervention-such as educational programs, mass media, support groups,
organizational incentives, or peer counseling-but the theory of change is one of
changing individuals, and the targets of the intervention include characteristics of the
individual, such as knowledge, attitudes, skiUs. or intentions to comply with behav■oral norms. This distinction between levels of intervention and the targets of interventions is an important one in understanding ecological strategies, and is simUar to
Steuart s distinction between units of practice (the theory of the problem) and units
of solution (levels of intervention).57
Interpersonal Processes
Interpersonal relationships with-family members, friends, neighbors, contacts at
work, and acquaintances-are important sources of influence in the health related behaviors of individuals. For example, significant others are important influences in the
ecision to visit a physician for non-emergency care, and the timing of doctor visits 58
Social relationships affect: How individuals cope with stress;59 the acquisition and
a
McLeroy. Bibeau et al.: Ecological Perspective on Health
j
♦
357
maintenance of alcohol and drug use behaviors;60 decisions about where to live;61 the
number of preventive health behaviors that individuals engage in;62 the risk of mental
illness;63 adolescents’ risk of pregnancy,64 and the ability of adolescents to cope with
pregnancy;65 political attitudes;66 and the risk of morbidity and mortality.67
Social relationships are essential aspects of social identity. They provide important
social resources, including emotional support, information, access to new social con
tacts and social roles, and tangible aid and assistance in fulfilling social and personal
obligations and responsibilities.68 These social resources, frequently referred to as
social support, are important mediators of life stress.69 and important components of
overall well being.70
Although the influence of interpersonal relationships on the health related behaviors
of individuals is widely recognized, health promotion interventions that use interper
sonal strategies have typically focused on changing individuals through social influ
ences. rather than on changing the norms or social groups to which individuals belong.
Examples in the areas of adolescent drug use and adolescent pregnancy prevention pro
grams are discussed below.
Drug Use Prevention Programs
Drug use prevention programs that incorporate social influence interventions have
viewed social influences on drug use as either “peer pressure,” or within a social influ
ence model in which drug use is viewed as being affected by individuals acquiring posi
tive attitudes, values, or norms regarding drug use from their social groups. Interven
tions based on a peer pressure model provide adolescents with knowledge and skills to •
resist negative peer influences; whereas interventions based on a social influence model
include information on the social antecedents and consequences of drug use. and
attempt to modify individuals’ perceptions of group norms about the use of drugs
through the use of peer counselors.71
The problem with these approaches to incorporating social influence interventions
into health promotion programs is that they ignore important aspects of the structure
and function of social relationships. Peer influence and coercion are approached as if
they were the result of a collection of dyadic interactions. What is missing is a recogni
tion of the importance of the source of influence and the social groups to which indi
viduals belong.72 For example, one can think of individuals as belonging to one or
more social networks, with networks defined as individuals who share linkages. Net
works vary in both structure and function. Structurally, some networks are relatively
homogeneous, whereas others are more heterogeneous. In some networks all members
are connected to one another, while other networks may be more diffuse (less dense).
In some networks, individuals share multiple linkages (multiplexity), while in other
networks relationships are less tight. Functionally, networks may provide individuals
with a variety of social resources, including information, access to social contacts,
social identity, emotional support, and instrumental support.73 Both the structure and
function of adolescent social networks may affect the risk of drug use.
Structurally, we may hypothesize that adolescents who have primary membership
in a dense, homogeneous network will be more influenced by the norms and values of
that group than individuals who belong to multiple, less dense, less homogeneous
groups.74 Since adolescent social networks may be more or less accessible depending
358
Health Education Quarterlx ' (Winter 1988,
of ““—
they are perceived as being more accessible or her-,
J5™"1 netWorks because
positions of relatively high status orarp
' n aUSe the deviant netw°rks occupy
1
I
being social isolated a7n a8 aTSSIVe Students-instead of aggressive individuals
*=—*” *—
.^e„
ing ovThZm^ZnVh6^0^ fr^eW°rk’ we can conceptualize schools as represent-
:xxr.«xxi, d“al is w ~
This reframing of the problem of adolescent drug use from one of nebulous peer
influences to one <of how existing network structures may influence individuals’ behaviors. allows one o begin thinking about non-individual interventions for drug abuse
prevention. That is.. our drug use prevention programs might focus on:
(1) Changing the norms about drug use within existing networks2 Increasing accessibUity to less deviant adolescent peer groups;
U) Creating alternative networks; and
(4) Decreasing the desirability of membership in deviant networks.
♦
A dolescent Pregnancy Prevention
pregnancy prevention ZT
mXs and Z
P"g”tncy
" P°SitiVe behaviors-8°
adolescent
McLeroy, Bibeau et al.: Ecological Perspective on Health
359
ienced. White males, however, may select best friends on the basis of sexual experience,
rather than being directly effected by best friends’ level of sexual activity.81’82 Thus,
there is evidence for differential friendship patterns based on sexual experience.
Families and sexual partners may also influence adolescents’ risk of pregnancy. For
example, the age at which adolescent females initiate sexual activity is associated with
the age at which their mothers initiated intercourse, and adolescent females with
mothers or siblings who became pregnant during their teens are also more likely to be
come pregnant as teenagers. Adolescents in more committed relationships with their
partners, and who have better communication patterns with their partners are more
likely to use effective contraceptives.83
This evidence of peer and family influences on risk factors for adolescent pregnancy
suggests that prevention programs need to include interventions directed at these
sources of influences. Specific types of interventions could include family support pro
grams network development, support groups, skills training,84 and the development of
norms for contraceptive use in male adolescent networks.
Interpersonal Interventions
4
The importance of interpersonal influences in drug use and adolescent pregnancy
suggests that, from an ecological perspective, interpersonal approaches should be
designed to change the nature of existing social relationships. Specifically, they should
be designed to modify the interpersonal social influences which serve to encourage,
support and maintain undesirable behaviors. While the ultimate target of these strate
gies may be changes in individuals, the proximal targets are social norms and social
influences.
Organizational Factors
Implicit in the preceding discussion is the assumption that an ecological perspective
tends to refocus attention away from strictly intra-individual factors and processes
which affect behavior and more towards environmental determinants of behavior, such
as the effects of interpersonal relationships. A third level of environmental considera
tions within the ecological framework concerns organizations. Specific areas of con
cern include: how organizational characteristics can be used to support behavioral
changes; the importance of organizational change as a target for health promotion
activities; and the importance of organizational context in the diffusion of health pro
motion programs.
Organizational Supports for Behavior Change
With many people spending one-third to one-half of their lives in organizational
settings—beginning with formal day care settings and extending through primary and
secondary schools, universities, and work settings—it is obvious that organizational
structures and processes can have substantial influence on the health and health related
behaviors of individuals. In the worksite, for example, the technology of production
A
360
Health Education Quarterly (Winter 1988)
may expose individuals to hazardous chemicals and risks from injuries and accidents
The pace of work, excessive work loads and responsibilities, job complexity, shift
work, and monotony have all been related to stress at work and to subsequent health
effects. Management styles, lack of participation by workers, poor relationships with
supervisors, and communication problems are also social worksite hazards.85
Organizations may have positive as well as negative effects on the health of their
members. Organizations provide important economic and social resources. Organiza
tions are important sources and transmitters of social norms and values, particularly
through individual work groups and socialization into organizational cultures.86 Vol
untary organizations, such as neighborhood and professional associations, may serve as
important mediators or mediating structures between individuals and the larger politi
cal and economic environment.87 Organizational memberships are also an important
component of social identity, and free time may be organized around participation in
voluntary associations, such as churches, professional groups, and local neighborhood
organizations.
As a context for health promotion activities and programs, organizations—particu
larly worksites-provide the opportunity to gain access to large groups of people
where they spend much of their time.88 Organizations provide the opportunity to
build social support for behavioral changes, particularly if the new behavior is a group
norm. 9 Organizational characteristics, such as the use of incentives, management and
supervisor support, changes in rules and regulations (e.g., smoking restrictions),
changes in benefits (e.g.. insurance coverage and child care), and changes in the struc
ture of work (e.g.. time off to participate in health related activities) may all be used
to support behavioral changes.90'91
Many of these characteristics of organizations have been used to support health pro
motion activities within worksites. Group competitions—which may promote group
solidarity and cohesion—have been used in weight loss programs.92 Incentives have
been used to promote smoking cessation and seatbelt use.93'94 Stress reduction inter
ventions have included improving worker supervisor relationships through supervisor
training.95
95 Corporations have begun to ban smoking at work and/or establish non
smoking areas.96 and some corporations have included environmental modifications —
such as changing and/or labeling food offerings in cafeterias —to support diet and
weight loss changes.3 Companies may also allow workers time off from work to par
ticipate in worksite programs, or may restructure working hours to encourage partici
pation.97'98
*
e
Organizational Change As the Target for Health Promotion
While many worksite programs have used organizational changes to encourage or
support behavioral changes among employees, the target of these interventions is
usually employees, and not the organization itself. An important component of organ
izational strategies that may be under-emphasized in worksite programs is creating
healthier environments in addition to creating healthier employees." A focus on
healthier environments may require that health promotion programs adopt an organ
izational development role, and establish linkages to other health-related efforts within
the organization, including environmental protection, safety, and union and personnel
activities. For example, a major health promotion effort in the worksite could involve
*
McLeroy. Bibeau et al.: Ecological Perspective on Health
361
the development of adequate day care services or alternative work schedules for work
ers with young children, in addition to offering classes in stress and time management.
The Green100 article in this issue of Health Education Quarterly discusses the differing
responsibilities of management, workers, and unions in achieving a comprehensive
ecological approach to workers’ health.
This discussion assumes that one of the purposes of health promotion programs in
the worksite is to change “corporate culture”; that is, to include concerns about health
outcomes in both tactical and strategic organizational decision making, and to include
health related norms and values as part of the corporate ideology. There are existing
examples of this both within and outside of the worksite. Johnson and Johnson101 has
established as a corporate goal having the healthiest workers in the world through
changing workers and changing the worksite environment. In this issue qIHealth Edu
cation Quarterly, Robins and Klitzman102 discuss the impact on worksites of a pro
gram to address the new Federal regulations governing hazard communications. They
suggest that health education programs in the worksite can influence the importance
of health as a worksite issue. Parcel, Simons-Morton, and Kolbe103 discuss four phases
of change in facilitating adoption of broad-based health programs in schools, including
institutional commitment, changes in policies and procedures, changes in the roles and
actions of staff, and new learning activities.
Organizational Influences on Program Diffusion
4
Nowhere is reciprocal causation between programs and organizations more evident
than in the adoption, implementation, and institutionalization of programs in com
munity settings.104 Few community health promotion programs are “free standing.”
Rather, community health promotion programs are almost always initiated or conduc
ted within some type of community organization or agency. Such organizations have
been termed “host organizations.”105 Because funding has been available from federal
and state sources, and private foundations, many organizations including schools, local
and state health departments, hospitals, and voluntary community health agencies
have initiated and implemented health promotion programs.
A current area of concern among health promotion practitioners and researchers is
the extent to which health promotion programs located within host organizations
survive over a long period of time in order to become firmly rooted in their host organ
izations. Because the missions and goals of these host organizations are often incom
patible with health promotion program objectives and activities, many programs do
not survive their initial period of grant funding. Such programmatic deaths can be both
wasteful and harmful. They are wasteful in that it often requires considerable financial
and human resources to implement successful programs. Premature termination, there
fore. can be disruptive both to the organization that has made accommodations to
implement the program, and to staff careers, since workers often make significant
investments in such programs. Program termination can also be harmful in that it may
be much harder for organizations to reestablish community trust after successful pro
grams are prematurely ended.106
When health promotion programs do survive past the initial funding period and be
come integrated into the host organization, they are said to have become institution-
362
Health Education Quarterly (Winter 1988,
tlonal process. An orgXion flufbe"otesXrhalXXof p”„"
•
.he .notion both UXXLXt KoXX.X" *
mportant organizational processes operate at each stage to affect the deo
r ♦
rniplemenianon. and .he depth and breadth of institutionalization For example' « •
tratnmg X'Xd ma‘; T0" f'°” UPP" k"1
f“ ’he Innovation
‘
hX,..be
related‘.^oXSXXi™ - ta°,'"‘°n ""'hl”
xr“xxxx=:es:
ho "
taff mUSt 1150 devel°P suPP°rt
o sZZnT aTdT ^at ^d^
health promotion activities within^he *
and
h°St °^tion’Z'on and
host orZzation or
P
°CCUPy 3
f°r prOgram activities ^^n the
XIf m
u f PrOgranl lnstltutionahzation. In this issue of Health Education
Quarterly. Monahan and Scheirer*- discuss how the diffusion of preventhJe“
cates XhXTstTte 7
StimUlated by eXternal pro8ram advocates• Program advo’ developers of an innovaZtoTciS alXtZ'leXXuXn '
•
Organizational Change and Health Promotion
This discussion of organizational processes in health r
promotion suggests that organ-
,i"heren, “/r eC°1°8“11
O«iJnal elunges „e
>-
1
Community Factors
oX C°nd“tasMstonX“'“,y'’ ha: b""
of ,he ke’ id!“ “ “h”'historically occupied a central role in public health 110 However the
gy^
and has lustoncally
.X XXbXsXi" “ m“y
logical sense
*
4k
.McLeroy, Bibeau et al.: Ecological Perspective on Health
363
sustenance needs.113 a unit of patterned social interaction.114 or simply an aggregate
of individuals in a geographic location.113
For the purposes of this paper community is viewed as having three distinct meanings. First, community refers to mediating structures, or face-to-face primary groups to
which individuals belong. This view of community embraces families, personal friend
ship networks, and neighborhoods. This is analogous to Brofenbrenner's definition of a
mesosystem.* Second, community can be thought of as the relationships among
organizations and groups within a defined area, such as local voluntary agencies local
governmental health providers, local schools, etc. Third, community is defined in geo
graphical and political terms, such that a community refers to a population which is
coterminous with a political entity, and is characterized by one or more power structures^e importance of these varying definitions of community is that they
have differing implications for the development and implementation of health promotion interventions.
Community As Mediating Structures
An iimportant component of community includes what have been called “mediating
structures.
.res. ’
These include family, informal social networks, churches. voluntary
associations, and neighborhoods, that may be important sources of social resources
and social identity.
These mediating structures are repositories and important influences on the larger
communities norms and values, individuals’ beliefs and attitudes, and a variety of
health related behaviors. Because mediating structures represent strong ties, changes
in individuals without the support of these mediating structures is difficult to achieve.
Mediating structures also serve as connections between individuals and the larger social
environment.87
Health promotion programs may use these mediating structures to deliver services
within communities, or may attempt to develop or strengthen existing neighborhood
organizations. For example. Eng, Hatch, and Callan39 have discussed the important
social functions that churches provide in rural, black communities, and the use of
these organizations as the focal point for health related interventions. Lasater. Wells.
Carleton, and Elder
have also discussed the use of churches as intervention sites in
a spin off of the Pawtucket Heart Health Program. A community organization ap
proach is represented by Minkler’s work26 in the Tenderloin District.
Community As Relationships Among Organizations
The second definition of community concerns the relationships among organizations within a political or geographic region. In many communities, the total resources
available for health and human services is severely limited. This is particularly true in
rural areas and small towns, and in some areas of the country where cities and states
are facing fiscal crises. Thus, in many communities organizations and agencies may
compete with each other for scarce resources, including donations, volunteer time,
media attention, and city and county tax dollars. Since many community organiza
tions may provide similar or related services, resource competition may carry over to
364
Health Education (Juarrerix (Wimer 198b)
ZZ^rX^h0™^ratl°n m PrOgramming’ reSUking use of
—===-===
■.
inH.X
ot.services- A community focus, then, for health promotion activities mav
influeneenCreaSln8 CO°rdlnation among community agencies, and coalition building to
Disc
awareness, local health policies, and resource expenditures
H^“d”” ;Xn'"“."“'t/ r^"a,lon a,e pro,wed by .
vended. Winder-
,he develop™,
Ze^-Tdd™ and 'I'’111' a8'nCy l"volv'm“t «>l’ environmenul potamts
M nkler addresses involving community organizations in work with the poor lnner
Community As Power
tHird deflniti0n Of community within the context of health promot.on conoften nIaT1111117 'i PT" StrUCtUres- Power structur« cities, counties, and states
sources LluX^ 'd
COmmunlty health P'^nis and allocating re’
unofficial an
i f !’
31 assistance- staffing. materials, and official and
unoiiicial approvals—for their amelioration.
tromX Of.the most imPortant roles played by community power structures is in con
trolling what issues are allowed to be placed on the public agenda.115 Since health
mo 10n issues may have political and economic ramifications, there will be poten.a consequences for powerful segments of the community. For example smoking h
noLie f he 1 1SSUee k 1S
mPortant economic issue. In the South the e!oElsewheL InThe^Vt dT f™’
W°rkerS’ and Cigarette ma™facturers.
toh Jen
/
J
States- smoklng is an economic issue to those who transport
hat benefit from t
°rganizations’ Marlers, and governm nts
probl ms a e of ec^65 On t°baCCO
dlet' nUtntion’ and obesity
problems are of economic interest to farmers, food processors, retailers, and restau
’ cal^ndLc^L^ and C°ndUCt b'/01 promotion P^ams often overlook the politi7 lead L
consequences of their proposed interventions. Such oversights can
or’
beCaUSe mpOrtant C“ity power structures acrive^y
rh J i t y ?
effectlve program implementation due to real or potential threats to
their political and economic interests.
potential mreats to
thote^L110^ 7tht
m°St 567616 health problems within a community are often
those with the least access to sources of community power. They are the poor the
homeler'the h
UneduCated’ the “"employed or the underemployed’ the
W ment bandlcaPPed- and those with socially derided health conditions such as
defint?
1.
’
alc0h01ism- Such ^“Ps are often left out of the process ol
labeled8
develoPlng Programmatic solutions. Such groups are often
dXrT'
y 2S
haXd tO reach’’They are hard reach because Leir mX
vtdual problems are so severe that they have little time, energy, or resources for parrid-
Z
<
McLeroy, Brbeau et al.: Ecological Perspective on Health
365
organized and arTctnofffromT11165
community bo2s
miy ooaras,
aCtlVltieS‘Such grouPs are rarely Politically
repre“"ta,i“ f«»"
disadvantaged population on
and (3) community organizing strategies.122’125
Community Interventions
dividuLf h
dlscussion indicates
defining communities as aggregates of inuals sharing common demographic or geographic characteristics neglects an
mportant aspect of community, that is communities as relationships Neglecting rela
lonsfups may reduce the acceptability of our interventions withm specZ su gro p"
tudes 8and H
- -"-s, norms aS
des and behaviors. These variations are not random, however, but are linked to
™oT0h i3nd 1subcultures- The extent to which our interventions conflict with
° hS
Sub'ultural nonns and- values is the extent to which we can expect specific
lent8 T m i
C°n!.,nunlty t0 resist
support our approaches. Furthermore negmg the relational features of communities may also lead us to disregard important
tions"
1
communities that may be used to support health related interven-
Public Policy
One
~ .v of the defining
ucunmg characteristics
cnaractenstics of
ot public
public health
health-apart from its emphasis on the
health of populations rather than the health of individuals-is the use of regulatory
policies, procedures, and laws to protect the health of the community.126 This use of
lav atd°M v01iieS raS had 3 dramatiC effect on 1116 health of the population. McKinay and McKinlay, for example, have estimated that the most of the decline in mortal
ity that occurred in the United States between 1900 and 1973 occurred as a result of
improvements in water supply, sanitation, housing, and food quality.127 including
laws governing the pasturization of milk.12 8
The success of these policies in reducing death and disability from infectious
diseases has led to the development of public policy approaches to address health risks
rom chronic diseases. These include: policies that restrict behaviors, such as prohibi
tion^ on smoking m public buddings and restrictions on alcohol sales and consumpion,
policies which contain behavioral incentives, both positive and negative such
as increased taxes on cigarettes and alcohol;180 policies which indirectly affect behaviors. such as reduced price supports for tobacco;181 and policies that allocate program
matic resources, such as the Prevention Block Grants, establishment of health promo
tion centers in selected universities, and the establishment of health promotion offices
and agencies in federal and state government. Policies may also affect access to health
366
Health Education Quarterly (Winter 1988.
promotion resources through the establishment of eligibility criteria, and the appropri
ateness of health promotion interventions by restrictions on how programmatic re
sources may be used. Examples include federal restrictions on adolescent pregnancy
prevention programs and the use of AIDS money in the development of promotional
materials.
There are several important roles for health promotion professionals in policy devel- ’
opment. policy advocacy, and policy analysis.132 Policy development activities may
include increasing public awareness about specific health and policy issues, and educat
ing the public about the policy development process. Public advocacy can take the
form of encouraging citizen participation in the political process-including voting and
lobbying, organizing coalitions to support health policy related issues, and monitoring
policy implementation, at the federal state, and local level. A policy analysis role
would include providing policy makers, the general public, and target populations with
policy options and promoting public input into the policy making process.
There is an important link among these policy roles and the concepts of community
discussed earlier. Policy development, public advocacy, and policy analysis have im
portant implications for communities. Berger and Neuhaus87 argue that public policies
should be designed to strengthen, rather than weaken the voluntary associations which
serve as mediating structures. As Milio131 notes, “the task for public policy becomes
one of creating environments—all of which have biotic and constructed socioeconomic
and interpersonal facets—that are likely to elicit health responses for most people
most of the time (page 4).’’ While Milio is generally speaking of the larger social envi
ronment. her statement also applies to the mediating structures in communities.
It is also important to recognize that mediating structures in a community serve as
connections between individuals and the larger social environment. Mediating struc- tures serve as points of access to. and influence on, the policy-making process. Thus,
the task of health promotion professionals—whether in policy development, advocacy,
or analysis —is to strengthen the ability of mediating structures to influence policy;
thereby, strengthening the mediating structures and their ability to meet the needs of
their members.
IMPLICATIONS OF AN ECOLOGICAL APPROACH
The preceding sections of this article have focused on identifying the need for and
characteristics of an ecological perspective on health promotion, with brief examples
to clarify each level of the ecological model. The purpose of an ecological model is to
focus attention on the environmental causes of behavior and to identify environmental
interventions. The six papers included in this theme issue provide in-depth reports on
a variety of applications of ecological perspectives, addressing different health pro
grams in a variety of settings. As we have noted, and as the authors of the subsequent
articles make clear, recent examples of practice applications of ecological models do
exist, although they do not dominate, the landscape of health promotion programs.
Further, some of the differences between individually-focused and ecologicallyfocused health promotion strategies are subtle, the central differences being in under
lying philosophies and specified targets of change.
Wallerstein and Bernstein142 discuss the adaptation of Paulo Freire’s ideas about
empowerment education to health education, and present a case study of an Alcohol
McLeroy, Bibeau et al.: Ecological Perspective on Health
367
PmnhSUbStaiLCe AbUSe PreventI0n (ASAP) Pr°g™m m New Mexico. Freire’s ideas
alT orZ,^"0311011 hS llberati°n’ S0ClaI action t0 Promote Participation ofindividuThe aITp
immunities; and gaining control over one’s life and society
The ASAP program uses peer education, experiential learning through interviews with
patients and jad residents, and adoption of active political and social roles in the com
munity The program aims at change at the institutional, public policy, and commun
ity levels as means to effect interpersonal and intrapersonal health related behaviors
n a review of environmental interventions to promote healthy eating, Glanz and
init ative^t
d
!nterdlSClph(nary PersP^ive on voluntary, organizationally-based
initiatives to reduce barriers to following healthier diets and creating opportunities for
action on a population-vide basis. They discuss five distinct types of interventions
originating from various health and non-health sectors in society: changes in the food
supply, point of choice nutrition information, collaboration with private sector food
vendors, worksite nutrition policies and incentives, and changes in the structure of
,and medlCal Carf rielated t0 nutr”ion- Each of these types of interventions can
arge segments of the population without imputing individual responsibility for
poor eating habits or requiring attendance at traditional educational programs. These
programs directly target several levels of an ecological model: institutional, public policy. community, and the physical environment.
Monahan and Scheirer108 address the role of state health department dental offices
as inking agents m the diffusion of fluoride mouth rinse programs (FMRPs) in public
schools. They use a social ecology perspective to analyze the various levels affecting
he use of linking agents. Their findings indicate that the state dental offices acted as
pivotal interpersonal links in both program initiation and continuation, and that the
linking agents’ long term commitment promoted institutionalization of the school
rMRPs.
Another article focusing on school health promotion examines the phases of change
in a cardiovascular risk reduction program which integrates organizational change with
student learning strategies. Parcel, Simons-Morton, and Kolbe103 engaged the involve
ment of individuals and groups in the schools at all levels-students, teachers, adminis
trators. and school district personnel-to facilitate adoption of broad-based health
programs. They identified four key phases of change: institutional commitment,
changes in policies and practices, changes in the roles and actions of staff, and finally,
new learning activities. Thus, effective implementation of school health promotion
programs requires active strategies to facilitate organizational adaptations to the inno
vation and the support of providers and administrators to ensure institutionaliza
tion.133
The growth of workplace health promotion has been a key area which has stimula
ted criticSflOf individually-oriented life-style change programs. In this issue, Robins and
Klitzman
present a description and evaluation of a hazard communication program
in one corporation with many local plants. They found that programs which were
more effectively implemented and better rated by workers were more likely to stimu
late changes in organizational and working conditions at the plants. They stress the
importance of reaching people at all levels of decision making, and apply the ecological
model to the workplace in terms of five levels of intervention: the worker, the work
unit, the local plant, the corporation/institution, and society as a whole.
The concluding paper by Kathryn Green100 addresses issues of responsibility for
health and control of factors influencing health in the context of workplace health
A
368
Health Education Quarterly (Winter 1988)
programs. She presents a matrix dividing influences on worker health in terms of the
extent of control by employers and workers, and then analyzes the responsibilities
of parties involved in workers’ health. The worker, union, employer, and government
each bear responsibility for various areas of physical and psychosocial health. Such an
ecological approach to workers’ health will result in the use of a variety of change
strategies and recognition of the limits of worker control over situational, regulatory,
and societal factors.
These articles identify important issues in adopting an ecological perspective. First,
several of the articles discuss the importance of environmental supports for delivering
health promotion services. While some health promotion programs are short term —
such as health fairs and some screening programs—developing environmental and
organizational support is necessary for adequate program implementation and ultimate
institutionalization.
Second, two of the articles discuss the use of environmental interventions to sup
port individual behavior changes. These include changes in: the physical environment;
organizational rules and regulations; and corporate culture. However, neither program
attempted to address all levels of the model. Choices in where to intervene will be
largely a function of program resources, the mission and goals of the host organization,
and the theoretical model guiding the intervention. The importance of an ecological
perspective is that it broadens our outlook to include environmental interventions that
may support the behavior change process. This suggests the need to incorporate
ecological models in our training programs, and to consider the development of
specialty areas in health promotion practice.
Third, these articles identify the importance of evaluating health promotion pro
grams at multiple levels. Since we know relatively little about how specific interven
tions may effect changes in organizational and community environments, and how
these environmental changes may affect the initiation and maintenance of behavior
changes on the part of individuals, an important aspect of health promotion program
evaluation is to describe the change process.
A fourth issue raised by authors in this issue concerns placing sole responsibility for
health on individuals by over-emphasizing the role of behavior in determining health.
Even viewing behavior within an ecological perspective will not adequately address
many of the sources of ill health, such as economic inequities, discrimination, genetics,
toxic exposures in the environment, unemployment, etc., except as they effect behav
ior. While an ecological model could be used to identify environmental sources of ill
health, the focus of the model as presented in this article is on environmental influ
ences on behavior. The effectiveness of interventions using the model, then, will be
limited by the extent to which behavior contributes to health or illness.
Perhaps the most critical issues in applying ecological approaches to behavior
change are ethical ones. While strategies based on an ecological model tend to mini
mize the likelihood of victim blaming, they can result in charges of coercion.134 Policy
approaches, such as raising the taxes on cigarettes, or banning smoking in public
spaces, may be viewed as restricting individual rights and freedoms. Corporate incen
tive programs for weight loss or smoking cessation may be subtly coercive when behav
ior change is viewed as linked to job retention, promotion, or salary increases. Social
support interventions may also be coercive when interpersonal social influences are
used to achieve behavioral changes. Even mass media approaches may be coercive
when they are based on appeals to emotions, or manipulate information.135 Such
McLeroy, Bibeau et al.: Ecological Perspective on Health
369
approaches can also be viewed as a form of paternalism and are considered by some to
be an invasion of privacy.136
An essential component of ecological strategies —in order to minimize the problems
of coercion and. particularly, paternalism-is active involvement of the target popula
tion in problem definition, the selection of targets of change and appropriate interven
tions. implementation, and evaluation. The process of using ecological strategies, then,
is one of consensus building.
By involving the target population in the description of the problem and its sources,
important health education has already occurred.137 As noted by Wallerstein and
Bernstein in this issue of Health Education Quarterly, the process of planning and
implementing programs also shapes our consciousness about the causes and responsibilties for health and illness, and may empower individuals and collectivities to address
health related problems.
However, the active involvement of the individuals and groups affected by health
promotion programs will not solve all of the problems associated with ecological
strategies. In many cases, it may not be possible to build consensus among all of those
affected, and in mass media campaigns, for example, it may not be clear who should
be involved in the consensus-building process.
In some cases, it may not be necessary to ethically justify restriction of individual
treedoms when the exercise of those freedoms imposes a clear harm to others. For
example, exposure of non-smokers to sidestream smoke may impose a health threat. In
the case of health threats, it is the responsibility of decision-makers to protect the
health of non-smokers by restricting the behavior of smokers. In other cases, where the
behavior of the individual has only direct effects on that individual, the ethical accept
ability of using coercive strategies is much less clear.138 For example, coercing indi
viduals into participating in an exercise program may be ethically questioned. Some
writers have suggested a communitarian ethic as a justification for ecological strategies
to protect the public from voluntarily assumed risks to health.139 Other writers have
argued that many of the ‘voluntary ’ risks to health are not assumed voluntarily at ail;
rather social factors influence and determine the risks that individuals assume.140 Thus
the use of social interventions to offset prevailing social influences are both appropri
ate and ethical. In reality, not all ecological strategies are coercive, and the use of
coercive strategies will ultimately be restrained by legal and social sanctions. The pre
vention of public resistance to ecological strategies will require educational approaches
to. “Assure informed consent from the public, and to assure that individuals who are
not ultimately protected by them are still in a position to protect themselves.”141
Notes
1. For example, the American Journal of Health Promotion, Health Promotion: An
International Journal, and Corporate Commentary are all devoted to health pro
motion issues.
2. For example, Health Education Quarterly has recently published theme issues on
“Ethical Dilemmas in Health Promotion,” 14(1), 1987, and “The Role of the
Schools in Implementing the Nation’s Health Objectives for the 1990’s,” 15(1),
1988, The Canadian Journal of Public Health recently published a “Special Health
Promotion Issue,” 77(6), 1988.
370
Health Education Quarterly (Wimer 1988)
3. For example, the Journal of Social Issues recently devoted a theme issue to “Chil
dren's Injuries: Prevention and Public Policy.” 43(2). 1987.
4. For example, the First International Conference on Health Promotion was held in
Ottawa, Canada, November 17-21, 1986.
5 . Similar issues have been raised within health education. See for example, Freuden
berg, N.: “Shaping the Future of Health Education: From Behavior Change to
Social Change.” Health Education Monographs, 6(4): 372-377, 1978.
6. Reciprocal determinism is a component of many psychological models, such as_
Bandura’s social learning theory. However, the sense of transactional models is
that individuals and environments interact over time to jointly determine each
other. This is distinct from some interactional models in which individuals and
environments jointly contribute to behavior, such as those tested by analysis of
variance or regression models.
7. Systems models, on the other hand, frequently use outcomes such as system func
tioning or production.
8. A network framework also suggests that we need to reconceptualize peer educa
tion models for preventing drug abuse. Clearly, peer educators should be selected
based on their position within existing networks. Instead, many peer education
programs rely on self-selected peers who may be peripheral to the existing net
works within a school. Thus, we would expect the success of peer education pro
grams to vary, depending upon the selection criteria for the peer educators.
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e
Section on AIDS
THINKING AND RETHINKING AIDS:
IMPLICATIONS FOR HEALTH POLICY
Elizabeth Fee and Nancy Krieger
In the United States, we see three main phases in the construction of the history of
AIDS, with each having very different implications for health and social policy. In
the first, AIDS was conceived of as an epidemic disease, a “gay plague,” by analogy
to the sudden, devastating epidemics of the past. In the second, it was normalized as
a chronic disease, similar in many ways to diseases such as cancer. In the third, the
authors propose a new historical model of a slow-moving, long-lasting pandemic, a
chronic infectious ailment manifested through myriad specific HIV-related diseases.
The new paradigm of AIDS incorporates the positive aspects of both earlier con
ceptions. It emphasizes, like the plague model, the etiology, transmission, and
prevention of disease but rejects its assumption of a time-limited crisis. It takes
from the chronic disease model an appropriate time frame and concern with the
clinical management of protracted illness but insists on the primacy of prevention.
The authors criticize both infectious and chronic disease models for their indi
vidualistic conceptions of disease and their narrow strategies for disease prevention.
They further argue that the traditional distinction between, and approaches to,
infectious and chronic diseases need to be rethought for other diseases as well as
for AIDS.
The history of AIDS does not simply present itself as a chronological succession of
events. It is a history that necessarily is constructed and that cannot simply be inferred
from the biological properties of HIV or the pathological realities of disease.1 The
history of AIDS is a human affair, and is part of a cultural process of attempting to come
to terms with a new and often terrifying series of events—of young people dying before
their time, of the intermingling of sex and death—in a period in which the world itself is
changing before our eyes and stability is an unlikely dream.
Centered on the bodily experiences of illness and death, the social meaning
of the history of AIDS intimately touches upon our ideas about sexuality and
societal divisions, social responsibility and individual privacy, order and instability, and
1 In this article we refer to AIDS as a disease and also to HIV-related diseases. The pathological events
initiated by HTV, including the destruction of the immune system, are appropriately designated as a single
disease process. This in turn permits the expression of various opportunistic infections and other disorders
(e.g., Kaposi’s sarcoma), which have been part of the changing case definition of AIDS elaborated by the
Centers for Disease Control. These latter infections and conditions are referred to as HIV-related diseases. This
somewhat confusing terminology is itself part of the historical process of the scientific construction and
definition of disease.
International Journal of Health Services, Volume 23, Number 2, Pages 323—346, 1993
© 1993, Baywood Publishing Co., Inc.
323
324 / Fee and Krieger
above all, health and the prospect of happiness. Understanding how we respond
to AIDS, how we think about this epidemic, is consequently important not only for
what it reveals about the ways in which health policy is created, but also for what
it implies about our ability to meet the challenge of future emerging diseases and
longstanding public health problems. By thinking and rethinking the history of AIDS,
we may thus be able to deal more effectively with a larger array of unsolved health
issues.
Within the United States, we see three main phases in the construction of the history
of AIDS, with each having very different implications for health and social policy. In the
first, AIDS was conceived of as an epidemic disease, a “gay plague,” by analogy to the
sudden devastating epidemics of the past; in the second, it was normalized as a chronic
disease, similar in many ways to diseases such as cancer; in the third, we propose a new
historical model of a slow-moving, long-lasting pandemic, a chronic infectious ailment
manifested through myriad specific HIV-related diseases.
THE FIRST HISTORY: AIDS AS PLAGUE
At first, AIDS had no history. A strange set of events occuned that were, for the most
part, ignored. Some apparently healthy young men exhibited rare opportunistic infec
tions and then died; only a few physicians and epidemiologists were aware that some
thing extraordinary was happening. Noticing that several of the young men were
homosexual, the epidemiologists gave the phenomenon its first name, gay-related
immunodeficiency disease (GRID). The epidemiologists became fascinated by an
apparently exotic lifestyle that included drugs (poppers) and large numbers of sexual
partners. As the numbers of reported cases grew, the disease began to acquire its social
identity as a new epidemic, a “gay plague” (1, 2).
The dawning recognition of a novel disease, a “gay plague,” touched two central
social ideas. One was the idea of homosexuality as a social, political, and medical
problem; the old association of homosexuality with disease was resurrected and rein
forced in cultural perception. But even more powerful was the idea of a new epidemic
disease. AIDS shocked the western medical world, appearing as a throwback to an
earlier era of infectious and fatal epidemics. AIDS seemed to appear out of historical
context, at once entirely new, but also old; it properly belonged to a distant and less
comfortable past, before economic and scientific progress had combined to banish the
ancient plagues. People in the western world had become familiar with a “modem”
pattern of chronic diseases, a familiar litany that began with heart disease and cancer and
included a long list of disagreeable but nonfatal illnesses. The chronic diseases were
associated with aging, and many considered them the characteristic ills of affluent
societies (3-5).
Mass infectious diseases had ceased to command the attention of health policy
analysts in the advanced industrial world; for the most part, they were firmly relegated
to the third world as diseases of underdevelopment. Even there, the worldwide eradica
tion of smallpox seemed to suggest that it was but a matter of time, organization, and
resources until the major infectious diseases would be eradicated. AIDS challenged
this hubris, together with the assumption that the late 20th century division of diseases
into infectious and chronic disorders naturally fitted an economic and geographic
i
I
I
I
•I
Thinking and Rethinking AIDS / 325
j
distribution, with the chronic diseases appearing in highly industrialized nations
and serious infectious diseases in the less developed countries. AIDS appeared at
first as a disease of the United States, Western Europe, and Australia. A disease of
unknown origin, a silent, fatal infection that killed young men in the prime of
life, it seemed to be associated with societies of affluence and perhaps even hedonism
(6). AIDS, it was true, quickly appeared rampant in Africa, but there it appeared in a
different guise—as a disease of heterosexuality and of poverty. There was some con
nection between the two, but it seemed to many that the phenomena of AIDS in Africa
and America were quite distinct. At the same time, Americans suspected that AIDS
had been bom in Africa; the idea, once publicly discussed, was indignantly rejected
by Africans. Nations were busy blaming each other for an epidemic that none wanted
to claim (7).
As the statistics on AIDS cases mounted, its identity as an inescapable “plague”
seemed confirmed. It appeared to mimic the frightening epidemics of the past: cholera,
yellow fever, leprosy, syphilis, and the Black Death. The history of AIDS—the history
that seemed relevant to understanding the new epidemic—would be the history of the
epidemics of the past (8,9). This somewhat arcane branch of medical history suddenly
gained new social relevance; policy analysts, lawyers, and journalists all wanted to
know whether past epidemics could provide some clues to the contemporary crisis. How
had societies attempted to deal with epidemics in the past? The contemporary meaning
of the plague was read in the face of AIDS (10).
This first reading of the history of AIDS accurately captured and reflected the fear and
confusion surrounding the disease. It also provided a frame of reference for talking
about the many ethical, legal, and health policy issues it raised. The history of plague
implied, for example, a history of quarantines, and quarantines for those with AIDS was,
at least in some circles, a serious policy proposal (11-15). The history of most past
epidemics (at least as read by liberal historians) suggested, however, that quarantines
were more an expression of social distress and fear than an effective measure for
controlling disease (16,17).
The new historical approaches to AIDS prompted by the plague analogy examined
such contemporary issues as social discrimination against those groups perceived as
the purveyors of infection: in past epidemics, those so stigmatized had been pros
titutes, the poor, or minority racial groups; they had been Jews, or Irish, or Italians.
The unreasoning prejudices of the past now seemed to be reflected in contem
porary social discrimination against gay men and intravenous drug users. To a
considerable degree, the history of past epidemics was read as a cautionary tale
of the health and social policies that should not be adopted in these more enlightened
days.
The perception of AIDS as a devastating epidemic discontinuous with the immediate
past fed into the millenarian tendencies of the late 20th century. The relatively stable
organization of social conflict in the postwar era was dissolving into uncertainty;
the capitalist world was mired in economic crises, recession, debt, bank failures,
long-term unemployment, and the collapse of an older industrial base; the communist
world was fragmenting into a series of political, economic, and national crises that
succeeded each other at breathtaking speed; environmental degradation and global
warming seemed to many to threaten the final destruction of an exploitative world
326 / Fee and Krieger
order. Popular books announced the “end of history” and the “end of nature” (18, 19).
AIDS fed this late 20th century sense of overwhelming catastrophe and continuing
apocalypse (6).
In this context, the infectious disease paradigm of equilibrium disturbed and paradise
lost took on new meaning. Many who were ecologically minded viewed humanity’s
meddling with technology as having disrupted the niches of natural organisms, thus
creating the possibilities for transmission of new diseases (20, 21). Conversely, conser
vative social commentators saw the problem not so much as one of technology but as
one of deviance. They viewed the disease as the revenge of nature on liberal society and
appealed to a lost world of “traditional values” and a more stable and authoritarian order
(13; 22, p. 48).
The growing sense of crisis, fanned by a sudden outburst of media attention and by the
ever-climbing statistics of those ill and dying, aided the widespread adoption of the
historical metaphor of an inexorable “plague.” The language of plague, of crisis, of
epidemic was in turn adopted by a gay community that organized to demand social and
political attention to the disease, financial resources to care for those affected, accel
erated scientific research to develop a cure and preventive vaccines, and mass public
education to help prevent further transmission of infection. In the face of seeming
societal indifference, gay activists demanded a “War on AIDS,” thereby adopting the
military metaphor often used by government to indicate that it takes a problem seriously
enough to devote significant financial resources to its solution (6, 23). (Thus, we have
had a “war on cancer” and a “war on drugs” but not yet a “war on homelessness” or a
“war on illiteracy.”)
The growing sense of crisis eventually permeated the levels of the federal govern
ment, and money began to fuel a massive scientific effort first to identify and then to
understand the viral mechanisms of the disease. With the new flow of funding for
research, scientists readily turned their attention to the race for discoveries. The view of
AIDS as epidemic fed scientific competition between laboratories and nations; the
competition for research funds was encouraged by the perception that large profits
would reward those able to produce the laboratory tests, vaccines, and pharmaceuticals
so urgently needed to address the disease. The scientific competition to unlock the
secrets of AIDS seemed at once more intense, more glamorous, and more hopeful than
the long struggle to deal with diseases such as cancer. Infectious diseases were believed
less intractable than chronic ills; the media waited breathlessly to announce new scien
tific breakthroughs.
In 1983, those waiting were rewarded with the announcement of the discovery
of the viral cause of AIDS, not once but twice—by both French and American
researchers (20, pp. 47-82). This is not the place to recount the international dis
pute that followed, nor the political compromise by which France and the United
States agreed to share credit for the discovery and to divide the considerable royalties
from the patented HIV diagnostic test (20, 24). Mirko Grmek’s (20) account is per
suasive, but for our purposes here, it is sufficient to note that the discovery of
what would be called, by international agreement, HIV would transform both the
scientific and the public perception of the epidemic. The identification and naming
of the viral cause of AIDS seemed to offer the first real hope that it could one day
be controlled.
Thinking and Rethinking AIDS / 327
The Health Policy Implications of the First Paradigm
I
The plague analogy reflected social fears and also helped fan them. A crisis mentality
marked by panic and confusion had surfaced; angry parents pulled their children from
schools where HIV-positive children were enrolled. Health departments closed gay
bathhouses, describing them as a locus of contagion. Newspapers and magazines,
including some prominent medical journals, published accounts that suggested the
entire population was at threat, that AIDS could perhaps be spread by mosquito bites, by
household contacts, or by kissing (25-27). Careful epidemiological statements about the
unlikelihood of infection by casual contact failed to pacify much of the population who
wanted definitive assurance that they and their families were not at risk. People began to
fear infection from restaurant and service workers, from their coworkers in offices, and
from public toilet seats. In this atmosphere of panic, many people with AIDS lost their
jobs, their apartments, their health insurance, and even their friends (28). The mounting
statistics being reported by the media suggested an exponential increase in cases and
deaths, the inescapability of the epidemic, its potential spread from defined risk groups
to the “general population,” and the conviction that the fragile and burdened health care
system would soon be overwhelmed.
The escalating public sense of crisis had met with government indifference to a
disease that was killing gay men; the Reagan administration was already committed to
cutting taxes and social expenditures, reducing health care costs, and turning over health
and safety regulations to private, enterprise (29). The confrontation between the
Washington policy establishment and gay community and public health leaders
prompted many to become involved in demonstrations, lobbying, and the creation of
alternative services and clinics. The previous organization and growing sense of self
identity and power of the gay community in cities such as New York and San Francisco
were now channeled into the struggle to redefine national policy so as to address the
emergency.
The sense of emergency could work two ways: to generate funding for AIDS
services and research or to make a case for Draconian methods of prevention and
social policies of exclusion. In the first instance, the perception of a sudden, time-limited
epidemic was used to justify the funding of AIDS services by taking money from
other budgets, such as those for Native American health services and for other
sexually transmitted disease programs (30, 31). Such transfers meant that overall
health expenditures could be contained; the money for AIDS was only a temporary
measure—until the emergency passed. In the second instance, immigration policies,
requiring the exclusion of those who were HIV-positive, harkened back to an older
conviction that diseases came to America from outside and could be avoided by
identifying and refusing to admit the sick. Within the cities most affected, gay com
munities coped with the dying while conservative commentators pronounced the disease
God’s retribution on the sinful (31, p. 18). Within the state of emergency, relatively
simple methods of prevention were developed to promote condoms and clean up the
blood supply.
The emphasis on AIDS as a sexually transmitted disease and the consequent social
and epidemiological interest in the sexual practices associated with viral transmission
produced an extraordinary new willingness to discuss sexual activities in graphic terms,
328 / Fee and Krieger
at least within scientific and health policy circles.2 Public discussion of sexual transmis
sion was more guarded, with some of the pronouncements about transmission through
the exchange of bodily fluids so vaguely worded that the populace was probably more
confused than enlightened by the information.
Despite the cautious approach to public description of sexual activities, AIDS did
bring new kinds of visibility to the gay community. For the first time, large numbers of
gay men (and women) were seen on television screens and in newspapers and magazines
talking about AIDS, lobbying, fundraising, and articulating alternative views. Health
policy was, for perhaps the first time on such a large scale, being made outside the usual
professional circles. Professional boundaries became permeable as people with HIVrelated diseases declared themselves de facto experts and began the process of renaming
themselves, redefining their illness, questioning medical authority, criticizing govern
ment spokespersons, demanding new and more appropriate services and more effective
drugs, and insisting on both their rights to confidentiality and their rights to public
expression and influence (34). The gay community refused the diagnosis of “promis
cuity” as the problem and insisted upon “safer sex” rather than celibacy. Taking
responsibility for AIDS as a disease, they also refused the language of guilt and
innocence and claimed a more scientific and more humanitarian view of the epidemic as
the problem of containing a virus while protecting the interests of those already infected.
The Problems of the First Paradigm
The sense of AIDS as an immediately catastrophic epidemic, a sudden, unexpected,
and disastrous return to a vanished world of epidemic disease, began to change in the
late 1980s. People were not, in fact, dying as rapidly as had initially been predicted. It
became clear that there was a long latency period; people lived with HIV infection for
10 to 12 years, and it was not the sudden killer it had at first been perceived to be. The
sense of immanent epidemic was diluted because a relatively low proportion of the
population was ill. One may, for example, contrast AIDS to the influenza epidemic of
1918 when 20 percent of the population became ill, of whom 2 to 3 percent died (i.e., 0.4
to 0.6 percent of the total population); now 0.1 percent of the population had become
sick over a ten-year period (35). Once the first series of shocks over AIDS had passed,
the society, like many of those infected, was learning to live with AIDS (36).
In the first epidemic of fear of AIDS, a tactic of many of those arguing for increased
resources to be devoted to the disease had been to stress the fact that AIDS was not
2 One can, for example, trace the increasingly explicit use of language within the august pages of the
American Journal of Epidemiology. Compare the clinical but quasi-graphic listing of sexual practices in the
article by A. R. Moss et al. in 1987 (32)—oral insertive, oral receptive, swallow semen, oral-anal insertive,
oral-anal receptive, rectal insertive, rectal receptive, urine exposure active, urine exposure passive,
manual-rectal insertive, manual-rectal passive, use of dildos insertive, use of dildos receptive, douching-with
the exhaustive listing of sexual practices in the article by R. A. Coates et al. in 1988 (33) mutual
masturbation, primary inserts penis in contact’s mouth, primary ejaculates in conUct’s mouth, conUct inserts
penis in primary’s mouth, contact ejaculates in primary’s mouth, primary inserts penis in contact’s anus,
primary ejaculates in contact’s rectum, conUct inserts penis in primary’s anus, contact ejaculates in primary’s
rectum, primary inserts finger in conUct’s anus, conuct inserts finger in primary’s anus, primary inserts tongue
in conuct’s anus, contact inserts tongue in primary’s anus, primary inserts object in contact’s anus, contact
inserts object in primary’s anus, primary inserts hand in conuct’s anus, conuct inserts hand in primary’s anus.
Thinking and Rethinking AIDS / 329
i
limited to the homosexual community but potentially threatened the whole population.
If it had struck the gay population first, this was merely a contingent fact; AIDS in Haiti
and in Africa was a heterosexual disease, and its spread to the “general population” was
just a matter of time. The crisis could not be contained in gay bars and bathhouses but
would soon spill out into America’s suburbs, schools, and churches. The death of movie
idol Rock Hudson in 1985 was, ironically, taken by many in the United States to mean
that “anyone” could get the disease; for the first time ever, President Reagan spoke about
AIDS (37, 38).
With the passage of time, however, the warnings about a brushfire epidemic had come
to seem overly alarmist. The disease had indeed spread, but not in any perceptible way
to suburban havens; instead, it had spread to inner city minority populations and
specifically to those using injectable drugs and their sexual partners (39). Despite
anecdotal newspaper stories about wealthy young white women who had contracted the
infection, the epidemic had not deeply affected worried white communities but was
largely contained within the several well-defined risk groups.
The transmission of HIV did not, after all, follow the plague model. Diseases like
plague spread very easily, whereas it had become clear that transmission of HIV is quite
difficult. It requires direct contact between people, usually by choice or else by the
anonymous but still intimate exchange of blood through transfusions. Once the blood
supply had been made safe and people had been made aware of the need for caution in
having sex or sharing drugs, AIDS began to be perceived as potentially containable. The
population, initially hoping for a miracle cure, had been repeatedly told that a vaccine
would take at least ten years to develop; people were thus learning to accept a longer
time frame for the disease.
Another reason for a diminished sense of an epidemic emergency was the discovery
of some apparently effective palliative treatments and the promise of more experimental
therapies to come; there was now some prospect of hope for those infected. Hospitals,
clinics, and other health care institutions were working out new ways of providing
services for AIDS patients; the disease was no longer such an anomaly and was
becoming a more routine and expected sector of health care delivery.
Perhaps most importantly, the groups affected were themselves refusing to look
on the disease as a death sentence. Numerous people with AIDS (PWAs) were sur
viving for many years and were vociferously insisting that the previous emphasis on
dying be replaced with a new more optimistic focus on “living with AIDS,” with
attention directed at those who were HIV-positive but not ill, and those who had
symptoms but were nonetheless capable of enjoying life, working, participating in their
communities, and experiencing a wide range of emotions and pleasures. They did
not want to be locked into a politics of fear and rejected being labeled as the “victims”
of disease.
Within the gay community, and to some degree the population at large, the emphasis
on safer sex now became a long-term strategy for a long-term disease; health education
programs continuously stressed the fact that the virus could not be casually transmitted,
and this understanding lessened the immediate panicked reaction to those infected. The
resistance to testing decreased as the tests could now be linked to some prospect of aid;
if infection were diagnosed early, medical care and pharmaceuticals could help. The
availability of palliative therapy, most notably AZT, then placed AIDS into the larger
330 / Fee and Krieger
pattern of chronic diseases with their emphasis on screening and early intervention and,
at least for some, the potential management of long-term disease.
THE SECOND HISTORY:
AIDS AS A CHRONIC DISEASE
The second history is therefore the conceptualization of AIDS as a chronic disease. In
this history, AIDS became normalized and appeared as one more chronic disease that
had to be managed, as part of the usual way of doing business. This is a history that was
constructed—and could only be forged—in relatively wealthy industrialized countries,
such as the United States and Western Europe, that could afford to provide health
services for other chronic conditions.
Central to this new history was a view of chronic diseases as maladies that either are
not infectious or else are not easily transmitted, develop over a long period of time (with
changes that can usually be detected by screening), entail a lengthy period of illness and
associated use of health services, are not easily cured, and are often fatal in the long run.
Classic examples include hypertension and other cardiovascular diseases, diabetes,
and many types of cancer. Although anomalies have long been acknowledged—for
example, cervical cancer may be linked to a virus; a myocardial infarct is an acute and
often immediately fatal event (40)—the category of “chronic disease” nonetheless has
been useful, particularly from the perspective of those who must live with these diseases
and the people and institutions responsible for providing health services.
In the second history, the metaphors of war and balance retreated into the body and
became internalized. Images abounded of the immune system as the body’s “defense”
against “external invaders,” with a new array of pharmaceutical agents forming
welcome auxiliary forces (6, 41, 42). The new emphasis on treatment and on “living
right” in order to live with AIDS harkened back to older, humoral notions of equilibrium
(43); popular self-help books on AIDS are replete with reminders about the need to
manage stress and to live a “balanced” life, with a “balanced” diet, adequate sleep, and
appropriate exercise (44-47).
Outside the body, the call for a “war against AIDS” was directed toward new
therapeutic discoveries and became a front for societal inaction in preventing the spread
of AIDS. Like the “war against drugs,” the official “war against AIDS” (at least in the
United States) bolstered the status quo; just as government funds poured into law
enforcement agencies and prisons while programs to combat poverty and rehabilitate
prisoners languished (48, 49), so too were federal monies increasingly directed toward
prestigious and profitable clinical trials while Congress fought over the allocation of
Ryan White funds for community-based AIDS services and prevention campaigns
(50-52).
As a chronic disease, AIDS was to be contained within its boundaries, like a sore that
festers but does not spread. In the United States, its history included sharp debates over
whether AIDS could “break out” and create a widespread “heterosexual epidemic”
(53, 54), as opposed to remaining within the communities of the dispossessed—
gay men, injection drug users, hemophiliacs, the poor, and people of color, in all
their intersecting permutations. Ensconced ever more firmly as a disease of “others,”
AIDS found its niche in the inner cities (55, 56), and as a “chronic disease” became yet
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another marker of chronic social inequalities that could be tolerated as long as only those
“others” died.
The Health Policy Implications of the Second Paradigm
I
In the second history of AIDS, attention turned to the ability of the health care system
to deal with this new chronic disease. Health policy professionals reasserted their
expertise in a familiar domain (50), and succeeded in at least partly closing out the
voices of the gay community and others newly entering the AIDS arena, for example,
the African-American community, women with AIDS, and advocates of needle
exchange (57). With budgets and scarce resources at stake, accuracy in estimates
became paramount. Costs of care were calculated and recalculated (58,59), while tallies
of the number of persons infected with HIV were revised downwards (50, 60). Increas
ing numbers of hospitals developed specialized AIDS units, a sign of the institu
tionalization of the disease (50).
Attention and funding also shifted toward developing new treatments. Reacting to
these changes, many AIDS activists plunged into political battles to speed the release of
approvals for experimental drugs and to demand new, more inclusive protocols (61-63).
Others continued to fight for improved health coverage and against discriminatory
practices by the health insurance industry (64).
The emphasis on treatment also led to a rethinking of questions about HIV testing,
including the conflict between individual privacy and mandatory reporting (65-69).
Ethical objections to testing people when nothing could be done to ameliorate their
health status lost their clout, and were replaced by arguments that people should—or
must—be tested for their own good. With fears about casual transmission relatively
assuaged, new concerns surfaced about the possible threat posed by long-living,
asymptomatic HIV-infected persons whose jobs routinely involved exposure to other
people’s blood, as in the case of surgeons and dentists (70-73). Reminiscent of earlier,
more hysterical “plague”-like debates about the likelihood of improbable transmission
scenarios, the debate about infected health care workers nonetheless belonged to and
epitomized this second history of AIDS: people infected with HIV were not simply
going to vanish through early deaths, and instead had to be reckoned with from the
long-term vantage point of managing chronic diseases.
The Problems with the Second Paradigm
The shift from a “plague” to “chronic” disease model involved much more than the
recognition that people infected with HIV and ill with AIDS may require health services
for an extended period of time. Each paradigm of disease carries its own assumptions,
concerning such basic issues as etiology, prevention, and treatment. Although framed in
biological terms, these assumptions nonetheless have a strong social core that cannot
be divorced from broader social attitudes about individual versus societal responsibility
for health.
In the case of AIDS, adopting this new paradigm did far more than direct our attention
to issues not anticipated by the plague model. It also introduced all the fundamental
assumptions and inadequacies of the chronic disease model itself. Because most chronic
332 / Fee and Krieger
diseases are considered noncommunicable and because their etiologies typically are
obscure, the conceptualization of AIDS as a “chronic disease” inadvertently undermined
the sense of urgency required to sustain societal efforts to prevent HIV transmission. To
reiterate the obvious, AIDS is a communicable disease whose transmission can be
prevented; this basic fact is deemphasized by the chronic disease model. Moreover,
much of the scientific research around chronic diseases focuses on disease mechanisms
and not disease origins; it emphasizes screening and treatment over prevention, and
prevention itself typically is framed as an individual responsibility (74). In the usual
pattern for chronic diseases, the primary concern is with managing the symptoms of the
ailment (and possibly curing the disease, if feasible); once appropriate remedies are
found, concern about etiology and prevention recedes. This pattern may be seen, for
example, in the cases of hypertension, diabetes, and cancer. The question becomes how
to stop the growth of a tumor once it starts or how to lower lipid levels once they rise,
rather than how to prevent the initial onset of disease. This pathological orientation may
be good for the pharmaceutical industry, but it does little for primary prevention.
To the extent that prevention is discussed, the strategies proposed for most chronic
diseases are thoroughly individualistic and rarely challenge the conditions of the
production of disease (75-78). Not only is disease prevention translated into the realm
of individual effort, but the only actions typically considered are those that can be
implemented by solo individuals. Little attention is accorded to possible disease preven
tion strategies to be used between persons with unequal power, such as consumers
versus food producers over pricing policies or workers versus employers over occupa
tional hazards. This orientation reflects the dominant view of individuals as isolated
atoms, rather than as persons who necessarily are carriers of the social relations of class,
race, and gender that permeate the society of which they are a part (79). It is also far
easier to counsel individuals about what they should eat (and blame them for poor
choices) than to get the food industry to change the production and promotion of “junk
foods,” just as it is much less controversial to encourage people not to smoke than to try
to prevent the growing of tobacco or to curb air pollution. Intended or not, these attitudes
toward the causation and prevention of chronic diseases now affect our thinking about
AIDS and, if not addressed, threaten to vitiate our still inadequate response to the
HIV epidemic.
Perhaps not surprisingly, our approach to AIDS already has begun to be influenced by
these troubling features of the chronic disease model. With the identification of HIV,
scientific interest shifted to the laboratory and the gaze turned inward, to the actions of
HIV within the body (1, 50). Relatively less attention was devoted to understanding
the complex societal factors affecting the social production and reproduction of the
epidemic. Social and scientific rewards go to those who successfully examine the
mechanisms of disease within the body. It is also less politically controversial to look
inside cells than to investigate the political economy of inner cities, the war on drugs,
prostitution, and the oppression of gays, women, and people of color.
Another common assumption built into the chronic disease model is that most chronic
conditions have a multifactorial etiology, but the diseases themselves are specific and
typically are characterized by the organ they affect (e.g., heart disease, ovarian cancer).
Moreover, most of the exogenous exposures contributing to their etiology are viewed as
ubiquitous or containable, and not easily eliminated (74, 80). Nor can the endogenous
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factors, such as genetic constitution or hormonal milieu, easily be altered—although the
challenge of doing so remains a major spur for much biomedical research today (81).
The consequent notion of “balance” between the host, agent, and environment that
informs the chronic disease model is much more accepting and pessimistic about the
long-term presence of etiologic agents than is the paradigm for infectious diseases. In
the latter, the agent is perceived as a noxious invader whose attack signals the rupture of
a prior equilibrium enjoyed by the host and environment; removing the agent and
restoring lost innocence becomes the goal. In the chronic disease model, however, the
focus is less on preventing exposure to or eliminating the agent than on the adaptation of
the host to life with the agent. The objective becomes elucidating how the mechanisms
of the host’s body can be altered or modified so as to deal better with the presence of the
agent. Obviously, adopting such a framework for AIDS could well be lethal.
Given the assumption of ubiquitous etiologic agents (both exogenous and endog
enous), the key research question in the chronic disease framework becomes why some
people are susceptible while others are not (81). This in turn has led to a vigorous search
for genetic markers, a trend now emerging in AIDS research as well (82). To the extent
that susceptibility is thought to be mediated by “stress” rather than solely by genes,
much of the emphasis in the chronic disease paradigm is on alleviating people’s reaction
to stress, rather than eliminating either the stress itself or the noxious exposure (80, 83).
It is easier for public health workers to modify people’s responses to existing conditions
than to challenge the “balance” of the status quo responsible for these conditions. Even
in those instances where the exogenous agent is deliberately manufactured, greater
priority is given to containment rather than eradication, as exemplified by the emphasis
on “permissible exposure limits” over product substitution in occupational health
(84,85). And, consonant with this orientation, more and more of the research on chronic
diseases is being directed toward factors primarily under the control of health care
professionals, ranging from the efficacy of patient education to iatrogenic illness. The
ultimate message is that the best way to change health is to alter aspects of the health
care system itself.
Certainly, not everyone concerned about chronic diseases has this narrow approach to
their prevention, management, and treatment (75, 78, 86). A minority public health
voice is challenging the acceptance of social conditions that contribute to current levels
of chronic disease. Emanating from the ranks of environmentalists, occupational safety
and health advocates, opponents of tobacco and of alcohol abuse, and nutritionists, to
name a few, its proponents have called for such measures as enhancing the regulatory
and punitive powers of EPA (Environmental Protection Agency) and OSHA (Occupa
tional Safety and Health Administration), enacting bans on smoking in public spaces
and workplaces as well as increasing taxes on tobacco and alcohol products, and altering
incentives to encourage food producers and retailers to market healthier foods at lower
prices (86,87).
Even so, most of the emphasis in chronic disease prevention remains targeted at
“lifestyle” risk factors, and especially at encouraging consumers to reduce their expo
sure to nonessential exogenous agents, such as “junk food,” tobacco, and excessive
alcohol and dietary fat. This strategy, moreover, works best with people who have
disposable income and leisure time to read and deal with the multiplying instructions
about how to keep healthy—not to mention living in safer neighborhoods, buying more
334 / Fee and Krieger
expensive foods, and joining health clubs (74,88). Conversely, it has been least success
ful when prevention efforts require challenging social relations as they really are, as
exemplified by the persistence of diseases of poverty and those due to occupational and
environmental health hazards.
Perhaps the best illustration of the weaknesses of the chronic disease model as a guide
for health policy is provided by the history of anti-tobacco initiatives. In many ways,
tobacco is the smallpox of chronic disease—it is the one agent that can be eliminated
and that can be aggressively fought by public health professionals, precisely because it
is a nonessential product. As such, it is the exception that proves the rule. Insofar as
smoking was seen solely as something that individuals inflicted upon themselves, much
of the public health effort was devoted to educating people about the hazards of tobacco
(in great part by affixing warnings to tobacco products and advertisements) and to
individualized smoking cessation interventions that only rarely succeeded. Efforts to
encourage crop substitution were half-hearted at best, and tobacco corporations faced
only minimal pressure to diversify their holdings. Only when tobacco-related chronic
diseases were redefined as “communicable,” courtesy of second-hand smoke and the
recognition that passive smoking constituted a health threat to nonsmokers, did the
public debate and its policy implications change radically (89-91). Prevention efforts
dramatically gained in strength and finally were able to restrict the use of tobacco in the
public sphere.
In sum, when we adopt the classic chronic disease model, we effectively embrace
what might be termed a postmodern public health policy, with all of its trappings and
flaws. In this postmodern world, one caught up in the fragmented dazzle of the global
market that reaches everywhere, people are seen to exist only as passive consumers, not
active producers, their lives a pastiche of splintered identities constructed from the
random output of our “information age” (92). With the death of the author comes the end
of accountability, and the defeat of the belief that systematic change can be achieved.
Instead, priority is accorded to the productions of the media, which reign supreme as the
ultimate symbol and purveyor of a “free choice” that isn’t.
This too is the condition of contemporary chronic disease policy. Oriented to the
market and the media, it consistently offers individuals the chance to choose between
preselected options about how to live better, even if these choices typically are beyond
the grasp of those who most need a change. Declarations on the need for prevention
serve primarily as commentary upon, rather than concrete challenges to, the social
conditions that give rise to disease, both chronic and acute, communicable and noncom
municable. Only in its refusal to cede “expert” status to members of the “lay public,” and
its desire to employ nonoverlapping, noncontradictory categories (for example, “infec
tious” versus “chronic”), does this paradigm retain important yet problematic vestiges of
its “modem” origins.
At a time when AIDS has already been designated as the first “postmodern” disease
(93), and has provided the text for reams of commentary and reflection upon contem
porary society, it is particularly important that AIDS prevention policies not succumb to
the fatal logic of the chronic disease model as construed in our postmodem world.
We cannot accept an approach that cleaves the categories of “communicable” and
“chronic,” that insists on an “either/or” logic when “both/and” thinking is required. The
failures of containment policies for communicable diseases already abound, as
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evidenced by the growing epidemic of drug-resistant tuberculosis, itself linked to the
HIV epidemic (94, 95), by the reappearance of cholera in the western hemisphere (96),
and by the rise of measles due to insufficient funding to cover the cost of vaccination
(97,98). Nor have individualistic strategies succeeded in reducing the incidence of most
noncommunicable chronic diseases. It is time for another approach, and time to forge
another history of AIDS.
THE NEED FOR A NEW PARADIGM:
AIDS AS A CHRONIC INFECTIOUS DISEASE
AND PERSISTENT PANDEMIC
The third history begins with the recognition that neither of the first two histories of
AIDS—as gay plague and as chronic disease—adequately reflects the complex realities
of HIV-related diseases. Indeed, AIDS challenges all of our categories. If a plague, it is
a peculiarly slow-moving plague; if a chronic disease, it is a notably communicable
chronic disease. The standard assumptions surrounding the categories of infectious and
chronic diseases thus fail to capture the multiple dimensions of AIDS.
These are not merely semantic objections. The words matter. We propose that a more
adequate conceptualization of AIDS must be based on the fact that AIDS is a chronic
infectious disease. Neither of these terms, “chronic” or “infectious,” can be eliminated
or ignored. Their order is, moreover, important from the point of view of prevention and
policy. By calling AIDS a chronic infectious disease (rather than an infectious chronic
disease), we emphasize the aspects of etiology, transmission, and prevention as opposed
to clinical management.3 Indeed, we might well term AIDS a collective chronic infec
tious disease in order to emphasize the inadequacies of dealing with AIDS from a purely
individualistic perspective; AIDS is, above all, about people in personal and social
relationships. And by calling AIDS a persistent pandemic, we emphasize both the long
time frame of the disease and its global impact. Changing our historical construction of
AIDS thus means changing the policies we perceive as relevant, and our sense of the
time frame for developing interventions and preventing disasters. At issue is the urgent
need to overcome the limitations of current ways of rigidly dichotomizing so-called
“infectious” and “chronic” diseases, for if we cling to outdated categories and
approaches, we will undercut our efforts to prevent and ease the burdens of AIDS.
In moving toward a new paradigm, we need to acknowledge that the old categories of
infectious versus chronic disease that prove problematic in dealing with AIDS break
down in many other places as well. The distinction between infectious and chronic
disorders provided the basis for an important polemic in the 1940s and 1950s, when
epidemiologists and public health officials were persuaded that their older emphasis on
infectious diseases was inadequate to the apparently noncommunicable chronic ills that
afflicted the populations of the more developed world (99,100); although that polemic
3 The terminology of “infectious chronic disease” places a disease in the general category of chronic
illnesses, with the term “infectious” used as a modifier. By contrast, “chronic infectious disease” highlights the
infectious character of the disease, modified by its chronic or long-term features (of both latency and period of
infectivity). Our taxonomy thus draws attention to the etiology, mode of transmission, and possibilities for
prevention rather than the more usual focus on pathology.
*
336 / Fee and Krieger
was successful, the categories now serve as much to impede as to promote thinking
about disease. Elizabeth Barrett-Connor (40) has already argued that the distinction is
arbitrary and is detrimental to understanding the epidemiology of a wide variety
of diseases. By cleaving the two realms, the traditional categories barely admit the
possibility of chronic infectious diseases (such as tuberculosis and herpes zoster) and
also suggest that we are somehow to think differently about latency, transmissibility,
etiology (especially unifactorial versus multifactorial), and behavioral risk factors for
uinfectious” versus “chronic” diseases, thereby skewing the research questions asked
and policies proposed.
The different orientations to time inherent in the infectious and chronic disease
models have quite different implications for disease prevention policies. The older
plague model fostered a general attitude of crisis, including Draconian approaches to
prevention; the chronic disease model expanded the time frame but turned attention
away from prevention toward disease management. The third and more inclusive model
implies that we need long-range strategies for dealing with the disease, including more
effective methods of prevention over the long haul as well as providing care and social
support for those already infected and those already sick. It acknowledges, like the
earlier plague model, the extraordinary disruption and devastation produced by an
infectious disease that afflicts people in their prime productive and reproductive years.
At the same time, it offers a less pessimistic approach for people who test positive to
HTV since it implies that a positive blood test is not an immediate death sentence but the
sign of a major problem that must be dealt with and lived with for many years, with
adequate social services, counseling, and health care.
As we begin to develop these programs, we must recognize the failures of prevention
in the traditional infectious and chronic disease models. On the infectious side, for
example, the reemergence of tuberculosis shows that, while it is important to find drugs
effective against pathogenic organisms, these may only provide a temporary respite,
perhaps lasting for several decades, before old problems reassert themselves. Effective
drugs should be used to buy time to address the social context of the production of
disease, not merely be developed as ends in themselves while the social context of
disease is ignored. People in the health field need to understand that we cannot expect to
address all of our ills within the health care system; planning for prevention should not
be focused on a single-minded search for a technical fix.
Our approaches to prevention of the noninfectious diseases have also been too
narrowly conceived. Too often the framework of prevention has merely been to per
suade individuals to become more educated consumers and to desist from consuming
hazardous products. More and more community-based interventions are now challeng
ing this limited approach (101-103). In occupational and environmental health, for
example, community-based efforts have proved far more successful than individualized
interventions. In the case of AIDS, community-based safe sex campaigns, needle
exchanges as a community endeavor, mass leafleting of bars, and community health
outreach workers are proving considerably more effective than earlier individualized
approaches (55,104).
Beyond this, AIDS has repeatedly demonstrated that people cannot be dealt with as
isolated individuals as they are in both the infectious and chronic disease models, but
must be addressed as members of particular communities with historically determined
Thinking and Rethinking AIDS / 337
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identities. Within the gay community, much thought and creativity has gone into the
development and promotion of safer sex practices. But cultural patterns of cruising and
sexual anonymity are directly related to historic patterns of discrimination (22); a
longer-term strategy for preventing transmission of sexually transmitted disease must
include the effective implementation of anti-discrimination statutes. By affecting both
the character and institutions of same-sex sexual encounters, AIDS may well have
long-term effects on the politics of identity within the gay community; just as identity
politics were largely a reaction to social discrimination, so the weakening of discrimina
tion can open up more political options (and diversity of social experience) within this
or any other affected group.
The forms of male sexuality related to AIDS transmission are certainly not restricted
to gay men; they are forms of male sexuality that have long been celebrated and
promoted, and they are culturally reflected and reproduced in our ideas of masculinity,
our child-rearing patterns, and the constant selling of sex as a commodity. We are also
only beginning to come to terms with the hidden world of bisexual married men who are
invisible to most AIDS programs, yet are crucially important for disease transmission
precisely because of the levels of secrecy involved. It is also important to consider the
needs of those men who have sex with other men but do not view themselves as part of
the gay (“white”) community. It may be more effective to reach them through churches,
minority organizations, and trade unions, and to conduct outreach efforts in bars,
truck stops, and areas known for prostitution. Within the more restrictive approach of
marketing safer sex, sex stores and sex videos have begun the enterprise of making
safe sex sexier, and condom manufacturers have started to develop more innovative
condoms in a variety of colors and tastes (105).
The overwhelmingly individualistic biomedical orientation of the infectious and
chronic disease models and their typical disregard for the particular health status of
racial/ethnic minorities in the United States also has distorted our understanding of the
full epidemiology and reality of AIDS. Much of the early writing about AIDS, for
example, ignored its prevalence and unique characteristics among people of color.
Patterns of homosexuality and heterosexuality are not, however, cultural givens; they
have different social constructions within white and minority ethnic communities, and
these differences need to be understood and appropriately addressed (106-110). Given
the multiple social and economic difficulties that many of these communities face, the
specific problems of AIDS need to be approached within an understanding of the issues
of employment, education, housing, economic development, and the struggles against
the drugs that are flooding inner city communities. Needle exchange programs, for
example, should be allied with drug treatment programs and other initiatives that offer
some hope for an alternative to long-term drug dependence (111, 112). Most of the
issues that are critical for people with AIDS, such as housing and health care, are
widespread problems throughout these communities.
The epidemiological categories of “risk groups” that are firmly embedded in the
infectious and chronic disease models have also tended to mask the class basis of many
health issues. AIDS and HIV-related diseases are no exception. Official AIDS statistics,
for example, report cases classified by age, gender, race/ethnicity, and mode of
transmission and do not provide any information on poverty or social class (113).
The invisibility of class in the official data mirrors the invisibility of class in public
338 / Fee and Krieger
understanding and public policy. For their part, most trade unions have not had AIDS
education on their agendas. A few unions are, however, now starting to take up issues
in AIDS eduction; the Service Employees International Union (SEIU), for example,
recently broadened its needle stick injury prevention program to include general educa
tional materials about safer sex and AIDS (114). As we move away from thinking solely
in emergency terms and in terms of static, individualistic “risk groups,” with the health
experts in charge of strategic planning for AIDS, it should be possible to develop more
coalition-based planning and policy making by involving unions and community-based,
minority, and gay organizations (115).
Similarly, the problems of AIDS among women have only recently received much
attention (116, 117) with the lag attributable, in part, to the predominance of narrow
constructions of AIDS. To date, women with AIDS have tended to be ignored and left
out of programs because they did not fit easily into gay male groups, because their
symptoms and constellation of infections did not fit Centers for Disease Control (CDC)
guidelines, or simply because AIDS programs were specifically designed for men
(118-121).
Just as AIDS shows the inadequacy of mutually exclusive categories of infectious and
chronic diseases, so too it challenges the traditional distinctions and separations between
maternal and child health, women’s reproductive health, pediatrics, and infectious
diseases. AIDS crosses all the boundaries and, especially for women with AIDS, the
boundaries themselves are part of the problem of gaining access to care and social
supports for themselves and their children. There are, for example, virtually no detox
programs that will take pregnant women or women with children.
The traditional assumptions around chronic disease care involve a family structure in
which women are available to provide care for a sick family member. The chronic
disease model rarely deals with the familial incidence of disease or situations in which
several generations within one household are affected by disease at the same time. In the
case of AIDS, mother and children may all be ill; we are also seeing a new generation
left orphaned at an early age (122,123). Such a situation requires new forms of care for
children and attention to the total impact of disease on the household, not simply on the
sick individual.
AIDS also poses the issue of women’s reproductive rights in dealing with disem
powered women whose ideas about childbearing may not fit those of their physicians or
other health professionals (124-127). Women with AIDS and women who use drugs
have found their reproductive rights restricted in every possible way. On the one hand,
the opposition posed between the rights of the mother and the rights of the fetus has led
to generally punitive attitudes toward any mother who fails to abide by the increasingly
rigorous standards of healthy motherhood; on the other hand, women are punished
because of social resentment of the financial demands that they and their children may
make on society (128). One response to the numbers of infants with AIDS has been to
deny women’s rights to bear children; health care professionals often assume that any
pregnant woman with AIDS should have an abortion. The presence of disease does not,
however, abolish a woman’s right to control her body, nor does it mean that all women
want to end childbearing. Women who want to have children despite HIV infection need
to be supported in this choice through the provision of health care for themselves and
their children; they are likely to need counseling, access to child care options, and
Thinking and Rethinking AIDS / 339
assistance with housing. Coming to terms with these questions in the case of AIDS may
prepare us for the many issues raised by the genetic screening tests that will soon be
available to detect a multiplicity of genetic disease markers (129). In our preoccupation
with the scientific potential of genetic screening, we have not devoted the necessary
attention to the social meanings and conflicts that will be precipitated by the application
of these technologies.
Nor is the problem of preventing AIDS in women simply a matter of encouraging
women to buy condoms, that is, simply an issue of purchasing a barrier to infection (as
the infectious disease model would propose) or of acting as a responsible consumer (in
accord with the chronic disease model). Any serious approach to prevention must take
into account women’s general lack of power in relationships with men; the consequent
relations between sexuality, economic dependency, and power; rape, coerced sexuality,
and violence against women; and the fact that casual prostitution may be an important
way of earning money in a world where women’s labor is often not valued (118).
Women’s ability to protect themselves from HIV infection is part economics, part
power, part physical danger, and part psychology; it requires social support and protec
tion for women who try to “Just say no.”
What Are the Health Policy Implications of This Third View?
When we conceptualize AIDS as a collective chronic infectious disease and persistent
pandemic, following the third historical model, we can take the time necessary to
develop more effective interventions. Whereas a classic, time-limited epidemic lasting a
few days, weeks, or months allows time only for immediate, emergency measures, a
longer time frame should enable us to address the myriad unanswered questions about
sexuality and drugs, and thereby develop appropriate mass education methods targeted
at multiple different communities (117, 130). We must also study the social context of
sexuality and drug use patterns: the cultural meanings of sexuality, not simply numbers
of sexual contacts, are an essential aspect of developing more effective forms of
prevention (22,131). For sexually transmitted diseases, we need a better understanding
of the various reasons that people engage in risk-taking behaviors, of how to sustain
changes in risk-taking behavior over time, of how people negotiate power within sexual
relationships, and how to balance risk reduction against abolition of harm. We know
very little about sexuality—what people like, what people think they want, what people
do—and we must more effectively address the political resistance to gaining this
knowledge. In the United States, the suppression of recent national sex surveys is a
foolish and dangerous refusal even to gather the minimal data needed (132-134). We
also need to rethink the standard patterns of prevention based on individual behavior and
to start thinking about prevention in terms of people in relationships—including both the
variety of sexual relationships, from anonymous to monogamous, and the larger social
relations of race, class, and gender.
We have seen that AIDS has affected several defined communities such as urban
gay men and injection drug users and that different health education and prevention
techniques are required to reach diverse constituencies. We cannot assume, however,
that HIV infection will be confined to these defined communities; while working on
different methods of prevention in communities already heavily affected, we should also
'sDl-S'Sxr
03824
I
340 / Fee and Krieger
in communities not yet deeply touched‘ ‘by' the
be developing effective prevention
we can learn ways of
disease. The longer time frame we now accept implies that
devastated. Our
preventing infection before many more whole communities areeffective planning;
fact that AIDS is achronic as well as communicable disease
rctatag We
=ISX"—incin’g
Mom ?1CaTr
es a
w°uid mean a abUi;y ?
th HIV related diseases, but would clearly provide an essential part of t e
i
setting P°licy. continued attention. The problems associated with
There are other ma«e*^
worked QUt and are still highly
testing and screemn or HIV h^v only m p
1
1
XeTtc.dealing whh other diseases as well. We are, perhaps, beginning to learn the
importance of having affected communities involved in the process of p anning
I
i
I
I
I
are likely to be also applicable to other new (and old) diseases.
I
CREATING A THIRD HISTORY OF AIDS
*
ASSESS’—
roppMJe »t .he
aon
^^"^pcnencc with AIDS should therefore not only help
■*
°„s
for o-he« diseases, bn. also force ns to ad^
whose very existence established the models used to construct the first and
histories of AIDS. As part of this, we must acknowledge that these old disea
AIDS persist both in the United States and around the world not simply because
Thinking and Rethinking AIDS / 341
of knowledge, but because of socially created political and economic obstacles, which
can only be overcome by being publicly identified and directly tackled. By capturing the
worst elements of both infectious and chronic diseases in the populations assaulted and
in the failures of health policy, AIDS has become a protracted disorder of the dis
possessed. It demands analysis of their situation in its totality and not simply as yet one
more disease problem to be approached in the usual fragmented and incomplete manner.
As the histories of AIDS so clearly demonstrate, we naturally look for analogies from
the past. In general, this is appropriate. It can also be grossly misleading. Prior construc
tions of disease—of plague, of chronic illness—have simultaneously enhanced and
constrained our understanding of AIDS and our response to this new epidemic. Each has
invited us to think and act in particular terms, using concepts and approaches shaped by
past periods of history. Complementary if not mutually exclusive, these successive
paradigms have demanded that we either wage war on a mass epidemic or else contain
a chronic ailment.
AIDS, however, has defied efforts at neat categorization. Challenging our narrow
taxonomies of disease classification, this new affliction has highlighted serious flaws
not only in the application, but also in the assumptions of predominant disease preven
tion strategies. In one short decade, AIDS has changed from a disease with no history to
one with a history in its own right, that is not merely derived from the past, but belongs
to the present we occupy and the future we forge. As we think and rethink our way
through this wretched and wrenching epidemic, we must be prepared to embrace its
complexities and contradictions. Perhaps by doing so, we will make ourselves more
open to responding to the demands of other emerging diseases, and more able to deal
with the scourges of the past that haunt us still.
^ote — This article was prepared for the International Symposium on Emerging
Infectious Diseases, sponsored by the Fondation Louis Jeantet and Fondation Marcel
MSrieux, and held in Annecy, France, April 6-8,1992.
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Direct reprint requests to:
Dr. Elizabeth Fee
Department of Health Policy and Management
School of Hygiene and Public Health
The Johns Hopkins University
624 North Broadway
Baltimore, MD 21205
Reducing HIV incidence in developing countries
with structural and environmental interventions
Michael D. Sweat and Julie A. Denison
AIDS 1995, 9 (suppl A):S251-S257
Keywords: AIDS, HIV, AIDS prevention, HIV prevention, behavior
change, social structure, environment, economics, developing countries.
Introduction
The AIDS epidemic is generally viewed as a health prob
lem, largely exacerbated by the risk behavior of people
who either do not know how to change, do not want to
change or do not have the means to change their level of
infection risk. This perspective of AIDS, as a disease of
the individual, has dominated prevention efforts. Struc
tural and environmental factors, however, such as poverty
and migration, make a significant contribution to the
spread of HIV infection [1,2], While it is important to
target the individual in attempting to prevent AIDS, a
more comprehensive approach, including interventions
on the structural and environmental level, may allow the •
effectiveness of prevention programs to expand beyond
that realized from only individualistic approaches. In this
review, we examine the potential for HIV interventions
at the structural and environmental level.
The typical theoretical approach to AIDS prevention
is based largely on individual psychology. Prevention
programs frequently attempt to motivate people to reduce their risk behavior, or maintain low-risk behavior,
r through persuasion. Education, information, counseling,
HIV testing and other services are provided to influence
individual psychological processes that appear likely to
produce changes in behavior. Many of the major the* ories of AIDS risk reduction, and health promotion in
general, are primarily psychological theories. These inelude the AIDS Risk Reduction Model [3], theories of
self-efficacy, the Stages of Change Model [4], the theory
of reasoned action [5], the Common Sense Model of
Illness Danger [6], the Precede Model [7], the Health
W Belief Model [8—11 J, social learning theory [12-14] and
others.
While the relationship between social, structural, and
environmental factors and HIV/AIDS risk is now better
9 understood, HIV prevention interventions that operate
on these levels are sorely lacking. In this review the use
of structural and environmental interventions for HIV
risk reduction is examined by (1) developing a theo
retical approach to levels of causation in HIV incidence
that goes beyond the individual perspective; (2) examin
ing structural and environmental factors that have been
shown to promote the incidence of HIV; (3) suggesting
possible structural and environmental interventions that
may prevent AIDS; and (4) presenting a research agenda
for further investigation on this topic.
Levels of causation
The causes of most health and social problems have mul
tiple levels, with each level having associated change
mechanisms with unique natural limits in their ability to
effect change. A typology of four levels of causation has
been identified, comprising superstructural, structural,
environmental and individual levels. Table 1 summarizes
each causal level for the discussion that follows.
Superstructural factors encompass both dominant val
ues about macrosocial and macropolitical arrangements,
often developed over long periods of time, and physi
cal and resource characteristics that result in advantages
or disadvantages. Examples of superstructural factors in
clude economic underdevelopment, sexism, racism and
homophobia. Mechanisms of change for the superstruc
tural l£vel include such actions as national and interna
tional social movements, revolution, land redistribution
and war.
Structural factors include laws, policies and standard op
erational procedures. For example, unregulated commer
cial sex and few laws to protect worker rights are likely
to increase HIV epidemics. Mechanisms of change at
the structural level include legislative lobbying, civil and
human rights activism, boycotts, constitutional and legal
reform, and voting.
Environmental factors include living conditions, re
sources, social pressure and opportunities available to in-
From the AIDS Control and Prevention Project, Family Health International, Arlington, Virginia, USA.
w. Sponsorship: This research was supported by The Kaiser Family Foundation and the Family Health International AIDS
Control and Prevention (AIDSCAP) Project under contract to the United States Agency for International Development.
Requests for reprints to: Dr Michael D. Sweat, Suite 700, 2101 Wilson Boulevard, Arlington, VA 22201, USA.
u
© Current Sdehce Ltd ISBN 1-85922-239-0 ISSN 1350-2840
S25i
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AIDS 1995, Vol 9 (suppl A)
Table 1. Levels of causation for HIV incidence.
Causal level
Definition
Superstructural Macrosocial and political arrangements,
resources and power differences that re
sult in unequal advantages
Structural
Laws,^policies and standard operating
procedures
Examples
Economic underdevelopment, declining
Change mechanism
agricultural economy, poverty, sexism,
homophobia, Western domination, im
perialism
National and international social move
ments, revolution, land redistribution,
war, empowerment of disenfranchised
populations
Unregulated commercial sex, bachelor
Legislative lobbying, civil and human
wage system, no family housing required
at \worksites, lack of human rights laws,
no financial support
for social services>
,.
rights activism, boycotts, constitutional
and legal reform, voting, political pressure, structural adjustment policies by
international donors
Environmental
Individual living conditions, resources
and opportunities, recognition of individual, structural and superstructural fac,ors
V
‘ camps with many single men and
Work
few women, few condoms,. high
preva„ 1 prevalence of HIV/sexually transmitted disease, family far away, few job opportu
nities, few social services, failing agricul
tural economy, industrialization and ur
banization
Community organization, provision of
social services, legal action, unionizalion, enforcement of laws
Individual
How the environment is experienced
and acted upon by individuals
Loneliness, boredom, lack of knowledge, low risk perception, sexual urges,
moral values, perceived self-efficacy,
perceived locus of control
Education, provision of information, improved self-efficacy, rewards and pun
ishment, counseling
dividuals. Examples include work camps with many men
isolated from their families, poor social services and ready
access to commercial sex. In essence, the environmental
level is the realization of individual, structural, superstructural, and other factors in the real world. Change
at the environmental level is best realized through such
processes as community organization, provision of ser
vices, legal action, and civil disobedience.
The individual level describes how the environment is
experienced and acted upon by individuals. Examples in
clude loneliness, boredom and a low perception of risk.
Changes on the individual level can be realized through
such factors as education, provision of information, re
ward and punishment, improved self-efficacy and coun
seling.
Structural and environmental
interventions
Many significant, large-scale changes in the reduction
of risk and in individual self-protective behavior can be
attributed to changes in the social structure and envi
ronment. Moreover, these changes in the area of health
promotion have often been wide-scale, nearly universal
and sustained over long periods of time. Table 2 sum
marizes some of the many structural and environmental
public health interventions that have been successfully
implemented.
Over the past 20 years, massive efforts have been made
to reinforce a reduction in cigarette smoking in the
United States through educational programs on the dan
gers of smoking. These individual approaches to the ces-
Table 2. Examples of structural and environmental interventions.
Enriching foods with nutrients to ensure adequate diet
Increasing educational opportunities for women,
which also results in reduced fertility rates
Taxing cigarettes to reduce consumption level
Conducting syphilis screening on all hospital admissions
Requiring head protection for motorcycle riders
Fluoridating water supplies to reduce cavities
Banning smoking in public spaces
sation of smoking encouraged many to stop; however,
not until smoking was banned in many public places did
the prevalence of smoking significandy decline [15,16].
These structural and environmental changes have had the
effect of forcing smokers to smoke near the entrances of
worksites exposed to the elements, and in special sections
in restaurants and airplanes. Perhaps more importantly,
this has also had the effect of labeling smokers as social
outcasts and deviants. Thus, by intensifying the individ
ual approach to the cessation of smoking with struc
tural (antismoking laws) and environmental pressures (so
cial isolation and stigma), the impact of prevention pro
grams was significantly increased far beyond the results
of purely individualistic approaches.
Seat-belt usage programs are another example of an in
dividual level intervention that has been significantly
improved by the addition of structural and environ
mental interventions to existing individualistic programs.
Early efforts at stimulating seat belt usage were based
on individual-level education campaigns. Not until laws
were passed on the use of seat belts at a structural le
vel did their prevalence of use become widespread in
the United States. This effect was significantly increased
when environmental-level interventions were developed
*
*
V
*
HIV prevention with environmental interventions Sweat and Denison
.n the form of a requirement for seat belts to be installed
^n all new vehicles. Again, the expansion to structuraland environmental-level interventions generated behav
ior change and risk reduction on a level that would be
extremely difficult to achieve with individual-level in
terventions alone.
Structural and environmental HIV intervention pro^grams have significant advantages over those that are
based solely on individual level approaches. Social norms
are most likely to change at the environmental and struc
tural levels, and with a change in the social norm comes
a change in associated behavior. Norms and values are
^developed primarily through socialization, which oc
curs through social interaction at the environmental level
[9]. Furthermore, norms can be influenced by structural
changes, such as laws and policies that require adherence
to proscribed behavior. Over time, the new behavior
can become habit, and the social norm and expecutions
‘catch up.’ For example, the seat belt usage mentioned
above significandy increased when the use of seat belts
was mandated by law. Eventually, many people who be
gan to use seat belts only to avoid traffic tickets became
so accustomed to them that they now use them without
thinking.
As we move into the second decade of the AIDS pandemic, several structural and environmental factors can
be identified as being significantly associated with the
promotion of HIV epidemics. Many social, cultural, eco-_
nomic and political factors can be shown to facilitate
HIV transmission. There are, however, three sets of social
forces that appear to be growing in significance: (1) eco
nomic underdevelopment and poverty; (2) migration,
urbanization and family disruption; and (3) war and civil
disturbances.
Economic underdevelopment and poverty
The relationship between economic underdevelopment,
< poverty and AIDS is most apparent cross-nationally.
Those countries with the lowest standards of living are
also the ones with the most serious AIDS epidemics in
terms of HIV incidence [17-19]. Similarly, AIDS exacer
bates poverty in poor countries hit hard by the epidemic,
contributing to a cycle of underdevelopment and AIDSrelated mortality [20,21]. Intracountry analysis also in
dicates that poverty, in both poor and rich countries, is
often associated with a high HIV incidence [19], and that
those with fewer economic resources are likely to die
more quickly from AIDS than those with greater wealth
[22,23].
W
*
Several factors that are the direct result of economic
underdevelopment and poverty operate on the structural, environmental and individual levels to increase
the potential for HIV infection. On the structural level,
few significant laws or policies regarding AIDS preven
tion are in place in developing countries. In general, in
S253
less developed countries, the poor often find that other
health and social issues are more important and imme
diate compared with AIDS, and there are few AIDS ac
tivists to encourage legal and policy reform. Moreover,
most developing countries have few legal restrictions
on management practices, and work environments often
foster HIV risk behavior through substandard pay, few
entertainment opportunities, isolation from the family
and limited access to health care, especially treatment of
sexually transmitted disease.
Structural adjustment programs and economic recession
have amplified the effects of poverty on the AIDS epi
demic in many countries. The reduction in basic so
cial services, infrastructure and educational opportuni
ties, together with increased unemployment, landlessness
and poverty brought on by economic decline and struc
tural adjustment programs has left Africa highly vulner
able to AIDS, since these economic forces promote mi
gration, family separation and sex work [24]. As Sanders
[25] notes: ‘Failure to identify and address the social and
economic factors underlying the spread of HIV infection
in Africa has... led to an overwhelming concentration
on sexual behaviors... without concomitant concern for
influencing their structural determinants.’
Migration, urbanization and family
disruption
Migration is significantly associated with the develop
ment of AIDS epidemics, especially in Africa [26-30].
Migration facilitates HIV transmission through several
processes. With declining agricultural production in ru
ral areas [31] and the lure of cash employment in
cities [32,33], many men migrate to cities in search of
work. This process generates large populations of un
employed and underemployed men in urban areas, sepa
rates men from their families and promotes urbanization
[34]. Many women also migrate to urban areas and work
camps in search of employment, often turning to prosti
tution to survive when other employment opportunities
are unavailable [35].
Those rural men who find urban employment frequently
use their wages to purchase sex from commercial sex
workers to satisfy their sexual desires, loneliness, bore
dom and lack of entertainment [36]. The link between
the spread of HIV infection and sexual contact between
sex workers and clients in developing countries is clear
[37—40]. Most migrants return home regularly, carrying
HIV into the rural areas [30]. Moreover, many migrants
have little knowledge of HIV and AIDS, and of ways to
protect themselves from infection, and they frequendy
do not realize they are risking infection [27]. These
individual-level factors have promoted AIDS transmis
sion in many developing countries.
Many structural and environmental factors have also pro
moted AIDS epidemics in developing countries. Sig-
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AIDS 1995, Vol 9 (suppl A)
nificant urbanization has occurred in many developing
countries over the past 30 years [41]. Economic depen
dency is significantly related to the rate of urbanization,
fueled largely through growth of tertiary and informal
economic sectors, and inhibited growth in the industrial
labor sector [42]. The increasing urbanization of devel
oping countries has significantly promoted HIV trans
mission on multiple levels. Urbanization brings people
closer together in time and space, allowing a rapid spread
of HIV through densely populated areas. Urbanization
of traditional societies has brought many people, often
young and with little knowledge of AIDS, into social
environments with fewer social control mechanisms than
they may be accustomed to having. Rapid urbaniza
tion has also promoted changes in the perceptions of
responsibility to the community and family [43], leading
many to experience loneliness, isolation and depression
[44,45], factors that likely promote risk-taking.
Military life has structural and environmental features
that often promote HIV risk-taking. Military popula
tions, mostly men, are often separated from their fam
ilies for long periods, leading to loneliness and sexual
frustration. In many countries in the developing world,
cash income is more readily available to members of
the military than to the general population, thus provid
ing the economic capacity to purchase commercial sex.
Boredom during peacetime is also a factor that promotes
frequent sex with prostitutes [49]. The culture of many
military institutions is often highly sexist, and it tends
to foster a group consciousness that can lead to peer
pressure to engage in risky behavior with little regard
for the potential for HIV transmission. Military culture
is based on deference to authority, not individualism and
innovative behavior. These factors have promoted high
levels of HIV incidence among members of the military
in many developing countries [47]. Prevention efforts
that attempt to mitigate these factors without significant
changes in the social structure and environment are not
likely to be effective.
War and civil disturbances
A growing factor that has to be considered in AIDS pre
vention is the effect of war and civil disturbances, which
have become significant facilitators of HIV epidemics
in recent years in many countries. Military populations
often run a very high risk of HIV infection [46], More
over, the effects of war, and preparation for war, pro
mote the spread of HIV though several processes, such as
(1) generating large numbers of refugees, (2) disrupting
prevention programs, (3) separating military men from
their families and (4) promoting a disregard for individual
human rights.
AIDS epidemics in Africa have been severely affected
by war. For example, thousands of people fleeing from
brutality in Rwanda have ended up in camps in Tanza
nia, Uganda and Zaire [47]. Conditions in these refugee
camps raise the specter of large-scale AIDS epidemics
due to poor social services, high population density, sep
aration of families, poor condom availability and little at
tention paid to AIDS education and prevention by health
workers. Recent efforts to address AIDS prevention in
Rwandan refugee camps in Zaire and Northern Tanza
nia (USAID and AIDSCAP staff, personal communica
tion, 1994) are commendable. However, the programs
should be evaluated carefully, and implemented in other
sites when appropriate.
War and civil disturbances have also disrupted AIDS pre
vention programs, for example, in Haiti, Rwanda, Nige
ria, Zaire, Uganda, Ethiopia, Myanmar, Mozambique,
South Africa, Angola, all of which have a significant HIV
incidence. A climate of political repression and fear is not
conducive to innovative AIDS prevention, and frequent
changes in funding for prevention are often affected by
donor embargoes on foreign aid, making both preven
tion and medical care for those infected with HIV dif
ficult to obtain [48].
Structural and environmental
interventions for AIDS prevention
Despite the clear relationship between structural and en
vironmental factors and HIV epidemics, there have been
few attempts to intervene on the structural and envi
ronmental levels, and when they have been attempted,
such interventions have rarely been evaluated for their
effectiveness. A few examples of attempts at structural
and environmental interventions can be found in both
developing and developed countries.
For example, in 1984 the director of the San Francisco
Public Health Department issued an order banning highrisk sex in gay bathhouses. The bathhouses were to be
regulated by ‘monitors’ who were responsible for eject
ing any patron who was seen engaging in high-risk sex
ual behavior. Later that year, bathhouses were ordered to
be closed [49]. There are some important lessons to be
learned from this experience. First, the initial reaction
of many in the targeted community was hostile. Many
saw the closing of gay bathhouses as an affront to their
civil rights to free association and sexual liberation [50].
However, soon after the regulation of behavior in the
bathhouses was initiated, few in the homosexual com
munity continued to raise these concerns. The impact
of the bathhouse closing also sent the signal that social
acceptability for unprotected sex for homosexual men
was no longer the accepted norm. The impact of these
actions on risk reduction remains largely unmeasured.
A unique structural and environmental intervention for
HIV prevention known as the 100% condom program
has been pioneered in Phitsanuloke, Thailand, an area
with very high incidence of HIV infection [51], The
key components of this program are: (1) commercial sex
workers must use condoms with all clients, (2) brothel
>
e
F
S255
owners must enforce condom use by assisting commer
cial sex workers with uncooperative clients, (3) condom
use is monitored in brothels, (4) compliance is moni
tored through a regular review of gonorrhea rates among
commercial sex workers, and (5) graduated sanctions are
applied for non-compliance, targeting brothel owners,
whose establishments are closed if repeated violations occur.
Initial reports indicate that this program has had a pro
found effect on the level of unprotected sex and on the
incidence of sexually transmitted disease and HIV [52].
The program has recently been expanded nationally, and
impressive results have ensued. A recent evaluation of
, the rates of sexually transmitted disease has shown a dra
matic reduction in incidence since the establishment of
this law [53], to the point that many clinics for sexually
transmitted disease clinics are finding very few clients
each day. Moreover, social norms towards unprotected
sex with prostitutes have dramatically changed [54]. Ini
tial reports indicate that it is becoming less acceptable,
and more difficult, to have sex with a commercial sex
worker without a condom in Thailand [53]. It remains
* to be seen whether these effects can be sustained, and
whether such a program would be effective outside of
J the Thai context.
One controversial structural/environmental intervention
for AIDS prevention was implemented in Cuba. Cuba’s
AIDS control program was, until recently, composed of
five key components [55] including: (1) blood screening
for HIV, (2) widespread HIV testing of the population,
(3) educational programs to reduce HIV risk behavior,
(4) isolation of HIV infected individuals in sanatoria with
better health care and living conditions than those of the
average Cuban and (5) clinical research to identify the
best treatment protocols for those with HIV and AIDS.
The impact of this intervention approach, based largely
on structural changes, has not been fully evaluated. More
recently, many of the sanatoria have been closed, and
community-based care is becoming more common.
These examples of structural/environmental HIV inter
vention programs raise several important issues. First,
like other intervention approaches, structural and en
vironmental interventions have significant potential for
violating individual civil rights. In particular, they pit
the rights of individuals against the concept of collec
tive community rights. Second, when the community
accepts and supports changes in the social structure and
environment, the intervention is more likely to succeed.
Third, the interventions should be evaluated in order
to identify their impact on risk behavior. Often, when
a structural or environmental approach has been taken,
there has been little coordinated attempt to evaluate the
impact on HIV incidence.
Table 3 provides examples of other possible structural
and environmental interventions. However, a clear re
search agenda needs to be developed so that the most
appropriate and effective programs can be implemented.
Moreover, the interventions need to be designed to serve
as models for emulation and to allow clear measurements
of real changes in behavior.
Table 3. Examples of potential structural and environmental
changes.
Potential structural changes
AIDS impact assessments required for large development projects,
especially those funded by international donors
Laws and policies that require 100% condom usage in brothels
Laws requiring family housing at migrant labor camps
Laws outlawing wife inheritance
Requirement for hotels to stock condoms in each room
Reduction of taxes on condoms
Changes in government policies that permit nationwide marketing
of condoms and explicit AIDS prevention by mass media
Potential environmental changes
Better recreational facilities at military bases to reduce boredom
and the desire to visit brothels
Changes in truck routes to allow truck drivers more time with
families
Employment of entire families for migratory labor rather than men
alone to keep families intact, and building housing for migrant
families at work sites
Staggered paydays to dissuade group brothel attendance
Provision of check-cashing facilities to dissuade payday alcohol
use and risk behavior in settings where saloons are the only
places available to cash checks
Policies that require 100% condom use with sanctions on brothel
owners who fail to comply
Access to AIDS prevention and care for sexually transmitted dis
ease at work sites
Mentoring programs at work sites with large numbers of migrant
workers to facilitate social integration of new arrivals
Availability of condoms in traditional and especially in nontraditional outlets such as bars, hotels, flower shops, truck stops
Improved care for sexually transmitted disease, such as use of syn
dromic management in treatment and better availability of drugs
Conclusions and recommendations
As the worldwide AIDS pandemic matures and changes,
so too must the approach to prevention. AIDS preven
tion programs need to incorporate more than just in
dividualistic psychological approaches to risk reduction.
It is important to learn more about the effect of so
cial, cultural, political and economic factors on HIV risk
behavior, and to develop creative, culturally appropri
ate and community-sponsored prevention programs that
make substantive changes on multiple levels. Although
superstructural factors such as poverty, economic under
development, sexism and homophobia are pervasive and
difficult to change, there are many opportunities to make
changes in the social structure and in the environment
that can lead to a significant reduction in HIV incidence.
Individual, psychological intervention approaches will
not promote optimum changes in behavior when struc
tural and environmental constraints are not addressed.
S256
AIDS 1995z Vol 9 (suppl A)
Community involvement in shaping and implementing
structural and environmental HIV interventions is a cru
cial factor in their success. As discussed earlier, when
communities are involved in a prevention program, it is
much more likely to succeed. However, there is much to
be learned about the process of community mobilization
and the techniques that best promote sustainable com
munity participation. It is essential, also, to ensure that
any outcomes are ethical, since the process of making
changes in the social structure and the environment in
order to address social and health problems carries a risk
of unethical outcomes. A research agenda for addressing
these issues needs to be developed and undertaken.
Four areas of research have priority when studying struc
tural and environmental interventions for HIV preven
tion. First, descriptive research is needed to clarify the
patterns of structural and environmental determinants of
HIV incidence, and their variations by region and tar
get population. Theories of behavioral change need to
be developed from this descriptive research, recognizing
causal processes on the super-structural, structural, envi
ronmental and individual levels.
Second, operational research is required to determine
what changes can be made in social environments that
will promote a reduction in risk behavior, and how the
changes will be interpreted by people affected by them.
In particular, it is important to determine how changes
can be presented to avoid or minimize negative per
ceptions by those affected. Research is also required to
establish the most effective mechanisms for making en
vironmental changes.
Third, the involvement of the community in develop
ing and implementing structural and environmental in
terventions needs to be better understood. Research is
needed to determine whether certain social environ
ments are more amenable to change with regard to fac
tors that promote risk behavior. For example, is it easier
to make structural and environmental changes in pop
ulations with strong community integration, or in areas
where people perceive a sense of a common threat?
Finally, research is needed to determine how the impact
of structural and environmental interventions can best be
evaluated. It is important to develop projects that clearly
show the effectiveness of structural and environmental
interventions on risk reduction. To this end, research
models are needed that allow a clear attribution of be
havioral changes to specific intervention programs.
4.
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13.
14.
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17.
18.
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22.
23.
24.
25.
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Rojanapithayakorn W: The One-Hundred Percent Condom Pro
gramme in Thailand: an update. A International Conference on
AIDS/V STD World Congress. Yokohama, August 1994 (abstract
Hanenberg R, Rojanapithaykorn W, Kunasol P, Sokal D: Impact
of Thailand's HIV-control programme as indicated by the de
cline of sexually transmitted diseases. Lancet 1993, 344:243245.
Kelly JA, Sikkema KJ, Wintt RA, et al.: Outcomes of a 16-city
randomized field trial of a community-level HIV risk reduc
tion intervention. VIII International Conference on AIDS/III STD
World Congress. Amsterdam, July 1992 (abstract TuD 0543).
Santana S, Faas L, Wald K: Human immunodeficiency virus in
Cuba: the public health response of a Third World country.
Int J Health Serv 1991, 21:511-537.
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Interventions for Adolescents
Peter Aggieton and Kim Rivers
1*
INTRODUCTION
<9
wr
The World Health Organization (WHO) and numerous other international organi
zations have identified young people as being at special risk of HIV infection.
Estimates from the Joint United Nations Program on AIDS suggest that up to 60%
of new HTV infections are among those aged between 15 and 24 years,1 and
UNICEF has estimated that two thirds of those who become infected with HIV will
do so before they reach 25 years of age.2 There is also evidence that the average age
at which young people become sexually active has fallen worldwide.3 With 800
million people under the age of 25 living in developing countries, the implications
of HTV infection for young people are of great concern.3
Developing countries, where resources are extremely limited, are most se
verely impacted by the AIDS epidemic,'* and adolescents in those countries are
likely to suffer most.5 The percentage of the population who are young is much
higher than in industrialized countries, as is the annual growth rate of the youth
population and the proportion of young rural to urban migrants.6 The level of risk
for youth in developing countries may be greater due to what Sweat and Denison,7
among others, have described as the ways in which social, cultural, economic, and
political forces, such as poverty, migration, urbanization, war, and civil distur
bance, facilitate HIV transmission. It is not surprising therefore that those coun
tries with the lowest standards of living are also among those with the most serious
AIDS epidemics.
With an increasing incidence of AIDS among young people in developing
countries, it is crucial to ensure that effective HIV prevention programs are
developed and disseminated. Young people also present an opportunity for halting
the epidemic. Since their sexual habits may not yet be firmly established, behavior
modification strategies may be more effective, relative to older people, in motivatAGGLETON snd KIM RIVERS • Thomas Coram Research Unit. Institute of Education,
University of London,(London WCIH ONT, England.
Preventing HIV in Developing Countries: Biomedical and Behavioral Approaches, edited by Gibney et al. Plenum
Press. New York. 1998.
231
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Peter Aggieton and Kim Rivers
ing the adoption and maintenance of HIV preventive behaviors.8 Yet, there is much
uncertainty about how best to approach HTV and AIDS prevention when working
with young people. This is due in large part to the ambivalent way in which young
people are viewed by adults. Hoffman and Futterman5 have noted that young
people are often perceived both as “small adults and as immature, inexperienced
and untrustworthy children.” Such attitudes have informed the theory, research,
and practice of many involved in developing and implementing health promotion
programs with young people. It is important therefore to examine underlying
assumptions about young people in relation to the design and implementation of
HTV prevention programs.
Aggieton and Warwick10 discuss in detail the ways in which young people and
their behavior have been characterized by those researchers and health practi
tioners who are concerned with adolescent health. They point out that usually, and
often in the absence of evidence, adolescence has been conceived as a period of
“storm and stress.” Young people have been almost uniformly viewed as irrespon
sible and hedonistic risk takers who regard themselves as impervious to danger. In
reality though, youth and adolescence are highly variable periods of life. Before
the mid-19th century, young people living in Europe made the transition from
childhood to adulthood at a much earlier age and more quickly than in modem
industrialized countries. Indeed, in many parts of the developing world today, the
onset of puberty often signals greater economic and social responsibilities rather
than increased opportunities for pleasure seeking.
Not only do young people’s experiences depend on historical, social, and
cultural background, but within a particular context their experiences are mediated
by gender, sexuality, socioeconomic status, state of physical and mental well
being, and so on. Since the turn of the century, psychologists and other researchers
interested in adolescence have tended to characterize young people in a largely
uniform manner. Stereotypical ideas about youth became so powerful that some
researchers began to talk about universal adolescent characteristics, ignoring such
influential characteristics as diversity of social background, ethnicity, gender,
sexuality, and other variables such as different age groups within the overall
category of “youth.” Studies of adolescence, then, have been dominated by biased
assumptions. This has serious consequences not only for young people and the way
they are viewed and feel about themselves, but also for work focusing on young
people and AIDS.
Among the central images to be found in the burgeoning global literature on
young people and AIDS are the “unknowledgeable adolescent,” the “high-risk
adolescent,” the “overdetermined adolescent,” and the “tragic adolescent.”11
Respectively, these categories describe young people who are ill-informed, in
clined toward unnecessary and excessive risk-taking, unduly conforming to peer
pressures, and those who have HIV infection or are living with AIDS. Such images
have dominated the work on young people and AIDS throughout the epidemic.
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Most importantly, these accounts are unlikely to speak to young people them
selves, since the predominant theme in them suggests that adolescent sexuality
needs to be controlled, restrained, and often sanctioned by others, namely adults.
Only rarely are youth afforded a version of their sexuality that provides a sense of
pleasure and the potential for human fulfillment. Future HIV-related work with and
for young people needs to start from a set of more realistic and less stereotypical
premises, acknowledging the diversity of young people’s experience, and adapting
prevention programs to ensure that different needs are met.
Stereotypical accounts of young people often have stimulated the develop
ment of sex education programs with a narrow focus. Adults are inclined to have
some difficulty acknowledging adolescents as sexuaf and potentially sexual be
ings.’ Concerns have been expressed and reflected in government policies that
providing too much or certain kinds of sex education may propel young people into
premature sexual relationships. As a consequence, many programs of sex educa
tion in both industrialized and developing countries have tended to concentrate on
abstinence and helping young people to say “no” to sex. Yet, several important
studies now suggest that well-designed programs of sex education, which combine
messages about safer sex as well as abstinence, may delay sexual debut, decrease
sexual activity among those young people who are sexually active, and increase
contraceptive use.12 In spite of such findings, work with young people historically
tends to have emphasized the prevention of pregnancy and, more recently sexually
transmitted diseases (STDs) and HIV infection, rather than the promotion of
sexual health. Only now and only in some parts of the world are we seeing a more
helpful shift from pregnancy and disease prevention toward broader, more multidi
mensional and rights-orientated conceptions of sexual health.13
Ultimately, this move toward the promotion of sexual health will draw youna
men into the forum, since a great deal of HIV-related intervention activities have
thus far focused on young women. Certainly young women in developing coun
tries are at increased risk of HIV infection when compared with young men
Estimates suggest that in Uganda, for example, HIV infection among women aged
13 to 19 years is 20 times higher than for young men of the same age group >
However, if prevention programs are to make a significant impact on the HIV
epidemic, it is imponant that more programs be targeted toward young men. The
stereotypical gender roles and unequal status of women in sexual relationships
mean that it is often difficult for young women to negotiate safer sex. That most
young girls have sex with older males further increases the power imbalance in
these relationships. Interventions that focus solely on girls and young women not
only deny the important power relations that exist between males and females and
the very real threat of sexual exploitation and abuse that many young females face,
but they also deny young men the opportunity to maximize their sexual health’
Similarly, many programs assume heterosexuality in young people, thereby deny
ing young people who have same-sex relationships the opportunity to acknowl-
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Peter Aggieton and Km Rivers
edge their own sexuality and to work toward protecting themselves from HIV
infection.
STYLES OF INTERVENTION
^Interventions designed to prevent HIV infection in young people have differed in style, theoretical framework, and level at which the intervention is pitched
Many interventions, designed early in the HIV epidemic, were ^
as bied
based on
j •• • t
«•
.
*
individualistic approaches using theoretical frameworks such as the health belief
model, the theory of reasoned action, protection "motivation theory, aud
and SU
social
i;iai
learning theory. Each of these models places emphasis on changing individual
behavior through information giving, rational discussion, and skill development
Such individualistic approaches tend to marginalize the social and cultural context
that informs individual experience. They tend to assume, for example, that people
having acquired cenain knowledge, insights, and skills, will be free to make
certain choices. Yet in both industrialized and developing countries people do not
behave in isolation of their particular social contexts. Young people may be victims
of poveny, abuse, and exploitation, in whichi case negotiating skills may be
difficult to exercise.
In developing countries people often express needs that are perceived to be
more pressing than the risk of HIV infection, such as educational and employment
opportunities. Rotheram-Borus et al.'* have pointed out that young people who
live with stressful situations, such as homelessness, may engage in "survival sex,”
which makes consistent use of condoms difficult. Baldo3 sums up these concerns
when she states that the burden of prevention of HIV infection cannot be borne
solely by the individual through attempts to regulate his or her behavior; this
burden is especially heavy for adolescents who face barriers denying them access
to education, health and social services.
The middle years of the epidemic have been characterized by a move away
from the individualistic models of intervention described toward models which
work at the level of community.15 Although definitions of community may vary,
these interventions have had a common concern with changing and reinforcing
norms by addressing groups of people assumed to share social experiences.15 The
increasing number of peer education programs that fall within the category of
community-based interventions have been perhaps the most important for young
people. Peer education utilizes members of an existing social group or network
who undertake communication and training with other members of the group to
which they themselves belong? Clearly, peers can be important sources of infor
mation and support for behavior change,16 but it should be noted that several
studies have found that young people need and desire communication and support
from trusted adults as well.17
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Most recently, and in response to some of the limitations of both individual
level and community-level interventions, researchers and practitioners have be
come interested in what Sweat and Denison7 refer to as “structural and environmental interventions.” These recognize that factors such as urbanization, civil
disruption, and poverty in developing countries have facilitated the growth of the
epidemic. For example, migration from rural to urban areas means that large
numbers of men leave their families in order to seek work in cities. While there
they may have unprotected sex with new partners, and on periodic visits home
introduce HIV infection into rural areas.
In relation to young people particularly, learning how to manage relationships
in ways that bring personal fulfillment without risk of HIV infection, social
policies that inhibit the growth of the epidemic need to be emphasized and
disseminated.5 For example, in many circumstances women lack the resources and
power to negotiate effectively with men over safer sex.15 Hence, social policies that
foster greater equality between men and women and greater access to education for
girls are crucial in halting the epidemic. Similarly, legal and policy barriers to
condom promotion and other relevant social and health services have to be
eliminated.3
While each of these levels of intervention may appear quite distinct and while
each is underpinned by quite different theoretical standpoints, future HIV and
AIDS-related interventions are likely to attempt to work simultaneously at one or
more levels. Young people need to be persuaded that HIV infection is relevant to
them, and certain enabling interventions at the level of public policy need to take
place to ensure that young people are able to behave in ways which will protect
their health.18
At all levels of intervention, questions about the most appropriate ways in
which to evaluate impact are important. Clearly, we need to ensure that the
interventions are effective and efficient. In the early days of the epidemic, people
used and adapted the skills and techniques that they already had, often without
engaging in any systematic evaluation of their interventions. Now, practitioners
and researchers must increasingly suppon their intervention program, curriculum
or strategy by producing concrete evidence of its effectiveness.19 The move toward
evidence-based HIV and AIDS-related programs means that intervention planners
must now think carefully how they can demonstrate program effectiveness. There
are a variety of ways in which to evaluate interventions, producing a range of
different types of evidence about what works and what does not, including
observation, objectives-based evaluation, theory-driven evaluation, randomized
controlled trials, and quasi-experimental methods.
In discussing the various interventions for young people in developing
countries, this chapter will take an inclusive stance: that is, a wide range of
evaluation methods will be considered, in spite of the current privilege
given
to randomized controlled trials and quasi-experimental methods.20 In addition, we
i
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Peter Aggieton and Kim Rivers
will consider some innovative programs that have not yet been systematically
evaluated. Furthermore, because the effects of health promotion programs may not
be immediately evident and it may take a lengthy follow-up period to observe
decreases in prevalence of HTV, a range of prevention strategies will be discussed
inc u ing ose still in development or ongoing and for which conclusive outcome
evaluation is unavailable.
countriesONS F°R young people ,n developing
Pans of the world have high prevalence of HIV infection but constant or
diminishing rates of infection; numerous countries in developing parts of the world
such as Africa, Southern and Central America, and Asia have been identified as
having high and increasing rates of infection. It is important to note that within
regions rates of HIV prevalence may not be uniform and may vary considerably
between countnes. It is also important to note that the countries that constitute a
geographic region are not homogeneous; rather, they are diverse in culture,
religion, socioeconomics, tradition, and practices. Understandably, this is not
helped by the mass media that often presents developing regions, most notably
Africa, as an undifferentiated whole rather than continents made up of different
countries.21 In spite of this, there are commonalities in the needs of young people in
developing countnes: access to education is often limited and attendance at school
may not be mandatory, common, or consistent; levels of literacy are lower than in
industrialized countries; young people may have increased economic and familial
responsibilities from a younger age; and most importantly, young people are more
likely to be living in or vulnerable to poverty. Young people in poverty and most
especially those living on the street are more likely to experience sexual coercion
or rape and to engage in sex for their economic survival.4 For the purposes of this
chapter, then, bearing in mind the aforementioned caveats, we will divide our
discussion of interventions for young people in developing countries into three
geographic sections: (1) Africa, (2) South and South East Asia, and (3) Central
Southern America, and the Caribbean.
Africa
Young people in sub-Saharan Africa have been most severely impacted by the
AIDS epidemic. In some cities, HIV prevalence among young pregnant women,
for example, is as high as 30%.^ Although sexual behavior varies between and
within countries on the African continent, there is clear evidence that young people
in Africa, like young people all over the world, engage in sexual acuvity earlier
than many adults acknowledge.1 In Guinea Bissau, for example, 50% of males
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aged between 15 and 19 years reported having sex in the previous year. In Malawi
56% of 300 young girls surveyed reported being sexually active, and of these 56%
reported having had sex prior to the onset of the menarcheJ7 Economic necessity
also means that young people are more likely to engage in sex work. In Malawi
two thirds of 168 female adolescents recently surveyed reported having sexual
intercourse in exchange for gifts or money, while at the University of Calabar in
Nigeria, nearly 15% of women studying said they engaged in commercial sex to
pay for their education.17
As in ail of the developing world, young women in Africa are at particular risk
of HIV infection. While up to 60% of all new HIV infections are among 15- to 24year-olds, females outnumber males by a ratio of two'to one.'7 There is consider
able evidence to suggest that women have increased physiological risk of HIV
infection.17 In addition, gender relations that are characterized by an unequal
balance of power mean that women are less likely to control sexual decision
making. The partners and husbands of adolescent girls are often men considera
bly older than themselves, more sexually experienced, and hence more likely to be
infected with HIV.1
J
Although many young people in Africa have accurate information about HTV
wear S’ eCOnomic disadvantage can obscure concerns about the epidemic In
1993, focus group discussions held throughout Zimbabwe with out-of-school
youth aged between 12 and 20 were conducted by the Ministry of Education and
Culture. Young people expressed frustration with the lack of opportunities to eam
money and acquire the respect from parents and others that is afforded through
having employment and a salary. In fact, these issues overshadowed any concern
about HIV infection.23
Large numbers of young people in Africa do not have access to education. For
eXum?n4_5% °f y°Uth agCd bctween 11 and 19 Years in Zimbabwe are out of
school. This means that programs designed to prevent HIV infection need to also
target out-of-school youth and to take into account the low levels of literacy that
are common among some people in parts of Africa.
Responses to HTV infection in Africa have varied enormously. Some of these
responses have consisted of attempts to encourage young people to remain sexu
ally abstinent, others to provide young people with access to information and
condoms as well as an opportunity to participate in a program.1 In some countries,
sex education is controversial and adults have attempted to restrict information
about sex available to young people for fear of a deterioration in moral values.24 In
spite of local taboos that surround talking openly to young people about sex a
vanety of prevention programs have taken place, with varying degrees of success.
These might be characterized as follows: peer education programs; school-based
programs; programs for out-of school youth; programs for youth at particular risk,
such as those living in the sheets and with refugee status; and programs using the
mass media and other media such as comic strips.
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Peter Aggieton and Kim Rivers
Combining peer education with increased access to condoms has had some
success in Cameroon. Initiated in 1993, 60 peer health educators were trained to
work with university students/J^Gwiefeet/. In addition, outlets for condoms on
campus were increased by 50%. Peer educators reached a total of 1600 students
£°nthS
‘he PrOgram began C0r’d0rn sales on camPus had increased by
30%. The program coordinators noted that increasing numbers of students both
requested information through the peer education program and applied to become
peer educators themselves.25
However, while the intervention led to increased sales and possibly use of
condoms, vanable access to and acceptability of condoms within Cameroon
remain bamers to increased condom use. In Zimbabwe, young people panicipating in focus group interviews observed that condom use is an effective strategy for
preventing HIV infection, but it is not realistic because of both poor availability
and negative associations with sex work, promiscuity and mistrust.25 This suggests
that distribution and increased accessibility are not enough to promote consistent
condom use.
Peer education aimed fdr university students has also taken place in Nigeria 26
After a preintervention phase involving the collection of qualitative and quantita
tive data, a Campus Women’s Alliance against AIDS (CWA) was formed at the
University of Ibadan with the aim of increasing knowledge and modifying risky
behavior. A 2-day training course was held for 30 self-selected peer educators A
vanety of CWA activities, including distribution of information and materials,
sponsorship of talks, and video and film screenings, were planned for a 12-week
penod. Of those attending the CWA events, 73% of females and 60% of males
reported that the activities were either very or quite effective at raising awareness
and the importance of abstinence or monogamy. As in many peer education
programs, the most important impact was on the peer educators themselves who
were observed to be very enthusiastic; perhaps the greatest measure of success is
that the CWA is now an ongoing program run 'voluntarily
*
by those initially trained,
Although the peer programs in Cameroon and Nigeria have enjoyed
success, it must be noted that university students are oneof the easier populaX^s
{'ll
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• .
7
■
of young people to access. First, high levels of education and literacy mean that it is
possible to use a wide range of materials and
methodsj in order to communicate
------------messages about HTV infection. Second, university attendance is often accompanied by an affluent background, thus decreasing, although not eliminating
entirely, the numbers of young people having to engageTn='risky practirefor
economic gain. Third, university students represent an older adolescentS?pulation
with whom it is possible to talk more frankly about HIV-related issues.
More challenging peer work has been conducted in Uganda with youth who
attend school and those who do not in 30 villages in the Rakai District. Four
hundred and seventy original respondents were interviewed in June 1994. Highly
significant increases in correct knowledge about transmission of HIV and use of
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condoms was found. Peer educators and peer education contacts were reported to
be six and five times more likely, respectively, to use a condom than those who had
no exposure.27
A randomized controlled trial was used to evaluate the impact of a school
based AIDS education program with high school students in a socially disadvan
taged African township of Cape Town, South Africa. The program was the
culmination of a process of consultation with teachers and students. Teachers were
trained in HTV-prevention information and the use of participatory methods. Over
a 2-week period, an intense, high-profile course was delivered throughout the
school. Various educational methods and channels, including structured informa
tion dissemination, group discussions, integration of AIDS content in the language
curriculum, and role playing, were used to promote AIDS-related messages To
assess the impact of the program, students completed self-report questionnaires
before and after the intervention. Students were compared with those in a school
with similar demographic characteristics but in which no specific AIDS education
was provided. At baseline, students at both schools had similar levels of HTV
knowledge, but following the program students in the intervention school had
significantly higher scores on most knowledge items. The program also sought to
promote more positive attitudes toward people living with AIDS- at baseline
acceptance of people with AIDS was very low in both schools. Small increases in
acceptance were reponed in the intervention school. In the intervention school, an
increase in the number of students who felt personally vulnerable to HTV infection
also was noted.
Although the intervention had a favorable impact on knowledge and some
attitudes, the impacton behavioral intentions was disappointing. There was a small
but statistically insignificant change in students’ intentions to use condoms follow
ing the program and negative attitudes toward condoms were still common. One
unintentional and undesirable impact of the intervention was that a rumor began in
the community that the reason for the intervention in one school and not others was
because teachers and pupils at the intervention school were infected with HTV This
caused teachers and pupils a great deal of distress. This raises important questions
about the care that must be taken when planning interventions and using ran
domized controlled trials. The researchers who evaluated the project felt that the
rumor most likely affected the overall impact of the program and resulted in high
levels of denial of vulnerability to HIV infection.28
In Tanzania, an innovative school-based program called Ngao (shield) was
designed to reduce risks of infection and improve attitudes toward people living
with AIDS. A randomized controlled trial was employed to evaluate program
effectiveness. Implemented for about 20 hr over a period of 2 to 3 months, the
program consisted of factual information disseminated by teachers, posters, songs,
poetry, and performances for younger pupils generated by the students. In addition
to working with students, panel discussions were held with eiders and parents.
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Peter Aggieton and Kim Rivers
However, national guidelines from the Ministry of Education prevented teachers
from explicitly addressing condom use with this age group.
After implementation of the Ngao program, pupils from intervention schools
reponed significant increases in exposure to AIDS information and discussion of
HIV/AIDS, in AIDS-related knowledge, and more positive attitudes to people
living with AIDS, relative to comparison schools. Six months after the interven
tion, pupils from the intervention schools reponed being exposed to and discussing
AIDS-related information far more frequently than did pupils from comparison
schools, a significant increase in knowledge and significantly more positive
attitudes to people with AIDS.29 The program designers conclude that work with
this age group, although still unusual in Tanzania, is both possible and fruitful.
An interesting school-based intervention that raises pertinent issues for inter
vention development has taken place in South Africa. In Africa, as in other regions,
values and cultural context are crucial considerations in designing programs. What
is more, traditional values about how, where, and between whom sexual activity is
acceptable may be in conflict with the real practices of both young and older
people. These factors are of particular importance when working with school
based populations, since parents, teachers, community, and government may be
particularly sensitive about the type of work that takes place with young people in
school. In Cape Town, a team of social scientists, health educators, and educa
tionalists developed a program for high school students drawn from a largely
Islamic community.30 Before the intervention, research revealed that althoughsex
outside of marriage is heavily sanctioned by the community, young people were
having sexual relationships. For teachers, however, it was important to heed
religion and respect and uphold values. Although teachers showed enthusiasm for
development of a program, they faced conflict in their role as Muslims—a role that
encompasses both the need to give religious guidance and counseling and the
desire to protect students. The teachers clearly felt conflicted over the different
needs and requirements of all various stakeholders in AIDS education: parents,
students, and religious and other community leaders. Through careful negotiation,
the researchers were able to agree with teachers that value clarification should not
be prescriptive for young people. Charts illustrating condom use were withdrawn
and the amount of information on condoms reduced. This project demonstrates the
need to work with the community and to help those who are delivering programs to
young people clarify first their own values about HIV-related issues.
Interventions targeting school-based populations are clearly popular in Af
rica, although large numbers of young people and some of the most vulnerable
young people do not attend school. Some researchers and health promoters have
suggested that through working with schools, it may be possible to reach the wider
community and out-of-school youth, who may be impacted by the messages about
safer sex disseminated to their school-attending peers.31
Reaching young people living in refugee camps or even more precarious
situations also will be challenging in some pans of Africa. War and civil unrest
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clearly have an important impact on the AIDS epidemic. Particularly innovative
work, which has attempted to operate simultaneously on individualistic, commu
nity, and structural levels, has taken place with Rwandans, including adolescents,
living in refugee camps in Tanzania.32 The project recognized that the conditions
of refugee life greatly increase the risk of HIV infection: the destruction of
families, deterioration of former social structures and mores, loss of homes and
income, overburdened health services, overcrowding, and an increase in the
commercial sex trade. Most at risk are women and adolescent refugees who are
vulnerable to coercive sex and rape. With particular reference to young people
cultural barriers posed a special challenge Rwanda, sex is rarely discussed with
young people. Meetings with religious and other community leaders in the camps
allowed project staff to develop culturally acceptable and appropriate messages
about HIV infection. These include strategies that focus on protecting future
fertility in a context where the ability to bear children has great social significance.
Reaching young people in this refugee environment where there were no
schools presented another hurdle, but through sporting events, which draw thou
sands of refugees, the young, most particularly young men, could be targeted In
intermissions, traditional dancers were recruited to incorporate messages about
HIV mto their performances. At the same time, condoms were distributed and
megaphones used to broadcast messages and songs. In refugee situations, young
women are at specially heightened risk, since they do not even have the limited
means to earn money that are available to boys. Consequently, they may be
coerced into exchanging sex for money, gifts, or protection. This project is
developing income-generating activities to enable them to earn some money
without endangering themselves. In addition, a series of "adolescent health days”
have been organized to demystify health services and encourage young people to
come forward for STD treatment. The first such event drew 700 people to one
clinic alone.
Finally, a number of innovative and attractive comic books have been
developed for young people in Africa. Although pre- and posttesting to determine
acceptability among young people has taken place, the impact of such resources
has rarely been formally evaluated. One study has revealed that even a single
reading of a comic book, which has been piloted to determine a high level of
acceptability among young people, can be associated with improved knowledge of
HIV infection and correct condom use.33
Central and Southern America and the Caribbean
In Latin America, the average age for first intercourse has been estimated at 15
years of age for boys and 17 years for girls.34 In particular contexts and areas, the
age of sexual debut may be earlier. In Mexico, for example, it is estimated that
almost half of ail teenagers are sexually active, while one in six of all live births is
to a mother aged 15 to 19 years.35 In a Brazilian school-based study, 36% of
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females reported having had intercourse by the time they reached 13 years.17 Not
surprisingly, the incidence of STDs and prevalence of HIV infection among young
people in this region is high: the Caribbean Epidemiology Center reports that
young people aged 15 to 29 years now account for 50% of all cases of AIDS.14
Social attitudes toward sexual activity for boys and girls vary radically in
many parts of the region: While sexual activity is often considered acceptable for
young men, it is sanctioned in young women. In Guatemala, for example, it is
commonly believed young men must have sex to enjoy good mental and physical
health. Here, the high social value afforded to virginity for girls, in conjunction
with a very different set of values for boys, may in itself lead to higher risks of HTV
infection. In Brazil and Guatemala, cultures where virginity in unmarried women
is highly valued, young people interviewed in a number of studies reported that
anal sex is often used as a means to protect a girl’s virginity.7
As in most parts of the world, young women in Central and Southern America
and the Caribbean have less power and control in sexual relationships. Gender
stereotypes too have an imponant impact on the epidemic. Research in Mexico has
suggested that traditional stereotypes about maleness affect the level of responsi
bility that young men take for using condoms, as well as promote the idea that one
partner may be appropriate for young women, but that in order to be manly a youn^
man must have several partners at one time.37 Young women also often find it more
difficult to suggest the use of condoms since they fear that they may be considered
too sexually experienced, or that the man with whom they are having a relationship
may reject them.
Economic need in this region means that young people are at increased risk of
HIV infection. In some areas, very large number of young people live on the
streets. In Brazil, for example, estimates suggest that 7 million young people are
living on the streets, with HIV seroprevalence rates ranging from 1.5 to 7.5%.38
Such young people are highly vulnerable to rape, coercive sex, and the economic
need to exchange sex for money or goods. The high prevalence of injecting dru*
use on the streets also presents another risk of HIV infection for these young
people.38 Clearly, young people who are concentrating on meeting their immediate
economic needs, and facing daily threats to their health and well-being, such as
those living on the streets, are difficult to reach with messages about a disease that
may or may not affect them some time in the future.
Responses to HTV infection in the region have varied, but some extremely
innovative work with young people has been conducted in Central and South
America and in the Caribbean. Perhaps more than in other regions, interventions
have focused on the development of sexual health, rather than on narrow concep
tions of disease prevention. Much of the work with young people here has been
characterized by an openness that is rarely found in other contexts; indeed, this
region has led the way for work with young people who are marginalized by
society, such as young people who live in the streets and gay, bisexual, and other
young people who have same-gender sexual relations.
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,nnn I" Be 1° Honzonte, Brazil, an outreach intervention has been ongoing since
1992. Youths living on the streets have been exposed to a series of communica
tion materials including videos and comic books. A preintervention survey of 329
youths was conducted as well as two phases of follow-up. Postintervention, the
perceived nsk of HIV infection rose from 33 to 95% in those surveyed. Overall
drug use decreased in the 90 days prior to the follow-up survey, and 70% of drug
users reported needle cleaning in follow-up surveys compared to none in the
preintervention survey. Although condom use increased by 32% among those
having sex with adult males, no change was reponed in condom use with peers
The Pegafao Program, initiated in 1989, set out to reach young male sex
workers aged 11 to 23 in Rio de Janeiro.^ Outreach wo’rk, often conducted in cafes
and bars, concentrated their efforts on listening to all the concerns expressed by
young men, not only those that related to their sexual health. This was important in
eveloping a relationship with the young men, since they did not feel AIDS was
more likely to kill them than hunger or violence from the police and clients
Conversations also revealed important information, such as the fact that many of
t e young men did not have contact with a gay community and so were unlikely to
be reached through that channel of information. Few of the young men contacted
were able to read, and they rarely accessed health services, thereby closing more
channels through which they might see or hear HIV-related prevention messages.
Evaluations demonstrated that whereas at baseline only 15% of the young men
reported that they always used a condom, 6 months into the project the figure had
increased to 65% and 1 year later to 80%. The associated decrease in STD levels
from 75 to 32% in the first 6 months suggests that the young men were engaging in
safer sex.40
°
In Recife, one of Brazil’s poorest cities, the Brazilian Center for Children and
Adolescents is involved in work to defend the rights of girls, especially those living
in the streets, brothels, and slums. Two projects have been developed for HIVrelated work: the Casa de Passagem (Passage House), which provides schooling,
suppon, food, and access to health care for girls aged 7 to 17. Here, the girls are
given space to talk about their lives and problems and are supported in a nonjudgmental way, which has given rise to some criticism from those in Brazilian society
who feel threatened by the lifestyle of street girls. As with the Pegafao Program,
asserting self-worth and valuing the self-perceived needs of the street girls was
given precedence over work on sexual health, since this provides a foundation for
helping young people to protect themselves from risks of HIV infection. Addi
tionally a follow-up program has been developed that trains graduates of the Casa
de Passagem to work with peers. UNICEF is now documenting the progress of the
program. Both these related programs are characterized by the promotion of selfesteem and empowerment.41
As a way of incorporating potentially the most marginalized of street youth in
Rio De Janeiro, a drop-in center street for youth included a special day each week
for young transvestites.38 Posters of young transvestites were displayed, which
o
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C°Uld C°me ‘0 the Center without fear
Globally, few programs focus on the positive aspects of sexual relationships
yet clearly tt ts not realistic to discuss the consequences and implications of sexual'
acuvity widtout discussing the pleasurable and meaningful nature of sexuality. In
Sao Paulo State in Brazil, a group of young people aged 15 to 20 were trained to
work in their communities for AIDS prevention. The training program included
discussion of beliefs, values, prejudices, behaviors, knowledge, prevention, sexu
ality, eroticsm, safer sex. and HIV and testing. As a result, young people together
sure fndVes"1 ’r8“1Zer4S2haVe develoPed a program that actively discusses plea-
In the Cyibbean. young people aged 8 to 19 have developed a musical review
about Hly infection and sexually transmitted diseases called “Vibes in a World of
Sexuality.” Originally developed in Jamaica, the review has now reached 50 000
people in five different Caribbean countries. Performances have taken place in 60
Jamaican schools, youth clubs, communities, and churches. Pre- and postperfor
mance evaluation has shown a 20% increase in correct knowledge about STDs and
HIV infecuon. Young people have shown their interest by staying behind to ask
questions, and the performers have received letters from parents thanking them for
helping them to begin talking with their children about sex.38
South and South-East Asia
a
that if effeCtiVe
P^^on Programs are not rapidly
developed and dtsseminated in Asia, it will overtake Africa by the end of the
decade in terms of numbers of newly infected people each year.43 To date, most of
the reported incidence of HFV infection has occurred in India and Thailand, but
numbers of infections are rising in other countries.44 Although less is known about
the sexual expenence of young people living in Asia than in other regions
estimates suggest that in some countries 70% of young people have had sex by the
age of 17. This clearly places young people in Asia at risk of HIV infection
In many countries in South and Southeast Asia, it is usual for young people'
most particularly young women, to marry at an early age. In the case of young
women, marriage to an older and more sexually experienced man is usual. Rather
than protecting young women from the risk of HIV infection, this kind of early
mamage may increase their risk. It is important to recognize that many young
women who have HIV infection have had only one sexual partner: their husband
Asmmany parts ofthe world, women in South and Southeast Asia often have
limited power to negotiate about sex with their partners. Women participating in
focus group discussions in Bombay have commented that because of economic
dependence on their husbands and fear of physical violence, they must quietly
submit to their husband’s sexual demands whatever they may be.47
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Stereotypical gender roles also place women at risk in cultures where having
too much knowledge about sex can stigmatize young women, making it very
difficult to ask that condoms be used. Studies in Thailand have revealed that young
women must pretend not to know anything about sex for fear that people will think
badly of them.48
In many Asian countries, much of the sex outside of marriage involves
payment or the exchange of goods. Young men may have their first sexual
encounter with a sex worker. One study in Thailand, for example, found that 44%
of Thai men had their first sexual experience with a sex worker when they were
around 18 years old.43 Similarly, some young women may find themselves drawn
into sex work, usually as a result of poverty and sometimes to pay off family debts.
The Chiang Mai Hill Tribes Welfare and Development Center in Thailand has
estimated that one in five girls from that area work as sex workers, some of whom
have been sold or given into prostitution by family members.43
Use of drugs may also place young people in this region at risk of HTV
infection. Patterns of drug use in Asia have changed in recent years:(\^hile older
drug users have tended to smoke opium, younger people are more likely to inject.43
If needles are shared, this can present another risk of HIV infection that needs to be
addressed.
As in many other pans of the world, young people in South and Southeast
Asia have the increased risks of HIV infection commonly associated with poverty
unequal life chances, urbanization and migration, rigid gender roles, and poor
access to education and health services. Many young people in South and South
east Asia, especially girls, do not attend school. In addition, girls often have
increased familial responsibilities and are based primarily at home, making them a
difficult group to reach.7
One intervention in India has attempted to reach such young women in lowincome communities in Bombay.49 In the preintervention period, information
about daily life, friendships, level of knowledge about sex, sexual activity, and
health problems was collected. A baseline survey was conducted on a sample of 85
adolescent girls to determine their knowledge, attitudes, beliefs, and practices with
regard to puberty, reproduction, marriage, sex, STDs, and AIDS. In developing the
intervention, it was clear from the outset that community and parental support
would be crucial, since sexual matters are not ordinarily discussed with adolescent
girls in this community. In addition, the girls were found to have heavy workloads,
necessitating support services, such as child care for the younger siblings for
whom the girls have responsibility. In addition, it was clear that for the intervention
to be effective, it had to look at issues related to women’s status and rights as well
as STD/HIV infection.
The intervention developed looked at issues around puberty, human sexu
ality, sexual exploitation and harassment, the human immune system and health
problems (with specific reference to HIV and STDs), women and AIDS, and the
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Peter Aggieton and Kim Rivers
development of a plan of action to protect oneself from HIV infection. Methods
included lectures, storytelling, role playing, group discussion, puppet shows, and
games. In each session, emphasis was placed on building the girls’ self-confidence
by encouraging them to participate and express themselves. Small incentives such
as door prizes and refreshments were offered to attract attendance. The average age
of the girls attending the program was 14 years. Simultaneously, an AIDS aware
ness program was .mplemented in the community. This included meetings with
different groups such as community leaders, parents, young men, and adolescent
boys.
Observations of the sessions suggested that the girls became more vocal and
self-confident as the sessions progressed. The level if participation, in fact, made it
impossible to cover the content of the course in six sessions, so a seventh had to be
added There was a great demand for the intervention to continue beyond the
seventh session, and suggestions were made by the girls on how to cut costs (such
as eliminating door prizes and refreshments). A follow-up survey of the partici
pants indicated that a higher proponion of the girls demonstrated correct knowl
edge than in the baseline survey. Eighty-three percent reponed that they had talked
to others about a range of topics covered in the intervention, with HIV/AIDS being
discussed by the highest number (62%).
In the Philippines, researchers have observed that most of the information that
young people receive about AIDS comes from the mass media and health care
providers. In many pans of the world this has resulted in high levels of knowledge
but continued nsk behaviors. A model for a school-based intervention for high
schoolers has been developed and tested in Manila.^ Four demographically
similar high schools in a semiurban district were selected for a randomized
controlled trial. An AIDS prevention program was implemented by high school
teachers, local AIDS experts, social scientists, and health educators to dispel
misconceptions, provide accurate information, foster positive attitudes toward
people living with AIDS, and develop skills aimed at clarifying values. After the
implementation, statistically significant effects favoring the intervention group
were observed in knowledge and attitudes toward people with AIDS, but no
statistically significant differences were observed in intended HIV preventive
behavior, although some delay to intended onset of sexual activity was recorded
Efforts are continuing to develop a program that will effect change in behaviors
Increasing numbers of young people in South and Southeast Asia are moving
to cities to seek employment. Such young people find themselves removed from
the protection and traditional expectations and values of the family and are
exposed to urban culture as well as often insecure conditions of work- This places
young migratory workers at high risk of HIV infection. One intervention aimed at
young female factory workers in Thailand has revealed that prior to their exposure
to AIDS education, the young workers did not perceive themselves at risk because
they identified HIV infection with sex workers and their clients and drug users «
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The young women also reponed that condom use is inappropriate in a love
relationship. In face-to-face interviews a number of the young women reponed
being sexually active, sometimes with more than one partner. The program
designers prepared educational materials based on their preintervention research
with the young women. Noting that the women enjoyed romantic dramas on
television and in magazines, a romantic novel was written about a factory worker
called Lamyai. Lamyai finds out she is HIV positive and tells her sister that she will
work in the factory to suppon her family until she becomes sick. The young
women responded positively to the story and reponed that they cried when they
read it and felt as if they knew Lamyai personally.
In addition to the production of educational materials, peer leaders were
trained to use educational materials with others. Peer facilitators gave young
women the chance to practice different kinds of negotiation with hypothetical
panners as well as undertaking sex and HIV-related education. All participants
were awarded certificates to say they had completed an AIDS education programthese were highly valued and the young women reported that having the certifi
cates enabled them to discuss issues with others. Another indication of the success
and acceptance of the program is that they used their own money to photocopy
materials ta take back to their villages.
Findings from the collection of Qualitative and quantitative data suggest that
this project improved young women’s communication skills and self-confidence
increased their perception of risk, and strengthened their intention to prevent AIDS
and help others. Peer education proved the most effective means by which to
influence beliefs and intentions to change behavior. The young women enrolled in
the peer leader group demonstrated the most significant improvements in knowl
edge and enabling skills and the largest increase in perceived vulnerability to HIV
infection. As a result of the program, the young women expressed more acceptance
and higher regard for women who prevented AIDS by negotiating condom use: “it
is not shameful now; it is up-to-date.”51
CRITICAL REVIEW OF METHODS USED
In this chapter we have discussed a wide variety of interventions, some of
which have been systematically evaluated and others that have not. The interven
tions reviewed can be divided into two types: those which have a strong research
orientation, for example, the school-based randomized controlled trial carried out
in Cape Town,28 and those in which research is not a priority, such as the work
carried out with girls in Recife, Brazil.41 Some of the interventions described were
motivated by the need to systematically evaluate program impact through ran
domized controlled trials and quasi-experimental methods. Other projects arose
from the need to take action immediately with young people who were facing
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Peter Aggieton and Kim Riven
particular risk of HIV infection. Although the latter types of projects are often
subjected to some kind of evaluation, the process of health promotion is more
frequently given precedence over research issues.
All interventions with young people need to evaluate the impact that they are
having, especially when increasingly health promoters are asked not only to
demonstrate that their interventions are effective, but that they offer good value for
money.w However, work in HIV/AIDS prevention presents those embarking on
eva nation with a difficult set of research issues. First, whereas in other fields of
health promotion most interventions use biological indicators to evaluate progress
accurate baseline data for HIV/AIDS in the developing world are often unavailable
or difficult to obtain.52 Where accurate data about the prevalence of AIDS do exist
they reflect infections that may have occurred 10 or more years ago, and thus are
unable to tell us much about recent changes in behavior. Incidence data, which
would be useful for evaluating the impact of interventions to prevent HIV infec
tion. are rarely available and expensive to collect.52 In the absence of such data
most researchers have attempted to gather information about changes in people’s
sexual behavior. Because sexual behavior among young people may be prescribed
or taboo it .s hard to ensure the validity of data. Even if we can assume that reliable
and valid information about behavior change has been collected, the process of
behavior change itself generates another concern. While interventions may be of
short durauon. behavior change can and does take many years to occur as
evidenced in earlier work on family planning.52
Notwithstanding the difficulties in evaluating HIV/AIDS prevention a num
ber of projects presented here have built-in methods of evaluation. There are a
vanety of ways in which evaluation can take place, and it would be unfortunate if
one or two methods were to be given precedence overall others. Recently, in HTV/
AIDS prevention work an increasing number of practitioners have employed
randomized controlled trials to test whether or not the intervention is successful
and have on occasion advocated this method as superior to all others 19 However
this method has a number of difficulties associated with it, not the least of which are
cost and the ethical problems that it can pose. The study in South Africa discussed
in this chapter highlights some of the problems that can occur when one population
is singled out from others around it for intervention. Research effects of this kind
may in fact influence program outcomes as much as the prevention program itself.
Qualitative methods, such as observation, focus group interviews, and faceto-face interviews, can provide rich sources of data. The evaluation of young
women in Bombay presented here reveals very clearly that the intervention has a
high level of acceptance among the participants; similarly, the information that
young female workers in Thailand reproduced educational materials using their
own money tells us a lot about the success of that particular project. Observation
when earned out rigorously and systematically, can provide useful clues as to whai
is taking place in health promotion. Like many programs worldwide, the US
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Government’s AIDS Control and Prevention projects (AIDSCAP) recommends
the use of multiple methods of evaluation for projects in developing (and indus
trialized) countries: “information from these sources can then be triangulated to
gain as complete a picture as possible of what is happening in the field.”52
It is important to bear in mind the strengths and limitations of different kinds
of data when making decisions selecting or implementing different type of HTV
and AIDS-related health promotion programs. By itself, no approach can answer
all the questions about the appropriateness and effectiveness of different interven
tions. However, by bringing together data collected in different ways, it may be
possible to distinguish some of the more promising approaches to HTV and AIDSrelated health promotion from those that may be less promising '5 It is also
important to remember that the purpose of HIV prevention activities with young
people ts to help reduce the risk of HIV infection. This goal must take priority over
other research concerns: for example, while it may be relatively easy to measure
changes in HTV knowledge, it is now clear that projects that focus solely on
imparting information about AIDS do not help young people reduce their risk of
infection.53 We must continue, then, to focus on what will assist young people
most, rather than develop evaluation programs that focus on what is most measurable.
SUMMARY
A range of different interventions among young people has been described in
this chapter. Some of the most interesting and possibly most effective ways of
working, however, are those programs that are ongoing and not yet fully evaluated.
Clearly there are some commonalities in the programs that are best received by
young people and might be most effective. Further, adults working with young
people in HIV prevention now have access to an increasing body of knowledge
about what does and does not work, particularly with respect to changing knowl
edge and attitudes. Still, what is effective in terms of promoting behavioral change
is not as apparent, because of a dearth of evaluations of intervention’s effects on
actual behavior, to the methods of measuring behavioral change with a reliance on
self-reports of behavior rather than incidence of disease and to the fact that lasting
behavior change is difficult to achieve and to monitor.
Despite considerable evidence from both industrialized and developing coun
tries that increasing levels of knowledge about HIV and its transmission does not
necessarily produce changes in behavior, many programs still place undue weight
on that approach. This is evident in several of the programs reviewed here. Young
people in the studies conducted by Kuhn era/.28 and Aplasca era/.50demonstrated
statistically significant improvements in levels of knowledge, but no correspond
ing changes in behavior or intended behavior. Asha Mohamud, Director of the
J
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Peter Aggieton and Kim Rivers
International Center on Adolescent
Adolescent Fertility
Fertility at the Center for Population, has
pointed out that although HIV/AIDS prevention programs u
are engaging adolescents m many countries, too often they are just “throwing mformat.on at ih=“y
«,
■_ *
■■■o •‘•*u““uuun ui mu youns
peop e.
While information about HIV and how it is and is not transmitted is
early important, simply providing the basic facts about AIDS does not suffice to
help young people protect themselves from infection.
infection
Study findings from around the world show that there is a gap between young
SnJ kn°*ledge and behavior' Romer “d Homik54 have shown that although
70-90% of the young respondents in 23 surveys conducted in Nonh and Central
^enca Europe, African, and Asia knew how HIV is spread and how it is
preventable, large proponions of young people whd were sexually active were not
using condoms and less than half those reporting condom use said that they did so
cons.stently. Programs promoting the acquisition of specific skills and the devel
opment of social norms for healthy behavior have proven the most effective in
reducing nsk. In addition, education programs implemented to promote abstinence
only have proven less effective than those offering a range of options in delaying
k^ow^d
t0?6? nSk behavi0rS- How«=ver, it should be noted that, like
faiowledge. skills alone may not be sufficient to help young people protect
themselves against HIV infection. In many parts of the developing world, the
soc.al economy, and political context within which young people live impact
dese “h d Ht0 enga8e HIV-Protective ^haviors. In several of the interventions
fact bed here’. y°Ung peop,e talked about the barriers generated by cultural
factors and soc.etal pressures that make it difficult for them to think about or act
upon a health issue that may affect them in some years’ time
While peer education programs are currently very popular, the programs
renewed here appear to be most effective with those who are trained to be peer
ducators rather than those who panicipate as recipients of peer education. This
may be because of the control that those trained as educators have over program
design and content, delivery, and empowerment. In addition, peer educators are
reUterisZs60'1"2' WhlCh
3 Preexisting degree concern with HIV-
in alUheT m°St|intereSting °f ail is the succ«s of Programs that take an interest
in all the very real concerns of young people living in precarious situations A
number of the programs enjoying success in Central and South America have a
Xh“ment t° 11Stenlng “ 1116 probI<=™ that young people themselves identify,
that J
i656 T pfrceived t0 be direct>y related to HIV infection. It is cleX
face^nUth8 P d°P 6 r deVelOplng countri« have a variety of very real difficulties to
face in their daily lives, and that the threat of HIV infection is only one of these
Programs that afford young people an opponunity to think about and talk through
HW inT" t
lmPaCt XllVeS may enj°y the greateSt IeVel of succ«s, given that
X°CCUrX
C°nteXtS th3t 376 brOader than the spher« of sexuality
and sexual behavior. Indeed, helping young people deal with pressing immediate
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concerns, such as the need to generate income, may play an important role in
helping them to protect themselves from HTV infection.
A number of programs still face restrictions and taboos around talking with
young people about certain issues to do with the prevention of HTV infection. In
Tanzania and South Africa, for example, it was not possible to talk about condom
use with young people in some schools. This occurs despite evidence that young
people in Africa, like young people in many other parts of the world, engage in sex
from a young age without using condoms, which are acknowledged to help prevent
HTV infection. Such restrictions reflect the concerns of adults rather than the reality
that young people experience. Sex education, and more recently HIV-related
education, for young people has had to face a series of such hurdles. Yet evidence
collected by the WHO, which summarizes 19 research studies, found that in no
study was there evidence that sex education leads to earlier or increased sexual
activity. Indeed, six of the studies found that sex education led to either a delay in
the onset of sexual activity or to a decrease in overall sexual activity.12 Programs
that focus on the reality of young people’s experience and use the needs of young
people themselves as their starting point are more likely to bring about behaviors
that help prevent HTV infection. As Hoffman and Futterman9 have pointed out, to
effect change in risk-related behavior, young people must be treated as genuine
partners in dialogue and decision making.
FUTURE DIRECTIONS AND RECOMMENDATIONS FOR WORK
WITH YOUNG PEOPLE IN DEVELOPING COUNTRIES
As the HIV epidemic unfolds and as new areas of the world are touched by the
tragedy of AIDS, prevention efforts involving young people must continue to be
given the priority they deserve. This is not because young people are more needing
of support than others; all groups have equal claim to the information and resources
important to protecting themselves and their sexual partners from HIV-related
risks. They deserve it since by working with those who are young, we may be able
to significantly alter the future course of the epidemic.
As the evidence reviewed in this chapter shows, we already have strong
indications of what styles of HIV-related health promotion work best with young
people and what do not. We know, for example, that programs that offer young
people a range of choices about sexual health are more effective than those which
focus solely on abstinence.12 We know too that program effectiveness requires an
acceptance of young people’s perspectives and needs, as well as their equal
participation in learning.9 And we know that programs must do more than attempt
to persuade young people to adopt safer sex and safer drug use, structural and
environmental circumstances must be enabling and supportive of such behavior
change, including condom use.5
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Peter Aggieton and Kim Rivers
Past successes and failures in HIV-related health promotion enable us to
identify a senes of pnncipies that underpin successful work. These include:
•
•
•
•
•
Recognizing the diversity of young people and their needs rather than
beginning from stereotypes and possible inaccurate presuppositions
Beginning work with the expressed needs of young people themselves,
and encouraging youth participation in project design and implementa-
Working in a climate of openness that acknowledges the realities that
young people face, rather than the preferences and prejudices of adults
Providing opportunities to address issues relating to gender, social status
heal^XUa lty
t0 prOm°te y0Ung Pe°Ple’s s^ual and reproductive
Undertaking more work with young men to enable them to think about
their role in relation to both their own sexual health and that of their
panners, as well as improving programs targeting young women.
Examining the positive aspects of sexual health including eroticism and
pleasure as well as the more negative aspects such as unwanted pregnancy
and sexually transmitted disease.
Promoting greater awareness of structural issues affecting sexual and
reproductive decision making, including rights and protection for young
people, as well as improved access to education and health services.
men J'th
T™0" t0
P™*1'5 in Pr°gram desig" and imple
mentation and with continuing research to identify other key components of
success, the new millennium may yet see the kinds of progress in HIV prevention
that generations, both past and present, have hoped for and deserve. But such goals
cannot be accomplished without the will of politicians and policy makers, many of
whom need to be more realistic in their appreciation of young people and their
needs. We need swiftly to jettison our desire to proscribe and prescribe, and to
substitute a respect for young people and their multifaceted needs. We need too the
courage to set m place a broad agenda for sexual risk reduction, that is, an agenda
that recognizes that there is no one style of risk reduction appropriate for all, but a
range of options from which young people, like adults, could one day be free to
cnoose.
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1
Addiction (1997) 92(7), 813-820
PRACTICAL BUSINESS OF TREATMENT
Reaching out beyond the hills: HIV prevention
among injecting drug users in Manipur, India
CHINGZANING HANGZO1, ANINDYA CHATTERJEE2,
SWARUP SARKAR2, GINZAMANG T. ZOMI1*, B. C. DEB2 &
ABU S. ABDUL-QUADER3
{ICM.R-WHO collaborative project, Churachandpur, Manipur, India; 2ICMR Unit for
Research on AIDS in N.E States of India, DL 172 Salt Lake, Calcutta 700091, India &
3 World Health Organization, Geneva, Switzerland
Abstract
Outreach interventions using ex-lDUs to inform and educate their peers about HIV/AIDS prevention
measures have been found to be effective in the United States and other developed countries. While
HIV/AIDS prevention programmes targeting IDUs have also been implemented in a number of developing
countriest very little information is available on the process of implementation of these programmes. This paper
attempts to document some of this knowledge, by describing the implementation process of an outreach
intervention targeting IDUs in a small town—Churachandpur—with high injection drug use and high HIV
infection rates, in the north-eastern state of Manipur. The paper describes the barriers encountered in
implementing the outreach and how these barriers were minimized. In conclusion, the paper makes the case
for targeting outreach to the larger community before targeting the IDUs.
*
Introduction
A number of different strategies have been used
to prevent HIV/AIDS among injecting drug
users (IDU). Among these, outreach interven
tions, using IDUs to inform and educate their
peers about HIV/AIDS prevention measures,
have been particularly effective (Abdul-Quader et
al., 1990, 1992; Neaigus et al., 1990; Watters et
al., 1990; CDC, 1990). Through outreach pro
grammes drug users have been informed of the
risks of HIV transmission; provided with both
bleach for decontaminating needles and syringes
and condoms for safer sex; and in some cases,
counselled
on
risk
reduction
measures.
Typically, these programmes have been imple
mented in developed countries.
The number of injecting drug users is growing
rapidly in many developing countries, bringing in
its wake a substantial increase in HIV infection
rates among these groups (Choopanya et al.,
1991; Sarkar et al., 1991, 1993; Suam & Crofts,
1993; Wodak, Crofts & Fisher, 1993; Htoon et
al., 1994; Stimson 1994). Although HIV/AIDS
prevention programmes targeting IDUs have
been initiated in a number of these countries
(Argentina, Brazil, India, Malaysia, Nepal and
Vietnam) many others remain without any out
reach programme or other interventions.
Correspondence: Abu S. Abdul-Quader, Programme on Substance Abuse, World Health Organization, 20 Avenue
Appia, CH 1211 Geneva 27, Switzerland. Tel: *41 22 791 4815; fax: + 41 22 791 4851.
Submitted 17th June 1996; initial review completed 26th September 1996; final version accepted 15th November
1996.
0965-2140/97/070813—08 89.50 © Society for the Study of Addiction to Alcohol and Other Drugs
Carfax Publishing Company
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
814
C. Hangzo et al.
Clearly, therefore, there is a need to initiate
interventions targeting IDUS in many other de
veloping countries. There is also a need to docu
ment and disseminate the experiences of
implementing interventions targeting IDUs. In
an attempt to document the knowledge and ex
periences gained from existing programmes, we
describe in this paper the implementation pro
cess of an outreach intervention targeting IDUs
in a small town—Churachandpur—in the north
eastern state of Manipur, India.
The goal of this intervention was to assess the
feasibility of implementing an outreach interven
tion targeting IDUs in a developing country set
ting with high drug use and high HIV
prevalence, and to assess the efficacy of the
intervention in reducing injection and sexual risk
among IDUs. In this paper we describe the
process of implementation of the programmes as
well the barriers encountered both at community
and individual levels in implementing the out
reach and how these barriers were minimized.
While data collected through periodic crosssectional surveys indicate that the intervention
has been making an impact in terms of HIV/
AIDS risk reduction, the paper, however, does
not report on risk reduction measures initiated
by the drug users. It also does not make any
attempt to examine the efficacy of the interven
tion in reducing risks for HIV/AIDS trans
mission. Discussion on risk reduction measures
and impact of the intervention are beyond the
scope of this paper.
Background
Churachandpur, also known as Lamka, is a small
town (37 000) nestling in the hills of north-east
India. It is 66 km from Imphal, the state capital;
communication facilities are poor. There are
nine major ethnic groups in Churachandpur and
as many dialects. Christianity is the dominant
religion. In spite of this diverse ethnicity, the
different dialects are widely understood and the
groups share a common way of life. Economic
underdevelopment has meant that the com
munity has retained its agrarian way of life,
where women work along with men. Most live in
extended families; the church and community
leaders have a major influence in the community.
Unemployment is very high. The town has a
heavy military presence due to the underground
political groups in the area which are engaged in
armed struggle for self-rule.
In Churachandpur, heroin injection began in
the early 1980s. Most of the heroin came from
Myanmar. There are currently estimated to be
around 600—800 IDUs in Churachandpur
(Sarkar et al., 1991). The town’s six drug treat
ment centres, which are run by voluntary work
ers, ex-users and doctors, use ‘Spiritual’ and
Twelve-Step treatment programmes. No mainte
nance treatment is available, abstinence from
drugs being the only behavioural goal. Some
IDUs have shifted
to injecting dextropropoxyphane, which is cheap and easily avail
able. The number of new dextropropoxyphane
injectors continues to grow.
Over 80°/o of the IDUs in Manipur are esti
mated to be HIV-positive (ICMR Report 199295). One per cent of the antenatal mothers
screened in maternity clinics have also been
found to be HIV-positive (ICMR Report, 199295). Mother-to-child transmission in the state
has also been documented (Panda et al., 1994).
Implementation of the outreach project
The major objective of the project was to assess
the feasibility of implementing an intervention
targeting IDUs. Since outreach to IDUs is de
pendent on a supportive community, it was
necessary to first create a caring environment to
ensure that IDUs could easily be reached and
provided with risk reduction information and
materials. Thus, before reaching the drug users it
was essential to educate the community at large.
The process of outreach to the law enforcement
authorities, the church and the community at
large is described below.
Outreach to the non-IDU community
Support from the police and the law enforcement
authority
To facilitate implementation of the intervention,
an advisory committee was set up with the local
district commissioner as the chairperson. The
committee members included local leaders, the
police commissioner, a number of church leaders
and some government health professionals.
As previously stated, due to the existing law
and order situation there was a significant mili
tary presence in Manipur. The police had been
very active in targeting the IDUs, regularly
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
HIV prevention among drug users in Manipur, India
harassing them and often arresting them if they
were found in possession of needles and syringes.
The advisory committee interacted with the local
law enforcement authorities in an effort to mini
mize police harassment and thus create a more
supportive environment in which to conduct the
outreach.
A number of advocacy meetings were held
with the police chief. At these meetings, the
senior project staff explained the rationale for
reaching IDUs—prevention of HIV/AIDS in the
community—and the need for support from the
police. These meetings generated positive re
sults: none of the outreach workers was arrested
and/or harassed by the police, even when they
wrere found in drug dealers’ homes and places
where drug users congregated to provide in
formation and risk reduction materials. This ad
vocacy also facilitated data collection from
IDUs.
Reaching out to the church and community leaders
In
Churachandpur,
local
church
leaders
influenced matters related not only to religion
but also other non-religious aspects of life in the
community. Drug use was considered anti-social
as well as immoral and HIV/AIDS was con
sidered to be a moral problem. There was no
awareness of the public health implications of
the disease.
Support from church leaders was essential in
order to reach the drug users and provide them
with risk reduction messages and materials. If
the Church had interpreted HIV/AIDS preven
tion among IDUs as condoning and facilitating
drug use, outreach would have been very
difficult. The situation was delicate since the
HIV/AIDS prevention information provided to
community members was sometimes contrary to
what the church preached.
A number of individual meetings were held
with local church leaders to provide them with
factual information on the HIV/AIDS situation
in the community and to highlight the import
ance of HIV/AIDS prevention among IDUs. In
addition, there were a number of group discus
sions with the church leaders to solicit their
views about reaching drug users, about kinds of
interventions that would be more appropriate in
Churachandpur and what, according to them,
were the barriers to HIV/AIDS prevention
among drug users. The initial meetings resulted
815
in a better understanding of the project among
the church leaders as well as a better understand
ing of the community attitudes towards the drug
users. These meetings continued even after the
outreach to IDUs was implemented. While atti
tudes towards drug users did not change, since
drug use was still considered to be antisocial and
immoral, the importance of the prevention pro
gramme was understood and supported by the
church leaders.
Reaching out in the community
In Churachandpur, the IDUs have strong family
and friendship ties. Much of their risk be
haviours have occurred within friendship circles.
Family members perceived HIV/AIDS among
the drug users as punishment resulting from
unsocial behaviours. They often took the drug
users to the police themselves; sometimes they
suggested sending them to remote places. The
families provided the link between the IDUs and
the outside world, and their support was vital to
reach the IDUs and provide HIV/AIDS risk
reduction messages.
Families and friends were approached in an
effort to raise awareness about HIV/AIDS in the
community; to increase HIV risk perception; to
create a supportive environment for the IDUs in
which to practice safe behaviours; and to create
social norms supportive of risk reduction by
IDUs. This involved regularly visiting friends
and family members of IDUs; providing them
with HIV/AIDS prevention information; dis
cussing with them the factors that would facili
tate risk reduction by IDUs; and how they
(friends and family members) could help the
IDUs to practice safe behaviours.
The larger community also discriminated
against the IDUs. The confidentiality and anon
ymity of HIV test results were not maintained
and the IDUs did not receive appropriate health
care support at local hospitals. Often when HIV
test results were known, seropositive IDUs were
discharged. Support at community level was im
proved through regular (monthly) meetings with
local NGOs, health service professionals and
hospital staff. A number of issues were discussed
at these meetings. These were: HIV testing and
counselling and the need for confidentiality,
health care for HIV positive IDUs, and the sup
port for HIV prevention activities among drug
users.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
816
C. Hangzo et al.
Outreach to IDUs
Outreach to IDUs was the next step in the
process (outreach to the non-IDU community
continued even after initiation of the IDU out
reach). The steps taken in conducting outreach
to IDUs are described below.
Recruitment of outreach workers
Outreach workers are the front-line soldiers in
the fight against HIV/AIDS. They are the ones
who go out in the street, make contacts with
drug users and serve as educators, counsellors
and leaders. It is important to select outreach
workers who will be trusted by the IDUs.
Since Churachandpur is a multi-ethnic and
multi-tribal town, it was important to have repre
sentation of its major ethnic groups. Of six out
reach workers representing different ethnic and
tribal groups, five had a history of injecting
drugs. Their past history of drugs, the fact of
their being a member of the community, and
their ability to communicate in the local lan
guages gave them the credibility to reach out
to their friends with acceptable prevention
messages and to build trust and rapport.
Training of outreach workers
The outreach workers were trained in: (a) basic
medical facts and epidemiology about HIV/
AIDS; (b) the importance of prevention of HIV/
AIDS among IDUs and their' partners; (c) HIV
antibody testing issues; (d) prevention messages;
(e) delivery of prevention messages; (f> risk of
relapse and how to prevent this; (g) when and
where to refer IDUs for drug treatment; and (h)
safety and security in the streets. The training
also focused on communication skills, so that
interaction with the IDUs in the streets would
take the form of social interaction and not lectur
ing. They were trained in completing daily moni
toring proforma with practical exercises. A preand post-evaluation of the training was also
done. The whole training exercise took 7 days.
Once the basic training was completed the field
supervisors accompanied them to the field for at
least 2 weeks for observation, improving effec
tiveness and correction of any misinformation
conveyed by the outreach workers.
divided into 24 localities including nearby
rural areas. Through qualitative mapping,
a number of areas were identified where the
IDUs gathered daily either to collect drugs or to
socialize. Various drug dealing places where
much unsafe injecting took place, were also
enumerated.
Outreach workers always travelled in pairs to
ensure safety and prevent relapse. These workers
visited the various localities following a flexible
weekly schedule to ensure maximum coverage.
They met the IDUs in the streets, in the areas
where IDUs congregated and in the dealers’
homes. On first contact, the nature of the project
was explained to the IDU and he/she was guar
anteed confidentiality. Prevention messages were
delivered after a few contacts; the messages were
hierarchical in nature, beginning with not using
drugs, injecting drugs or sharing injection equip
ment, to cleaning adequately with bleach (which
was demonstrated), avoiding multiple sex part
ners and regularly using condoms. The outreach
workers distributed liquid household bleach in
small plastic bottles along with cookers used for
drug mixing; clean water in a water container;
clean cotton to be used as a filter; and condoms.
The bleach kit, containing all the above items,
was designed by an injector.
At the beginning of this outreach effort,
leaflets and stickers containing prevention mes
sages were distributed to the IDUs. When the
outreach team started distributing bleach kits
and condoms it became easier to conduct out
reach, since the materials were highly sought
after. In the initial months, when bleach was
largely unknown to the IDUs, instructions had
to be given as to its use.
Within 1 year the project was able to reach
more than 750 of the estimated 800 IDUs and
distribute about 4000 bleach kits. The number
of bleach bottles and condoms distributed to the
IDUs indicated both the extent of the reach as
well as the feasibility of implementing such a
programme (Table 1).
Table 1. Contacts made by the outreach team and
distribution of risk reduction materials during the last 1.5
years
Total number of contacts made with IDUs
Strategy of daily outreach
Before initiating the outreach, the town was
Number of bleach kits distributed
Number of condoms distributed
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
5959
3930
4734
HIV prevention among drug users in Manipur, India
Referred
In addition to providing information and risk
reduction materials, the outreach workers also
referred drug users for injection and HlV-associated medical problems such as thrombophlebitis,
abscess (common with dextropropoxyphane in
jectors) and other infections to the team doctor
in the project office or in the drop-in centres.
The doctor visited severely ill IDUs at home.
Referrals for drug treatment were also made.
Current users as volunteers
Use of current users as volunteers to conduct
outreach to IDUs has always been controversial.
Very little information was available regarding
the experiences of using active IDUs to provide
risk reduction information and materials.
Active IDUs were recruited as volunteers to
work with the outreach team and to help in
reaching newer groups of IDUs. The volunteers
were recruited from different age and ethnic
groups and localities. The strategy of having a
team consisting of both active users and ex-users
was found to be very effective in reaching new’
injectors.
The volunteers were given a brief training on
HIV'AIDS risk reduction. They were always ac
companied by the outreach workers, who pro
vided the information-education on HIV/AIDS
prevention.
Outreach at dealers' place
VG'hi’.e outreach to shooting gallery owners and
drug dealers has been suggested as a possible
way of reaching IDUs, very little information is
available describing the process. In the Churachandpur project, outreach intervention was
also targeted through drug dealers where IDUs
met to buy and use the drugs. First, a survey of
the drug dealing places in Churachandpur was
conducted. This was done by the outreach work
ers with help from volunteers. This brief infor
mal survey provided data on the estimated
number of drug dealing places, locations of these
places and also some indication of how they
operated. Initially, the dealers were approached
by the outreach workers together with the volun
teers and the project objectives were explained.
They were given assurances that the purpose was
not to collect information but rather to provide
817
the IDUs with information-education on HIV/
AIDS prevention. Gaining the trust and
confidence of the drug dealers took a number of
months. In addition, because of continuous po
lice enforcement, the drug-dealing places were
not fixed but rather mobile. This also made it
difficult to have continuous access to the dealers.
The outreach workers regularly visited dealers’
homes to distnbute HIV/AIDS prevention infor
mation and risk reduction materials. There were
a number of volunteers who regularly distributed
bleach at all the possible drug-dealing places. A
number of dealers themselves collected bleach
kits regularly from the drop-in centres for use by
IDUs who came to them to buy drugs.
Outreach at drug treatment centres and in jail
There are six drug treatment centres in Chura
chandpur. Only one of them provides medical
detoxification and the remaining five focus on
spiritual healing. The capacity of the centres
varies between 10 and 30. The drug users usu
ally stay about 2-6 months at the treatment
centres.
The project outreach workers made regular
weekly visits to the treatment centres and pro
vided HIV/AIDS prevention information. Dur
ing these visits, the outreach workers conducted
both individual and group discussions with the
drug users. In addition to HIV/AIDS prevention,
these discussions also focused on issues related
to drug prevention. The drug users were also
given the assurance that, after leaving the treat
ment centres, they would continue to receive
HIV/AIDS prevention information and coun
selling from the project staff.
Fifty per cent of the IDUs in Churachandpur
had been in jail at least once in their lives. In
many cases they had been sent to the jail by the
family members to keep them off drugs. In ad
dition, the police also arrested drug users and
put them in jail. However, after coming out of
the jail, most of them reverted to previous drug
using risk behaviours.
The jail provided an opportunity to meet the
drug users and provide them with HIV/AIDS
prevention information. The local jail in Chura
chandpur could accommodate about 80 people
at one time. The outreach workers made weekly
visits to the jail and conducted HIV/AIDS
prevention information and counselling session
in the jail. The drug users were also asked to
- Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
818
C. Hangzo et al.
contact the project staff when they came out of
the jail.
Drug users* organizations
Drug users’ organizations have been found to be
very effective in reaching those drug users who
have been reluctant to identify themselves be
cause of the legal or stigmatizing environment.
In The Netherlands, for example, drug users first
formed their organization in the 1970s and by
1984, when HIV/AIDS became a major issue
among them, there were 30—40 such organiza
tions (Friedman, de Jong «& Wodak, 1993). The
organizations in The Netherlands focused on
reforming methadone programmes, initiating
syringe-exchange schemes and protesting against
harsh police activities. Similar organizations were
formed in other countries in western Europe.
While the relationship between drug users’
organizations and HIV/AIDS risk reduction
among IDUs were not clear, studies conducted
in New York indicated that group efforts to
shape the norms of injection drug users can lead
to increased consistent condom use and bleach
use and to decreases in syringe sharing, injecting
at shooting galleries and other risk behaviours
(Friedman et al., 1992). Similar findings had
also been reported by Jose from a similar study
conducted in New York (Jose et al., 1996).
In Churachandpur, the outreach workers
helped the IDUs in forming a drug users’ organi
zation. The organization had a large growing
membership and met on a weekly basis to dis
cuss the problems related to HIV/AIDS preven
tion, other health concerns and other non-health
problems faced by the IDUs. The meetings also
discussed various factors for facilitating risk
reduction.
The project provided support to the organiza
tion by allowing it to use the drop-in centres for
its regular meetings. It also assisted the organiza
tion in printing its newsletter. The organization
has been found to be very helpful in reaching
those IDUs who have not been contacted by the
outreach workers.
Drop~in centres
In addition to street outreach, two drop-in cen
tres were set up to serve as field offices as well as
places where IDUs could come to obtain infor
mation and discuss any problems with the field
staff. One of the centres was in the heart of the
town, close to the areas where IDUs congre
gated. The other centre was mobile. Depending
on the need for focusing on different areas this
centre has been moved a number of times. On
average 10-15 IDUs came to the drop-in centres
daily for risk reduction materials (bleach, water
and water container, cooker or cotton) and/or for
a cup of tea. The drop-in centres functioned as
places for conducting interviews, focus group
meetings, group education and medical assist
ance. The centres also served as recruitment
points for current IDUs as volunteers.
Constraints in outreach implementation
Even though there have been successes in using
outreach to educate IDUs and provide them
with risk reduction materials and other services,
outreach also has its problems. Conducting out
reach to IDUs has been problematic mainly be
cause of the illegal nature of drug use. It has
been particularly difficult in Churachandpur be
cause of the existing law and order situation in
Manipur in general, the attitudes of the com
munity at large and lack of any support services.
Other constraints included relapse and low
morale among the outreach workers; lack of
understanding among church and community
leaders, and increasing problems in the law and
order situation in Manipur due to political insta
bility and intensified police activities. The bu
reaucracy involved was also cumbersome. The
local administrative authority also needed to be
informed about the implementation of this inter
vention in order to coordinate support from the
local authorities.
The deteriorating political situation of the
town at the time (general strikes, unrest,
killings), affected the progress of work in Chura
chandpur. On many occasions the project staff
had to take risks. In many instances negotiation
with different political groups was needed so that
outreach could continue. On certain occasions,
when a general strike was called by one of the
political groups, special permission had to be
obtained for the outreach workers to go out and
continue to provide risk reduction materials to
IDUs.
Lack of services
In Churachandpur there was a real lack of any
services including health care. In addition,
in terms of HIV-related illness of the IDUs,
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
HIV prevention among drug users in Manipurt India
nothing was available. Proper drug treatment
referral was also difficult. There was no facility
for any kind of maintenance treatment pro
gramme and the existing treatment facilities only
preached complete abstinence.
There were no facilities for voluntary HIV
testing and counselling. Whenever someone
wanted to be tested for HIV, they were referred
to the hospitals in Imphal, 60 km away. The
project did not have the resources to set up HIV
testing and counselling services, and had only
one medical officer hired for the project, whose
job was limited to prescribing medication and
sometimes making home visits.
Relapse and low morale among outreach workers
In addition to the above-mentioned constraints,
relapse and low morale among the outreach
workers also hampered the project (five of the six
outreach workers had a history of drug use).
This means that outreach activities were carried
out with fewer staff. The outreach workers were
sent to a detoxification programme in town and
a support group was established to discuss these
issues. One of the project senior staff had train
ing in health counselling, and she provided
counselling to the outreach workers, addressing
the problem of relapse.
Morale improved immediately after the work
ers’ initial training, thanks to the novelty of the
- approach, and positive feedback from supervi
sors and drug-using friends. However, after a few
months, when outreach became routine, things
began to slow down. The necessity to constantly
reorientate, train, innovate and harmonize the
activities with the changing situation in the field
imposed a heavy burden. Encouraging inputs
from the workers and involving them in the
decision-making process and feedback after
analysis of the collected data has helped.
Conclusions
Even under the difficult conditions described
above, the experience so far has been quite posi
tive. The outreach workers were able to reach
out to IDUs in the community, contact a large
number of them and provide them with risk
reduction messages and materials, all in an en
vironment which was not supportive of IDUs.
This showed that it was possible to implement
outreach in an area with high drug use and high
819
HIV prevalence in a developing country with few
services, political turmoil and a background of
ethnic conflict.
Despite many difficulties, the community has
been very supportive towards the project. There
have been no major incidents or mishaps. The
families at the project site were also supportive.
Since the intervention began the IDUs have
only rarely been harassed by the police. The
project has been successful in creating com
munity support; furthermore, while changing
general attitudes towards IDUs may take some
time, the community has accepted the import
ance of HIV/AIDS prevention among IDUs.
Among the policy makers and politicians, it was
previously seen as a disease of marginalized pros
titutes and drug users and not a public health
priority. However, advocacy has changed this
and HIV/AIDS is perceived as being a major
public health concern. A number of HIV/AIDS
prevention initiatives have been launched in
Churachandpur. One of the local NGOs has
initiated a small syringe-needle exchange pro
gramme in Churachandpur. The authorities have
requested the senior project staff to examine the
possibility of providing sterile syringes and
needles to IDUs and the Manipur State Health
Department has already developed proposal for
expansion of the syringe-needle exchange pro
grammes in Churachandpur and establish simi
lar programme in other districts. While this may
take some time before it is implemented, the
interest shown and the action taken by the ad
ministration in the expanding and initiating of
such a programme was partly due to advocacy.
Since the initiation of this project, the World
Health Organization has funded a small study to
examine the efficacy of HIV/AIDS home-based
care and also to assist in setting up a network of
those involved in health care. This network in
volved the local hospitals, NGOs and volunteers.
The advocacy directed to the larger community
including the NGOs and health-care profession
als also facilitated the initiation of this project.
In many developing countries, outreach to
IDUs will require first conducting outreach to
the non-drug-using community. Given the na
ture of the problems (marginalization and dis
crimination of drug users, lack of services in
general), it is vital to accomplish this as a first
step in facilitating outreach to IDUs. The out
reach to IDUs was not conducted in a vacuum.
It was initiated within a community and it was
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
820
C. Hangzo et al.
also directed to the community. The project was
very successful in reaching the IDUs and also
creating a supportive community environment
and community norms conducive to risk re
duction. The experience gained in Churachandr
pur can be utilized in setting similar outreach
programmes in other countries of south-east
Asia.
Acknowledgements
ITiis study was supported by the Global Pro
gramme on AIDS, World Health Organization.
We are grateful to Dr S. K. Bhattacharya, Princi
pal Investigator, ICMR Unit for Research on
.AIDS in North-Eastern states of India for his
critical comments on the manuscript. We also
thank Dr Kevin O’Reilly for his continuous sup
port for the project.
References
Abdul. Quader, A. S., Tross, S., Friedman, S. R.,
Kouzl, A. C. & Des Jarlais, D. C. (1990) Street
recruited intravenous drug users and sexual nsk
reduction in New York City, AIDSy 4, 1075-1079.
Abdul Quader, A. S.» Des Jarlais, D. C.» Tross, S.,
McCoy, E.» Morales, G. & Velez, I. (1992)' Out
reach to injecting drug users and female sexual part
ners of drug users on the Lower East Side of New
York City, British Journal of Addiction, 87, 681-688.
Centers for Disease Control (CDC) (1990) Up
date: reducing HIV transmission in intravenous drug
users not in treatment—United States, Morbidity and
Mortality Weekly Report, 39, 529, 535-539.
Choopanya, K., Vanichensi S., Des Jariais, D. C. ct
al. (1991) Risk factors for HIV seropositivity among
injecting drug users in Bangkok, AIDS, 5, 1509-1513.
Friedman, S. R., Des Jarlais, D. C., Neaigus, A. et al.
(1992) Organizing drug injectors against AIDS: pre
liminary
data
on
behavioural
outcomes.
Psychology of Addictive Behaviours, 6, 100-106.
Friedman, S. R., de Jong, W. de Wodak, A., (1993)
Community development as a response to HIV
among drug injectors, AIDS, 7(suppl 1), S263S269.
Htoon, M. T.» Lwin, H. H., San, K. O., Zan, E. &
ThWE, M. (1994) HIV/AIDS in Myanmar, AIDS,
8(suppl 2), S105-S109.
Indian Council of Medical Research (ICMR)
(1995) Unit for research on AIDS in north-eastern states
of India: project report (1992-1995) (DL 172 Salt
Lake, Calcutta 700091).
Jose, B., Friedman, S. R.. Neaigus, A. et al. (1996)
Collective organization of injecting drug users and
the struggle against AIDS, in: Rhodes, T. &
HarTNOLL, R. (Eds) AIDS, Drugs and Prevention:
perspectives on individual and community action, 216233 (London, Routledge).
Neaigus, A., Suftan, M., Friedman, S. R. et al. (1990)
Effects of outreach intervention on risk reduction
among intravenous drug users, AIDS Education and
Prevention, 2, 253—271.
Panda,
S.,
Nabachandra,
T.,
Sarkar,
S.,
Chakraborty, S., Naik, T. N. & Deb, B.C. (1994)
Herpes Zoster in an HIV-positive 14-month-old
baby. The National Medical Journal of India, 7, 6364.
Sarkar, S., Mookherjee, P., Roy, A. et al. (1991)
Descriptive epidemiology of intravenous drug
users—a new risk group for transmission of HIV in
India, Journal of Infection, 23, 201-207.
Sarkar, S., Das, N., Panda, S. et al. (1993) Rapid
spread of HIV among injecting drug users in north
eastern states of India, Bulletin on Narcotics, XLN,
91-105.
Stimson, G. V. (1994) Reconstruction of subregional
diffusion of HIV infection among injecting drug
users in southeast Asia: implications for early
intervention, AIDS, 8, 1630-1632.
Suarn, S. & CROFrs, N. (1993) HIV infection among
injecting drug users in north-east Malaysia, AIDS
Care, 5, 273-281.
Wa lters, J. K., Dow'ning, M., Case, P., Lorvick, J.,
Cheng, Y. T. & Fergusson, B. (1990) AIDS pre
vention for intravenous drug users in the com
munity: street-based education and risk behavior,
American Journal of Community Psychology, 18, 587596.
Wodak A., Crofts, N. & Fisher, R. (1993) HIV
infection among injecting drug users in Asia: an
evolving public health crisis, AIDS Care, 5, 313-320.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
M. Suresh Kumar, MD MPH
Shakuntala Mudaliar, MBBS DPM
i
Desmond Daniels, MA
Community-Based Outreach HIV
Intervention for Street-Recruited
Drug Users in Madras, India
SYNOPSIS
Objective. Community-based outreach to drug injectors is an
important component of human immunodeficiency virus (HIV)
prevention strategy. The purpose of this chapter is to evaluate the
effectiveness of community-based outreach HIV intervention that
has been implemented in two locations in the city of Madras,
India, to reduce risk behaviors for HIV transmission.
Methods. Baseline data were collected for street-recruited injecting
drug users (IDUs) at two outreach locations in Madras, India
(n = 250), and follow-up data are available at I 8 months (n = 61).
Baseline (n = 150) and follow-up data (n = 87) were obtained
from a control group of IDUs recruited from locations at which
outreach services were not utilized.
Dr. Kumar is a Psychiatrist with the
Institute of Mental Health, Madras,
Results. Significant decline in injecting risk behavior was noted at
18-month follow-up from baseline for the IDUs recruited from
Punarjeevan Drug Treatment Centre.
outreach locations.
Madras, and Consultant for SAHAI Trust,
Madras. Dr. Mudaliar is a Consultant
Psychiatrist with Arogyam Drug Abuse
Conclusion. Results indicate that outreach services for drug users
produce significant changes in injecting risk behavior but that
sexual risk behavior is difficult to change. There are problems in
Treatment Center, Madras, and SAHAI
implementing and evaluating the interventions, and the research
Trust. Madras. Er. Daniels is the Director
findings are limited because HIV serodata were not studied for
of SAHAI Trust, Madras.
all participants.
Address correspondence to:
Dr. Kumar, Punarjeevan Drug Treatment Centre, 10 Vaidyaram Street, T. Nagar, Madras 600 017 India;
tel. 91-44-434-5668/91-44-433-2285; fax 91-44-434-1976; e-mail <msuresh@md2.vsni.ner.in>
•
58
PUBLIC
HEALTH
REPORTS • JUNE
1 99 8 • VOLUME
113. SUPPLEMENT 1
Community-Based
-w- njecting drug use, in particular injecting opiates,
I is increasing in the Indian subcontinent. In some
I parts of India, like Manipur in northeastern India,
I a rapid increase in human immunodeficiency
■ virus (HIV) infection has occurred.1-3 Since 1983,
Madras has experienced a serious heroin problem; since
1991, opiate injecting has steadily increased. Easy avail
ability of injectable preparations like buprenorphine has
certainly contributed to this escalation. There is an urgent
need to develop and implement appropnate HIV prevention
intervention strategies that should be monitored and
evaluated rigorously.
HIV Prevalence among IDUs in Madras, India
HIV infection was first documented in Madras, India,
in 1986 in a commercial sex worker; since then, the
infection rates for HIV have shown a spiraling upward
trend. Though heterosexual transmission of HIV is the
predominant mode, escalating drug use, in particular
injecting drug use, is causing concern. The absence of
denominator populations of drug users, in particular drug
injectors, clearly limits the methodological validity and
reliability of HIV prevalence estimates in Madras.
Injecting drug users (IDUs) are predominantly seen in
certain geographic locations of the city. These areas have
been identified using treatment data, ex-IDUs’ knowl
edge, outreach work, arrest records, and narcotic raids
and seizures. Prevalence estimates have been carried out
on nonrandomized convenience samples from treatment
centers, 5 voluntary testing from drug users,6 and
unlinked anonymous serosurveillance data from the not-
Table I. HIV prevalence estimates from three
samples in Madras, India
Sample
Size
Convenience sample from treatment centers
Institute of Mental Health, Madras*
Punarjeevan Drug Treatment Centre**
SAHAI Treatment Center, 1996®
Voluntary testing
SAHAI Ftekd Station*
Prevalence
estimate
(Percent)
100
200
50
16.0
15.0
19.0
138
174
•Reference 4
bReference 5
*Sf^6^ Treatment Center (^published data)
UBLIC HEALTH REPORTS • JUNE
1998
• VOLUME
Outreach
Intervention
in-treatment, community-based samples. The samples
have been smaller; nonetheless, it is remarkable that the
prevalence estimates from the three samples have been
15% to 20% (see Table 1).
It also is important to observe that the prevalence of
hepatitis B virus (HBV) also is high among IDUs and is
estimated at 33% in a community-based sample.6 Findings
from the community-based research initiatives show that
many drug users are unaware of the existing HIV testing
facilities at Madras and the majority of them are reluctant
to test themselves. The number of agencies involved in
testing and counseling is low, and existing facilities do not
attract, access, or help drug users. There are at present no
support groups for HIV-positive drug users.
In response to escalating drug abuse and its attendant
health consequences, outreach services for drug users
were established in 1993 in Vepery and Royapuram,
India. These locations were chosen because of high
prevalence of drug abuse as indicated from the treatment
records and through street knowledge and greater involve
ment of church-based community development activities.
The services were established and maintained by SAHAI
Trust, a nongovernmental organization involved in drug
abuse prevention and treatment of drug abusers; the
Trust is supported by the Catholic Churches of Madras
Diocese. A comprehensive assessment of HIV risk behav
ior7 among street-recruited IDUs was carried out in 1994
using ethnographic techniques, focus group interviews,
and some indepth interviews with drug users. Studies
assessing risk behavior were carried out on the treatment
population.4-5 The following findings are derived from
the above studies.
Injecting Risk Behavior
Drug transitions. The prevalence of injecting as the
chief mode of administration for opiates, and heroin
in particular, has been recent, and certain factors have
facilitated the transition from “chasing” heroin to inject
ing heroin. Street scarcity of heroin occurred after the
crackdown on Tamil militants in Madras, following the
assassination of Rajiv Gandhi, the former Prime Minister
of India, near Madras in 1991. This crackdown caused
heroin users to shift to the easily available injectable
preparation called buprenorphine. The use of buprenor
phine by some physicians to treat the withdrawal
symptoms of heroin abusers facilitated the belief that
113. SUPPLEMENT 1
59
Kumar
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AL.
buprenorphine was a good substitute for heroin, and
moreover, the drug was economical and easily procured
Since 1991, buprenorphine abuse has escalated among
opiate users, and when heroin was available in the illicit
market again, many preferred to use heroin bv injecting.
At present, about three-fourths of the current users of
opiates are IDUs. In addition, most new users are being
initiated to opiates by injecting.
Levels of sharing. AU the assessment studies on the
out-of-treatment and in-treatment populations suggest
that sharing of syringes and needles is very common.
More than two-thirds of the injectors interviewed admitted
to sharing injecting equipment in the past month.47 The
syringes and needles available and used in Madras are
two separate pieces that can be detached easily. These
2 milliliter or 5 milliliter syringes can be purchased from
pharmacies without a prescription, and needles alone
can also be bought separately. At times needles are not
shared, but the syringes are shared. Sharing is customary
among friends. Indiscriminate sharing—sharing with
strangers and casual acquaintances that was prevalent
at the beginning of the injecting epidemic in Madras (as
extracted from the ethnographic diaries of researchers in
the early 1990s)—has become infrequent in recent years.
Indirect sharing. Indirect shanng is very common. Use
ot common spoons, solutions, and cotton swabs as well as
• participating in “frontloading’' are all common among
heroin users; dipping the needles into the ampules is
common among buprenorphine users.
Frequency of injecting. Heroin injectors injected
frequently, and on average, they used the drug two to four
times daily. Buprenorphine users injected less frequently
because of the long-acting nature of the drug.
• Social context of drug use. The heroin networks in
Madras were more cohesive and functionally reinforcing
than the buprenorphine networks. Most heroin users were
m touch with other drug users, at least for purely func
tional reasons such as procuring the illicit substance. Their
networks also were larger in size and consisted of more
members who knew each other. Even though the ties and
bonding changed over time, at any point in time heroin
e users had at least one drug user with whom they had a
reciprocal relationship. In contrast, the buprenorphine
networks were smaUer, and most individuals had only one
or two drug-using individuals in their network. Most drug
users lived with their families; the mother, sister, or
60
spouse was always supportive of the drug user, and the
family ties continued in spite of heavy drug use. Heroin
users take the drug in chaotic street scenes, and purchas
ing venues facilitate sharing practices. Heroin users pur
chased the drug in the dealers' settings, where many drug
users congregate to use the drug and where needle
sharing is common. Drug users gather to shoot drugs
at common shooting locations such as abandoned build
ings and public toilets. AU of these settings influence
risk behavior.
Sex risk behavior. Because heroin users reported
spending most of their time searching for the drug, their
reported interest in sex was low. But a good many of them
admitted to engaging in sex in the past year. Casual sex
and commercial sex were frequent. Most were reluctant
to use condoms, and the rate of condom use during their
most recent sexual encounter was alarmingly low.
Buprenorphine users reported more risky sexual behavior
compared with heroin injectors.5-6 Sexually transmitted
disease (STD) infections were frequent.
Outreach model. The outreach team, consisting
primarily of ex-users and professional social workers,
forms the backbone of HIV intervention activity. The
outreach workers recruit IDUs from the street and
provide various interventions at the street level. Apart
from the face-to-face education about acquired immuno
deficiency syndrome (AIDS) and its transmission, these
individuals are provided with information on decontami
nation of syringes. Bleach and condoms are distributed
by the outreach team. Advice on medical and social
problems and service information also are provided, and
outreach workers facilitate the use of addiction treat
ment services. Outreach activities are concentrated in
two locations with a high prevalence of drug abuse in the
city: Royapuram and Vepery. Though most outreach
. interventions were focused on individuals and on chang
ing individual knowledge, opinion, and behavior, the
focus is slowly shifting to changing the peer and social
norms about risky behavior. Instead of targeting individ
uals, drug networks are increasingly being targeted.
The focus of the research described in this chapter
is to evaluate the impact of community-based outreach
HIV intervention on the risk behaviors of IDUs through a
longitudinal study. The study examines the extent to
which unsafe drug-injecting and sexual behaviors
decreased between baseline and the time when drug
users were interviewed at follow-up and whether or not
the risk reduction was the result of the intervention.
PUBLIC HEALTH REPORTS • JUNE 1 9 9 8 • VOLUME 113. SUPPLEMENT 1
Community-Based
Methods
Community outreach group participants. Current
njectors of drugs—defined as those who had injected
irugs in the past two months—were recruited for this
•tudy; 125 consecutive IDUs were recruited from street
)utreach at each of the two locations. Baseline data were
•ollected, and this sample was followed up after 18 months61 individuals were available for follow-up assessment.’
semiannual follow-up assessments also were done.
ommumty-based outreach group intervention,
he community-based outreach intervention initiated by
AHAI Trust aims to facilitate improvement in health
nd reduction in risk of HIV transmission for drug users
ho are not effectively reached through existing services
- through traditional health education channels. The
rug users are reached in their own communities and
cal settings. Outreach is provided by recovering drug
iers, indigenous to the selected communities, who are
miliar with the current users and their milieu.
The elements of outreach in our settings include
oviding AIDS education and distributing bleach and
ndoms. Outreach activity largely concerns raising
/areness about drugs. HIV and AIDS in general, HIV
msnussion, and local drug treatment and HIV prevention
tivities. Outreach is offered one on one in private
ttings and ls supported by promotional literature for
irate clients. Tasks include contacting people to deliver
-■ach, distnbute condoms, offer support and advice on
2ial and medical problems, and facilitate the use of exist; services. In our outreach model, clients are provided
:h at least three sessions in private settings:
Session 1 raises awareness about drugs, HIV trans
mission, correct techniques for needle decontamination
with bleach, and condom use.
Session 2 reinforces the components of the first
session and assists clients in identifying their own
specific nsk behaviors and understanding the strategies
to reduce their HIV risk.
Session 3 provides information about existing services
and advice on social and medical problems. Clients at
this stage also are encouraged to seek HIV antibody
testing and counseling.
Since clients need to be transported to a different
non for HIV antibody testing and counseling, the
Outreach
Intervention
response to this service was {poor. Less than one-fourth
(n = 58; 23.2%) of the clients recruited from outreach
locations completed the HIV antibody testing, and less
than one-eighth (m = 30; 12%) of the clients returned for
their test results.
In the control locations, there were no outreach
services. The outreach and control sites did not differ in
other intervention programs, including needle exchange
and network intervention.
Control group participants. A control group of current
ID Us was recruited from locations at which no outreach
services were available; a sample of 150 IDUs completed
the baseline assessment. The primary means of recruitment
was by word of mouth. After 18 months, 87 individuals
were available for follow-up assessment.
Measures. Baseline assessments were performed for
both groups, and data were collected, including socio
demographic information, patterns of drug abuse, and
HIV-related risk behavior, both injecting and sexual.
After 18 months, follow-up data were available on
drug use patterns, HIV risk behavior, and behavior
change for 161 clients from outreach locations and 87
clients from the control group. The baseline and follow
up interviews were done by independent trained
researchers, and the outreach interventions in the two
outreach locations were carried out by outreach workers.
The subjects recruited were not paid for the interviews,
and when necessary, food, soft drinks, and medical assis
tance were provided for them. The intake period was
from January to March 1995, and the follow-up period
was from July to August 1996. The majority of the re
cruited sample did not receive HIV antibody testing and
counseling; this was a serious limitation of this study.
Drug risk behavior was measured for the 30 days
prior to the baseline interview and the 30 days prior
to follow-up. This allowed for a comparable interval
of time over which to measure behavior nearest to
the baseline and follow-up interviews and, in the case
of the follow-up interview, provided time for risk
reduction to be expressed in the period between inter
views. The time interval over which sexual behavior was
measured was longer than for the drug risk behavior,
thereby providing a sufficient interval to measure the
sexual activity of subjects who had infrequent sexual
encounters. Data on sexual behavior—numbers of sex
partners, history of commercial sex, and history of
STD infection—were measured 12 months prior to the
baseline interview. Sexual risk behavior at follow-up
LIC HEALTH REPORTS • JUNE 1 9 9 8 •
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Table X Demographic characteristics of IDUs from outreach and control locations (N = 400)
Variable
Age
18-24
25-34
35 +
Caste
Scheduled
Others
Marital status
Married
Unmarried
Education
Illiterate
Middle school
High school
IDUs from outreach locations
(n = 250)
Percent
45
130
IDUs from controi locations
(n = ISO)
Percent
75
18
52
30
31
86
33
95
155
38
62
69
115
135
46
54
62
88
40
16
22
15
122
88
49
63
65
42
35
was measured for the period between baseline and
follow-up interviews.
Follow-up interviews were conducted on 161 (64.4%)
subjects from outreach locations and 87 (58%) control
subjects. The characteristics of the individuals who
were and were not followed were compared for demo
graphics, drug use, and HIV risk behavior; there was no
significant difference between the groups on any of
these variables.
The outcome was assessed using HIV-related drug
81
2!
P-vaiue
NS
57
22
46
54
NS
41
NS
59
NS
43
alcohol use at follow-up was indexed as increase, decrease,
or no change.
Results
and sexual risk behaviors such as frequency of injecting,
sharing needles (receptive or distributive sharing), number
of sex partners, history of commercial sex, and alcohol
use. Frequency of injecting was evaluated as one to six
times per week and among daily users as one to three
times daily or four or more times daily; a change in
the frequency of injecting at follow-up compared with
baseline is indexed as increase, decrease, or no change.
Sharing of syringes or needles was assessed as no sharing,
sharing less than once a month, sharing less than once a
week, or sharing very often; a change in the frequency of
sharing at follow-up was recorded as increase, decrease,
or no change. Number of sex partners in the past year
was recorded as no partner, one partner, or two or more
partners; change during follow-up interview was indicated
as increase, decrease, or no change. Similarly, history
of commercial sex was obtained for the past year, and
change at follow-up was indicated. Alcohol use was
evaluated as no use of alcohol or occasional use of alcohol
in social settings with a frequency not exceeding once a
week, use of alcohol one to seven times a week, and use
of alcohol on a daily basis. A change in the frequency of
Comparison of subjects from outreach locations
and control locations. Participants recruited from all
locations were male. Outreach has not been able to iden
tify female drug users, and it is common knowledge that
the prevalence of opiate use among women in Madras is
disproportionately small. After several years of outreach
activity in a variety of geographical locations, we have
identified only two female IDUs. The data from treatment
centers in Madras also indicate a negligible number of
female IDUs in treatment. Hence it was decided to
recruit only male IDUs for the current study.
At baseline, there were no significant differences
between the participants from the outreach and control
locations on demographic data like age, caste, marital
status, and educational status (Table 2). Comparisons
were made between the two groups for drug use patterns
and HIV-related drug and sex risk behavior. The IDUs in
both groups were primarily using heroin or buprenorphine.
In our sample, 59.4% of IDUs from the combined outreach
and control sites, 57.6% of IDUs from outreach locations,
and 61.3% of IDUs from the control locations were in
jecting heroin primarily. Significant differences were ob
served at baseline for needle use frequency (P = 0.0168),
needle use frequency among daily injectors (P = 0.0095),
and commercial sex (P = 0.0214) (Table 3). The IDUs at
the outreach locations exhibited high risk behavior in
both injecting and sexual practices. About three-fourths
62
REPORTS • JUNE
PUBLIC
HEALTH
1998 • VOLUME 113, SUPPLEMENT 1
Community-Based
Outreach
Intervention
Table 3. Drug use and other HIV-related risk behaviors of IDUs from outreach and control locations, at
baseline (N = 400)
IDUs from outreach locations
(n — 250)
Percent
Variable
Type of drug
Heroin
Buprenorphine
Needle use (past 30 days)
1-6 times/week
Daily users
Needle use among daily users (past 30 days)
1-3 times/day
4 or more times/day
Sharing (past 30 days)
No sharing
Sharing, less than once a month
Sharing, less than once a week
Sharing very often
Sex partners (past 12 months)
None
I
2 or more
Commercial sex (past 12 months)
Yes
No
History of SID (past 12 months)
Yes
No
Alcohol use (past 30 days)
No misuse
1-7 times/week
Daily
P-value
144
57.6
92
106
42.4
58
61.3
38.7
NS
65
185
26.0
74.0
56
94
37.3
62.7
X25.7I
P = 0.0168
129
69.7
30.3
79
15
84.0
X26.73
P = 0.0095
10.0
16.0
34.0
18.0
17.3
32.0
32.7
NS
56
25
40
16.0
85
100
40.0
27
26
48
49
57
100
93
22.8
40.0
37.2
27
51
72
18.0
34.0
48.0
NS
80
170
32.0
68.0
32
118
21.3
78.7
X25.29
P = 0.0214
49
201
19.6
24
126
16.0
84.0
NS
80.4
34.8
48.8
16.4
63
55
32
42.0
A* 5.67
P = 0.0588
87
122
41
(74.0%) of IDUs from outreach locations used needles
daily, and 62.7% of IDUs recruited for the control group
used needles daily. Among the daily needle users from
the outreach locations, 30.3% injected four or more times
daily; 16.0% of the daily needle users from the control
locations injected four or more times daily. Forty percent
of the IDUs from the outreach locations shared needles
and syringes very often, and only 10.0% did not share;
from the control locations, 32.7% of the IDUs shared
needles and syringes very often, and 18.0% did not share.
In the total sample of 400 from the combined outreach
and control sites, 37.3% were sharing syringes or needles
(receptive or distributive sharing) very often. Alcohol
use is common among IDUs, and 65.2% of IDUs from
outreach locations and 58.0% of IDUs from the control
locations used alcohol. Nearly one-third (32.0%) of IDUs
from outreach locations and 21.3% of IDUs in the control
group admitted to having commercial sex in the past
12 months. In the total sample of 400, 41.3% of IDUs
had two or more sex partners in the past year, and 18.3%
PUBLIC HEALTH REPORTS • JUNE
IDUs from control locations
(n — ISO)
Percent
1998 • VOLUME
36.7
21.3
of IDUs had a history of STDs in the past year. The high
levels of risk behavior observed in Vepery and Royapuram
were among the primary reasons for establishing outreach
services in these two locations.
Behavior change between baseline and follow-up.
At 18 months, follow-up data were available for 161 IDUs
from outreach locations and 87 IDUs from the control
locations. Comparison was made using the change in
risk behavior at follow-up. This comparison reveals that
the participants from the outreach locations engaged
in significant protective behavior and practiced injecting
risk reduction behaviors (Table 4). Because there were
statistically significant differences in three of the HIVrelated risk behaviors—(1) needle use in the past month,
(2) needle use among daily users in the past month, and
(3) commercial sex in the past year—between individuals
recruited from outreach locations and control locations
at baseline (Table 3), change scores were used to index
change in the level of risk behavior at the 18-month
113. SUPPLEMENT
1
63
Kumar
E T
A L .
Table 4. Change from baseline to foll<
low-up for HIV-related risk behaviors of IDUs from outreach (O) and
control (C) locations (N = 248)
Variable
Needle use frequency
Sharing
Sex partners
Commercial sex
Alcohol use
n
O = 161
C = 87
O = 161
C = 87
O = 161
C = 87
O = 161
C = 87
O = 161
C= 87
/ncrease
(*>)
No change
37
35
18
22
32
(23.0)
(40.2)
(H.2)
(25.3)
(19.9)
63
24
68
35
92
54
14
26
16
44
12
(16.1)
(16.1)
(18.4)
(27.3)
(13.8)
104
50
99
61
Decrease
(39.0)
(27.6)
(42.2)
(40-2)
(57.1)
(62.1)
(64.6)
(57.5)
(61.5)
(70.1)
(%)
P-vaiue
61
(38.0)
28
(32.2)
0.0146
75
30
37
19
31
21
18
14
(46.6)
(34.5)
(23.0)
(21.8)
0.011
NS
(19.3)
(24.1)
(H.2)
(16.1)
NS
0.0431
follow-up. To assess change in each risk behavior, partici
induce changes in sexual risk behavior. The next steps for
outreach require clear definitions of the various activities
and selection of activities that are situationallv appropnate The social networks through which HIV'is transthC S3me S°CiaJ networks that can be co-opted
for HIV prevention.9 It is to these networks that future
outreach services must tum to encourage behavior changes
m communities of injectors.
While there is some reason for optimism that HIV risk
reduction among IDUs is occurring by way of reduced
frequency of needle sharing and needle use, there is no
significant change in sexual risk behavior in this data set
with this intervention. Given the complexities of the sexual
relationships of IDUs, it is likely that there are multiple
03%"fth
I8’monthfoiIow-up’whereas °nly
reasons why sexual risk behavior change is difficult to
103% of the control-group IDUs always cleaned syringes
encourage, and it is unlikely that any sudden breakthroughs
and needles with bleach before use, 29.8% of individuals
will change that outlook.'9 Interventions to achieve
from outreach locations always cleaned syringes and
greater levels of risk reduction therefore need to be more
eedles before use. There was no significant difference
effective. Previous research has indicated that peer pres
ha
X? ^l1’5 ,n SeXUaJ risk behaVIOr: ™e than
sure may be important in determining the degree of
of the IDUs in both locations did not exhibit sexual
sexual nsk reduction," which suggests that interventions
nsk behavior change.
need to harness social relationships to influence safer sex.
In the case of drug risk behavior, evidence indicates that
Discussion
■ outreach projects that involve the target population and
encourage a collective response to behavior change may
Outreach has provided substantial opportunities to con
be more effective than interventions that restrict their
tact and work with the hard-to-reach IDU population.
focus to individuals.1219 Communitv-oriented models aim
This is a relatively new field in India. Manipur plus a
to improve health by changing norms at the community
few other northeastern India locations have outreach
level:
they are geared to encouraging subcultural
activities for drug users,6 and other outreach programs are
changes,
14 in which individual behavior change is facili
operating in Calcutta, New Delhi, and Madras. Results of
tated
by
the
behaviors and attitudes of peers.
outreach activities demonstrate that IDUs are capable
Many
IDUs
are known to be alcohol dependent.15
of positive behavior change. This study indicates that
Calsyn
and
colleagues
16 report in a study of patients receiv
betavior change is unfortunately confined to injecting
ing or taking methadone treatment that "use of alcohol to
nsk behavior only; outreach programs do not appear to
intoxication” increased frequency of heroin and cocaine
pants were categorized as decreasing the frequency of the
behavior, increasing the frequency of the behavior, or not
changing the frequency of the behavior.
h chv kqLare test WaS Used t0 interpret the change in
ch nsk behavior and participation in outreach activities.
Needle use frequency declined significantly (P
= o.oi),
and sharing also decreased significantly (P =
0.01) among
participants from outreach locations compared to IDUs
460T/o0HD J”5 Fr°m the °^each locations,
6.6% of IDUs decreased sharing needles and syringescompared to 34.5% from the control locations. Alcohol
use increased significantly (P = 0.04) among those from
he outreach locations (27.3%) compared with the control
64
PUBLIC HEALTH REPORTS ■ JUNE 1998
• VOLUME 113. SUPPLEMENT 1
Community-Based
o7alcnohTusand W°men
inCreaSed fre^encv
alcohol use in women was associated with "unsafe"
sexual behavaor. Latldn and colleagues" observed that
Outreach
Intervention
composed of locally influential opinion leaders. All the
proposed intervention efforts were discussed at advisory
group meetings and were endorsed by the board before
risl^ n8a |Oh°! once a day or more was associated with
being implemented. Addicts were identified by the police
and\e
'!ldePendent °f ^e use of cocaine
if
they were m possession of a synnge, so many drug users
and heroin Their study highlighted the need for more
stopped carrying syringes when they went out in search of
intense HIV prevention and other drug and alcohol
Trn'r
COmPeiIed sharing Practices at places outside
treatment programs for IDUs. Alcohol use was high in
un,
u
h0USeS
andParticuiar- at doers’ locations.
su jects from outreach locations—48.8% used alcohol
When this was brought to the attention of the advisory
board, the issue was taken up with the police, who agreed
At 18-month follow-up, 27.3% of the subjects in the
not to harass addicts who possessed personal svringes
outreach locations had increased their alcohol consump
11,15 P0,'Cy ck3"86 haS facilitated carrying of personal
tion. The mcrease in alcohol use might be part of a com
synnges
by IDUs in the community.
pensatory change dynamic in which participants in the
One
of the areas in which we need to concentrate
u reach sites reduced high risk drug-injecting behaviors
is
sexual
risk behavior. There is a large group of bupre
totZT
aJC°h01 USG 3S P- * compensator
norphine injectors in Madras'® that mav require different
preventi
/ lmpOrtant t0 consider alcohol abuse
intervention strategies. Easy availability of injectable
UsforlDUs.^^"1
°UtreaCh
Ppreparations like buprenorphine, diazepam, and chlorpheneramine maleate (Advil) has significantly contributed
the h'iV PfrOblernS
faced du™g
to the prevalence of injecting in Madras. Many drug
the HIV intervention implementation in Madras The
probfom f injecting dnjg use js not a
users prefer a combination of the above drugs popularly
referred to as "CAT' (Calmpose-Diazepam, Advil, and
AIDS intervention in general, and the focus is onlv on
Tidigesic-Buprenorphine),
and there is an urgent need
woX°rSeXU4 ,tran7,SS'°n and ta^cts commercial sex
tor ngorous control measures in Madras. Outreach work
orkers and long-distance truck drivers. Many agencies
ers are pressured to assist with the medical problems
involved with drug abuse do not cons.der HIV interention
ot IDUs, and strengthening primary medical care is an
n urgent issue. This problem has been overcome bv the
emerging concern. There is an urgent need to improve
-reation of an umbrella organization called the Society for
and expand HIV testing and counseling facilities. Our
Prevention. Research and Education on Alcohol and
outcome evaluation is extremely limited by the absence of
Drugs (SPREAD), which brought all the drug agencies
data on seroprevalence, even though the literature shows
that seif-reported behavior changes have proved to be reli
vith .ts main function to educate all the agenc.es about
able
and valid measures. At present, attempts are being
he significance and urgency of HIV risk reduction. Initial
made
to counsel and test all recruited individuals for HIV
ommunity resistance to HIV intervention efforts was
intervention. Future outcome studies will certainly use
overcome by the formation of a community advisory board
the seroprevalence data as an outcome measure.
"'is ZthVn5
I
and I6'4% used alc°hoi d iY
■eferences
■ Sarkar 5. Mookerje. R Roy A. Naik TN, Singh JK, Sharma AR.
et al. Descnpov. epidemiology of intravenous heroin users-
I99U37o1-7UP f°r
°f HIV *
. Kumar SM, Mudaliar S. Comparative analysis of HIV sexual and
substance use risk behaviors among injecting heroin users and
J
■ Sarkar S, Das N. Panda S. Naik TN. Sarkar K. Singh BC et al
Rapid spread of HIV among Injecting dnig usen in
states of India. Bull Narcotics I993;XLV-9I-IO5
' e^
SHSlngh HL> BhUn'’ SC- Sin«b Y|. S-gh PK.
et al Intravenous drug users: a new high-risk group for HIV
infection in India. AIDS 1991,-5:1 17-S.
P
V
Joseph R. HIV risk behavior and risk reduction among injecting
U^iv • ISW." tr"tnWnt
Dr. MGR Medi J
uprenorphine users in a drug treatment program. In:
Navaratnam V, Vemela D, editors. International Monograph
J°* PU aU Penan*: Center for Dru« Research, USM; 1997
p. /O-fl.
6’ ST nM'Td*" W'
S* Solon™ S. Shakunu!.,
Darnel. D. HIV risk behavior of injecting buprenorphine user, in
of TeeFr ,
Harrt!
edit°r- PrOgram and abltr’«s
N HA
" On AIDS 1,nd Drug Abuse- sponaored by
NIDA and N H In conjunction with the 57th Annual Scientific
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r g* °n Problems °f Dru8 Dependence. Inc; 1995
Jun 10-15; Scottsdale, AZ. p. 20.
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1998
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E T
A L .
7. Kumar SM, Daniels D. HIV risk reduction strategies among
injecting drug users in Madras Gty: an assessment research
report. New Delhi: Caritas India; 1994.
8. Hangzo C, Chatterjee A, Sarkar S, Zomi GT. Deb BC, AbdulQuader AS. Reaching out beyond the hills: HIV prevention
among injecting drug users in Manipur, India. Addiction
1997;92:813-20.
9. Stimson, GV Eaton G, Rhodes T, Power R. Potential development
of community-oriented HIV outreach among drug injectors in
the UK. Addiction 1994;89:1601-11.
10. Des Jariais DC, Friedman SR. HIV and intravenous drug use.
AIDS 1988:2 Suppl l:S65-9.
I I. Abdul-Quader AS, Friedman SR, Kouzi AC, Des Jariais DC.
Street-recruited intravenous drug users and sex risk reduction in
New York City. AIDS 1990;4:1075-9.
12. Friedman SR, Neaigus A, Des Jariais DC. Sotheran JL, Woods J,
Sufian M. et al. Social intervention against AIDS among injecting
drug users. Br J Addict 1992:87:393—405.
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13. Friedman SR, De Jong W. Wodak A. Community development
as a response to HIV among drug injectors. AIDS I993;7
Suppl l:S263-9.
14. Friedman SR. Going beyond education in mobilizing subcultural
change. Int J Drug Policy 1993;4:91-5.
15. Belenko S. Alcohol abuse by heroin addicts: review of the
research findings and issues. Int J Addict 1979;14:965-75.
16. Calsyn DA, Saxon AJ, Wells EA, Greenberg DM. Longitudinal
sexual behavior changes in injecting drug users. AIDS
1992;6:1207-1 I.
17. Latkin C, Mandell W, Oziemkowska M, Vlahov D, Celentano D.
The relationships between sexual behavior, alcohol use, and
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Baltimore, Maryland. Sex Transm Dis 1994:21:161-7.
18. Kumar SM. Buprenorphine abuse in Madras City, India. In:
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p. 49-69.
■
REPORTS • JUNE 1998 • VOLUME 113. SUPPLEMENT 1
Harm reduction in Asia: a successful response
to hidden epidemics
Nick Crofts, Genevieve Costigan, Palani Narayanan,
Jennifer Gray, Jimmy Dorabjee, B Langkham, Manisha Singh,
Aaron Peak, Carmina Aquino and Paul
for the Asian Harm Reduction Networks matt
Copyrigh
y
>3
AIDS 1998,12 (suppl B):S109-S115
Keywords: HIV, injecting drug use, Asia, harm reduction, prevention, needle and syringe exchange
Introduction
Transmission of HIV through the sharing of contaminated
injecting equipment among injecting drug users (IDU)
in the different countries of Asia, as in .many other parts
of the world, has often been crucial to the development
and nature of the epidemic and explosive in character
[1]. In most places this transmission continues unabated
and has proven problematic for the development of
effective responses.
The frequent lack of effective response to HIV infection
among IDU. despite the presence of active national AIDS
programmes, stems from a combination of a lack of
concern, a failure to recognize the importance of this
aspect of the epidemic, difficulties in dealing with issues
of illegal drug use, which are politically and culturally
sensitive, and perceptions of IDU as being noncompliant,
not concerned with their health, and too difficult or
unworthy to work with [1]. In addition, the prevailing
climate is often one of a uniquely law and order approach
to the problems of illicit drug use, in which the effective
strategies of harm reduction, which are based on working
with the affected community, are seen as contradictory
and inimical to fundamental drug policy. Finally, harm
reduction approaches that have been seen as successful in
developed countries, which include needle and syringe
exchange programmes (NSEP), drug substitution
programmes, methadone maintenance therapy (MMT),
and peer education [2], have often been characterized as
culturally and politically inapplicable in Asia [3].
Despite all these barriers, successful programmes for the
prevention of HIV transmission among IDU have sprung
up in many Asian countries, illustrating the validity of the
principles underlying the harm reduction approach. This
approach, derived originally from the field of drug
dependence treatment, recognizes that the goal ofabstinence,
while desirable, is often unattainable, and it seeks pragmatic
approaches to decrease the harm associated with drug use
while not necessarily decreasing that drug use [2].
Importandy, although these programmes share a common
philosophy, this is expressed in very different ways in
different localities with different political, cultural and
historical circumstances. To illustrate both the diversity
and the common thread running through these
approaches, here we provide a brief description of seven
of the more established programmes and of the Asian
Harm Reduction Network formed in 1996 to support
the work of these programmes.
Although the majority of these programmes have
evaluation mechanisms, few have undergone external or
published evaluation based on behavioural or morbidity
outcomes. Thus, sources for these descriptions are often
reports prepared for internal use or for funding agencies.
The programmes
Ikhlas, Kuala Lumpur, Malaysia [4]
The Ikhlas Community Centre in Kuala Lumpur,
Malaysia, began as a street outreach programme established
by members of Pink Triangle (the first nongovernment
AIDS organization in Malaysia). The activities were
focused upon IDU in Chow Kit, a red light district in
Kuala Lumpur.
From the Asian Harm Reduction Network, Fairfield, Victoria, Australia.
Requests for reprints to: Paul Deany, Asian Harm Reduction Network, Office for Communicable Disease Control, Region 10,
447 Chiangmai-Lampoon Road, Muang District, Chiang Mai 50000, Thailand. E-mail: deany@burnet.edu.au.
© Lippincott-Raven Publishers ISBN 0-41283-650-5 ISSN 1350-2840
SI 09
1
S110
AIDS 1998, Vol 12 (suppl B)
The IDU in Chow Kit are generally homeless and in
poor health, and were initially suspicious ot the outreach
workers who they assumed worked for the government.
The outreach workers had to persist in building up trust
and reassuring the IDU that they were there to help. In
manv cases, the workers found that the immediate needs
ot IDU had to be attended to before they could
concentrate on HIV/AIDS information.
Eventually, a small drop-in centre in Chow Kit was
established where IDU could come for medical treatment,
food and information and counselling about HIV/ AIDS
and safer using practices. Apart from these services, the
drop-in centre provides a shower, laundry, recreational
facilities and an area where clients can sleep. Given the
homelessness ot most ot the IDU. these facilities respond
to their immediate needs and therefore attract them. The
drop-in centre’ also provides information on rehabilitation
and referral for clients who want to stop using drugs.The
medical facility at Ikhlas treats 20 clients per dav. and the
centre itself provides three meals daily and currently sees
75-100 clients per day. Seventy per cent of their clients
are aged 21—29 years and many ot them have been living
on the streets tor more than 5 years. iMost have been
through prisons and rehabilitation centres several times.
Outreach on the streets of Chow Kit is conducted three
times a week. Clients are given a pack contaimng a bottle
of water, a bottle of bleach, a leaflet, a bottle of iodine,
gauze, piaster, vitamins and panadol.
Ikhlas believes that the success of their programme is
measured by the enormous increase in the knowledge of
HIV/AIDS among IDU. Many clients have changed their
behaviour by no longer sharing injecting equipment,
reducing the number ot times they inject per day and
changing from injecting to smoking. The medical
attention, and the information about injecting related
health problems, has resulted in fewer abscesses and
paralysis of limbs, with many clients reducing or stopping
dangerous practices such as injecting pills. HIV-positive
clients of Ikhlas are now taken to a medical specialist for
treatment, clients who are discharged from hospital are
provided with temporary accommodation and families
are advised on care for their HIV-positive children. More
clients are beginning to request rehabilitation and detoxi
fication services. Although not all rehabilitation attempts
work. Ikhlas has found that those people who choose
rehabilitation, rather than being forced into it. are much
more likely to stop using drugs.
Needle exchange, Mae Chan, Thailand [5]
The Akha hill tribe villagers of the Mae Chan district of
Nonhern Thailand live about 30 km south of the
Burmese bonier on the lower tip of the Golden Triangle.
The villagers have a long history of using opium for social,
ritual and medicinal purposes. Until the late 1980s. opium
was readily available and the majority of the using
population smoked or ate opium on a daily basis. As opium
became less available (as a result of opium crop eradication
in the south and the establishment of laboratories
producing heroin in the north) the type of heroin available
was more suitable tor injecting than smoking.
NSEP were established in three villages with evidence of
drug use and a clear indication that IDU was not onlv
prevalent but increasing.The injecting of drugs was a fairly
new behaviour and one that villagers felt unsure about.
Meetings to discuss HIV prevention were held in each of
the villages, involving the villagers, the IDU, the village
committee, male elders and local representatives of the
Thai government. After much discussion, the villagers
agreed that an NSEP would be useful.
The NSEP commenced in November 1992: a register
was drawn up recording users’ names, the number of times
they injected daily, the amount of heroin they used per
day and some details of the sharing networks among IDU.
The village committee in each village undertook the
responsibility for distributing clean needles and syringes
and disposing of old ones.
Each user was educated individually about safer using
techniques, following the 2 x 2 x 2 method used in
Australia — cleaning the needle and syringe twice with
cold water, twice with bleach and twice again with cold
water. The uncertainty of continued needle and syringe
supply meant they had to be conservative with the
numbers of needle and synnges distributed, limiting this
to a maximum of three needles and syringes per user per
week.
The operation of the NSEP in these first three villages
worked in a fairly systematic way for a year and a half,
until the supply of needles and syringes abruptlv ran our.
By this time, however, the IDU had developed a strong
sense of responsibility in their using behaviour and had
become accustomed to using their own injecting
equipment: in the majority of cases they were no longer
sharing needles and syringes.
The NSEP now operate on a two-tiered level: direct
exchanges and an on-request basis. The direct exchanges
operate in six villages, along similar lines to the original
exchanges, but are now administered by paid health care
workers. Records are kept of the number of needles and
syringes distributed and the number returned each week.
75 IDU are provided with up to three needles and syringes
per week in these district exchanges. Of the needles
distributed, more than 90% are returned.
Drug substitution programme, New Delhi, India [6]
SHARAN, the Society for Serving the Urban Poor, is an
urban development nongovernment organization (NGO)
in New Delhi, India. In the early 1990s, SHARAN
identified a growing problem of IDU among urban slum
Harm reduction in Asia Crofts et al.
dwellers. Many of the IDU had serious health problems
associated with their injecting, such as incorrect injecung
practices with consequent development of ulcers,
abscesses, cellulitis and thrombophlebitis. SHARAN
found that there was frequent needle and syringe sharing
with little cleaning occurring between use, thus increasing
the risk of the spread of hepatitis and HIV
As the price of heroin increased, the users began switching
from inhaling heroin to injecung buprenorphine (trade
name Tidigesic). SHARAN’s focus group with IDU
indicated that IDU began injecting buprenorphine
because they believed it would help them stop using
heroin and because buprenorphine was cheaper.The focus
groups also revealed that most heroin inhalers are potential
injectors: all that is required for them to take up injecting
is a decrease in heroin availability.
SHARAN clearly saw the need for some intervention
with the IDU and established a trial programme of
sublingual buprenorphine. This established that
buprenorphine was acceptable to heroin addicts, had few
4 side effects, blocked the effects of subsequently
admimstered doses of morphine, appeared to induce only
a low level of physical dependence and significantly
dimimshed the self-administration of heroin.
SHARAN had already made contact with many IDU
through their detoxification camps. The substitution
<6 programme began on a pilot basis in early 1993 with 30
IDU and quickly expanded to 300. Initially the doses of
buprenorphine were administered through a street
delivery system. As their clients increased, SHARAN
established a drop-in centre where their clients could
receive their dose.
jp Clients are given buprenorphine for 1 year free of charge;
k after this they are offered prescriptions, which are reviewed
monthly During this time, any client who wants to
detoxify can do so in SHARAN s detoxification camps
or they can be referred to other services. Short term
rehabilitation is also offered and clients can embark on a
structured dose reducuon programme.
From February 1995 to January 1997,315 of the 1320
buprenorphine clients attended the clinic regularly; 34%
(447) of the clients were IDU and of these 33% (148)
had given up injecting; 35% (158) had stopped sharing
equipment and/or reduced the frequency of injections.
*
Through a system of Peer Education and Peer Research,
SHARAN has continued to interview and evaluate clients’
attitudes to the programme: most clients have reponed
that their quality of life, economically, socially and health
wise, has improved. As a result of this experience,
SHARAN believes that oral buprenorphine is a feasible,
low-cost and effective tool to diminish the risk of HIV
among high-nsk opiate injectors.
The SHALOM Project, Manipur, India [7,8]
The Society for HIV/AIDS and Lifeline Operauons in
Manipur (SHALOM) was established in late 1994, after a
1 year feasibility study into the problems of IDU and
HIV infection in Churachandpur township in Manipur.
Churachandpur is a predominandy tribal and Christian
region in the northeastern part of India, bordering
Myanmar.
The first HIV cases in Manipur were detected among
IDU in late 1989. Of the 1.8 million people in Mampur,
an estimated 40 000 are IDU, over 60% of whom are
HIV-positive. Churachandpur was chosen as the site for
the project as it had 3000 IDU and highly motivated
community leaders who were deeply concerned about
drug use and HIV infection.
After wide consultation with community leaders, church
leaders, womens groups, youth and educational institu
tions, drug users and law enforcement agencies SHALOM
decided to establish an NSEP. A 1995 study in Churachandpur showed that the main reason drug users were
sharing needles and syringes was the fear of being arrested
if found with injecting equipment. The NSEP aimed to
reduce the sharing and remove possibly infected syringes
from circulation. Consultation with police resulted in their
support for the NSEP with officers allowing SHALOM
workers to carry injecting equipment and not harassing
IDU for carrying syringes.The Manipur Minister of State
for Health, after viewing evidence of the effectiveness
and community acceptance of the programme, also
granted permission for the programme and included the
harm reduction approach in his State AIDS policy.
In August 1995, the NSEP began by offering clients stenle
syringes, needles, swabs, cotton, distilled water and client
ID cards. SHALOM employed peer outreach workers,
most of whom were ex-users, to visit different parts of
the town, exchanging needles and syringes and providing
information on HIV/AIDS. The peer educators work in
pairs, partly to give each other the support not to start
using again.
IDU can also exchange their needles and syringes at the
SHALOM building. Other services and choices offered
by SHALOM include medical attention, home detoxifica
tion, institutional detoxification and rehabilitation, use of
bleach to clean needles, home based care for HIV infected
people, confidential HIV testing and counselling, com
munity education and recreational and vocational re
habilitation.
Between April 1996 and March 1997,25 719 new needles
and syringes were distributed to IDU and 15 641 used
needles and syringes were collected: overall the syringe
return rate was 61%. In the same period, SHALOM staff
provided detoxification services 444 times to 349 drug
users.
S111
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AIDS 1998, Vol 1 2 (suppl 8)
LALS, Kathmandu, Nepal [9]
The Lifesaving and Lifegiving Society (LALS) was
established in 1991 by two volunteers in Kathmandu.
Nepal. Heroin has been used in Nepal since the 1970s,
initially by ‘chasing the dragon’, but increasingly through
injecting. It is estimated that there are 25 000—IO 000
drug users in Nepal with about 10% injecting their drugs.
Nepal is surrounded by countries with extensive HIV
epidemics among their IDU, including Myanmar and
northeast India.
Save the Children Fund, Ho Chi Minh City,
Vietnam [10,11]
The first detected case of HIV in Vietnam was in
December 1990. By April 1997, 5401 people were
reported as being infected with HIV, 759 of whom had
developed AIDS, 430 of whom had died (based on
government figures). It is estimated that about 70% of
people detected with HIV are IDU. There are about
200 000 drug users in Vietnam; half are IDU and about
30 000 live in Ho Chi Minh City (HCMC).
When LALS began its work, injecting was a hidden
phenomenon and the rates of sharing injecting equipment
were extremely high. Although it was possible to buy
needles and syringes from pharmacies, most IDU did
not purchase them for fear of being identified as a drug
user.
In HCMC most users inject ‘black water', a by-product
of opium mixed with water, commonly injecting several
times a day and sharing needles. The majority of drug
users in HCiMC have been using drugs for a long time:
the majority are men in their forties and early taffies, many
of whom started IDU during the war.
LALS began by distributing sterile injecting equipment
in exchange for contanunated equipment among the IDU.
It took some time to establish trust with the IDU. who
had not before expenenced offers of assistance without
the insistence that they go into treatment. At first, the
outreach workers did not have an office and therefore
visited IDU three to four times a week on the streets.
They bought the necessary injecting equipment and
medical supplies with their own money and from
donations.They found that the level of knowledge about
HIV was low and injecting techniques were poor.
The HIV/AIDS Prevention and Education programme
of the Save the Children Fund UK has been operating in
Ho Chi Minh City, Vietnam, since 1992, having found
that little was being done to educate and promote HIV
prevention among IDU. A programme was established to
target IDU using a peer education approach.The initial
approach involved distributing disinfectants to shooting
galleries, but it was soon discovered that the disinfectant
was inappropriate (for example, bleach), or that the users
were not in control of their own injecting equipment
because they used the dealers syringe at the shooting
gallery.The message was moderated to promote cleaning
syringes with water.
Initially, the community and authorities believed that
LALS was promoting and supporting drug use. Through
negotiations and discussions with community leaders
LALS gradually earned respect. The suppon of the Chief
of the Narcotic Division helped to ease problems with
the police. In 1997. LALS still met with the local police
every Tuesday to discuss their programmes and emphasize
the importance of police suppon.
LALS now has 24 full-time workers including eight
community.’ health outreach workers (CHOWS). The
outreach teams include ex-drug users, nurses and social
workers, working with approximately 860 IDU. They
visit 65 different areas in Kathmandu to perform needle/
syringe exchange, distribute condoms, and give primary
health care and counselling to IDU and their families/
sexual parmers. LALS also educates the community about
HIV/AIDS and prevention methods. Syringes are
exchanged on a one to one basis with no limit on the
number of exchanges at any particular contact. Between
August 1991 and February 1997, 173 798 exchanges
had occurred.The data from LALS’ research shows that
there have been significant changes in injecting
behaviour, in relation to HIV risk, by clients who have
been in contact with LALS, and that HIV is not spreading
among these IDU. HIV seroprevalence among LALS’
clients surveyed between 1991 and 1994 remained stable
at below 2%.
In 1995. a 3-month pilot NSEP was begun, targeting two
shooting galleries. It soon became simply a needle and
syringe distribution programme, because IDU did not
want to carry needles and syringes on them for fear of
arrest. It is possible that the pilot programmes will be
expanded, and the government is now runmng its own
pilot NSEP in HCMC.
The SCF employs 10 outreach workers, who go out to
the streets on their motorcycles most days. They provide
services to IDU in 16 areas of the city, visiting IDU in
coffee shops near shooting galleries or in their own homes.
They deliver IEC (STD/AIDS information, condoms,
drug use/dependency) materials and give advice on safer
using practices and HIV/AIDS.They have established peer
support groups in which IDU share their experiences,
give updates on the local scene and role play scenarios
that they have witnessed. Other activines include home
visits, involvement in‘The Friends House’ — a house for
HIV infected IDU who are homeless or have been
abandoned by their families, musical groups performing
songs about HIV prevention, medical referrals and
community education.
SCF provides services to an estimated 3000 IDU (1996),
of whom 60% are seen on a regular basis. The outreach
€
►
I
I
Harm reduction in Asia Crofts et al.
services developed by the programme are to be extended
to six other provinces in Vietnam.
ASEP, Cebu City, Philippines [12,13]
The AIDS Surveillance and Education Project (ASEP) is
implemented by PATH, Philippines in cooperation with
the department of Health/National AIDS/STD Preven
tion and Control Programme, local NGO and city health
depanments. One of its programmes is a harm reduction
project aimed at IDU in Cebu, an island south of Manila.
^The project began in 1994, after intensive interviewing
" of IDU in Cebu City, and is the first of its type in the
Philippines.
The cumulative total of notified HIV infections in the
Philippines (December 1996) was 861 people, of whom
295 had developed AIDS and 154 had died.
Crystal methamphetamine is the drug of choice among
♦the Philippines drug users: although some ot it is
^manufactured locally, most is imported from China. Hong
Kong and Taiwan. A study conducted among IDU in
Cebu in 1994 discovered that the respondents had used
♦drugs for between 5 and 15 years, that needle sharing
was usual and that they were not using effective measures
to disinfect their needles and syringes. One needle and
^syringe might be shared by between three and 13 people.
♦The primary reasons for sharing equipment was a lack ot
^money, the inability to obtain clean equipment and
'camaraderie among friends.
The Cebu project runs along similar lines to LALS in
Nepal. The 11 staff consist of a project coordinator, tour
♦senior Community Health OutreachWorkers (CHOWS),
two junior CHOWS and four administrative and support
staff. Manv of the CHOWS are former drug users, which
. has helped bridge the gap between the client and the
health provider. The CHOWS provide services 5 days a
^week to about 500 IDU who either live in or come to
”the area. They deliver basic information about sexually
^transmitted disease (STD)/AIDS, condom education/
negotiation skills/distnbution, IEC materials, risk
Wreduction counselling, safer injecting practices, needle
cleaning (by distributing bleach and water), needle and
s syringe exchange, primary health care and referral for
appropriate medical or drug rehabilitation services.
♦Although the project has not been going for long, it has
^managed to contact the difficult to reach IDU and has
brought about some behavioural change: needle and
' syringe sharing has decreased, bleach and water has been
accepted as a way to clean equipment and knowledge
about the transmission of HIV/AIDS has increased.
During the period January to March 1997, 1614 people
were seen for counselling about STD/AIDS, drug
problems and other personal issues. Over 600 IEC
materials were distributed. Over 1100 containers ofbleach
and water were distributed to individuals, satellite centres
and for demonstrations during training and orientation
of needle exchange members. The total number ot
needles/syringes exchanged was 2007 (low because ot
insufficient supply).
The Asian Harm Reduction Network [14]
The Asian Harm Reduction Network (AHRN) was
formed in 1996 by delegates frcm Asia to the 7th
International Conference on the Reduction ot Drug
Related Harm in Hobart. A secretanat was established
and a coordinator employed. A series of meetings
established a structure for management of the Network,
with a Steering Committee and an Executive mainly
consisting of workers from harm reduction programmes
in Asia.
The AHRN’s mission statement emphasizes its role in
supporting the existing programmes, and working for the
implementation of new harm reduction programmes
across Asia. In its short life, its membership of more than
800 has grown to include virtually every programme
involved in the prevention of HIV infection among IDU
in Asia, as well as several hundred other individuals and
agencies interested in and supportive of this approach.
AHRN is in a position to increase the ability of program
mes to lobby for support for harm reduction without
exposing individual programmes to potential adverse
responses from national authorities, and to coordinate with
regional funding and other agencies and programmes. It
has been extremely active in these areas, in raising the
profile of IDU in relation to national and regional HIV
epidemics and in disseminating information across the
region and globally.
Discussion
Our aim in reviewing these seven case studies here is
twofold: first, to give examples of successful indigenous
programmes for the prevention of HIV infection among
IDU in Asia based on harm reduction principles: and
second, to illustrate the need for local expression ot these
principles, which varies according to context — political,
cultural, economic and so on.
The success or otherwise of these programmes can be
measured in various, formal and informal, ways. In only
one of the programmes (which began before prevalence
had risen significandy) has there been demonstrated
prevention of an epidemic of HIV infection among IDU
[9]. This success is in accord with findings from many
cities around the world, where the institution ot NSEP
while HIV prevalence was low has been associated with
continuing low prevalence [15]. In the Asian region, most
of these programmes have come into being only after
HIV prevalence among IDU has risen, often to very high
levels, as in Manipur in northeast India [16]. Controlling
S113
5114
AIDS 1998, Vol 12 (suppl R)
HiV epidemics among IDU where presences are already
high has been achieved in developed countries, but it has
also been shown to be far more difficult than preventing
increases from low levels [17,18].
H
g
often leads to increased entry into treatment, often with
greater commitment.
This illustrates another important measure ofsuccess: these
programmes, starting by meeting the immediate needs of
their chents tor primary health care and the means for
protection against HIV infection, provide a channel of
access to drug detoxification, treatment and rehabilitation,
n many cases, these clients would not normally have had
access to these services in any other wav. Nevertheless
the primary goal of the programmes is not reduction in
drog use. which is seen as complementary to primary
objective of preventing HIV transmission.
Commonly, the programmes' experience when first
starting is that their potential clients have a deep suspicion
unm riTk
6 °f
°f
and
My CarmS gestUre trom the soclecv in
which they live - IDU in most Asian societies (as in
most societies) are soc.al pariahs, or even social enemies.
Programme workers initially face hostility from their IDU
clients; their motives are seen to be either to force the
drug user into treatment or to be part of the government s
ug control strategy. Overcoming this perception is often
surmn C “trn '
that SUch Programmes have to
surmount. NGO can usually work in this area more easily
han can government organizations, as the IDU are less
hkely to associate them with the government agencies’
often mandatory and repressive approach.
In general, strategies to prevent the transmission of HIV
among IDU come down to the final common pathway
of the sharing of injecting equipment — breaking this
sharing nexus breaks the chain of transmission. Hosv this
is done will vary, and NSEP are not the onlv wav
Disinfection of used needles and syringes before reuse is
also likely to have some impact, but the experience here
illustrates the necessity of devtsing locally acceptable
strategies. Bleach as a strategy was devised in one paracular
c^tural setnng — that of San Francisco in the mid-1980s
118], For some of these programmes, bleach provides an
acceptable second line; for others, it is not appropriate
locally and other means of disinfection have been sought.
Much has been learnt about the effective prevention of
HI V among IDU in Asia; particularly that it can be done
and that it is worth doing. These programmes represent
enormous effort on the pan of dedicated individuals- the
challenge now is to increase the programmes in number
and coverage throughout Asia to a scale commensurate
with the scale of the epidemic.
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is to begin by meeting
i.
"" "
2.
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experience of these programmes is the necessity of
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S115
'Superstar' and 'model brothel': developing
and evaluating a condom promotion program
for sex establishments in Chiang Mai, Thailand
Surasing Visrutaratna, Christina P. Lindan*,
Anake Sirhorachait and Jeffrey S. Mandel*
Objectives: We developed and evaluated a multifaceted AIDS prevention program
to increase condom use among sex workers in the city of Chiang Mai, Northern
Thailand.
Subjects and methods: A year-long intervention targeted sex workers, brothel owners
and clients, promoted cooperation between these groups and the public health office
and established a free condom supply for sex establishments. Nearly 500 women
from 43 establishments took part in the program, encompassing nearly all direct sex
workers in urban Chiang Mai. The intervention included repeated small-group training
sessions for sex workers in which experienced women ('superstars') acted as peer
educators. The 'model brothel' component encouraged all brothel owners in Chiang
Mai to insist on mandatory use of condoms by sex workers and to encourage clients
to use condoms. Before and after the intervention, specially trained volunteers posing
as clients tested a subsample of sex workers to see whether they insisted on condom
use.
Results: The intervention was well received by sex workers and obtained strong
support and cooperation from brothel owners. Before the intervention, only 42%
(10/24) of women surveyed by volunteers posing as clients refused to have sex without
a condom, even when the client insisted and offered to pay three times the usual fee.
Following the program, 92% (72/78) refused; 1 year later, 78% (69/85) refused during
the same scenario.
Conclusions: An innovative program directly involving sex workers as peer educators
and enlisting the support of brothel owners and operators can result in improved
condom use over time. Lessons learned from this program may be applicable
elsewhere.
AIDS 1995, 9 (suppl 1 ):S69-S75
Keywords: AIDS, HIV, prostitutes, Thailand, Asia, women, intervention.
Introduction
’
The rapid spread of HIV among female sex workers in
Thailand has eclipsed the earlier epidemic of HIV infec
tion among injecting drug users [1-3], particularly in the
northern provinces of Thailand bordering Myanmar and
Laos [4]. In June 1989, the first national sentinel serosurvey discovered a prevalence rate of 44% among direct
(brothel-based) sex workers in Chiang Mai province [5].
Since that time, similar rates among direct sex workers in
urban Chiang Mai have been confirmed [6], with sero
prevalence rates of up to 65% found in some brothels
[7]. Recent studies have shown HIV infection rates of
12-15% among young male army conscripts and 16%
among male patients with sexually transmitted diseases,
foreshadowing the spread of HIV to the general popu
lation [8—10].
The initiation of young women into the sex industry in
Thailand, as in many parts of Asia, arises amid despe-
From the Chiang Mai Provincial Public Health Office, Chiang Mai, Thailand, the ’Center for AIDS Prevention Studies
(CAPS), University of California, San Francisco, USA, and tNakorn Ping Hospital, Chiang Mai, Thailand.
Sponsorship: This work was funded by the Chiang Mai Provincial Public Health Office, the Program for Appropriate
Technology and Health (PATH) and NIMH Grant MH42459, CAPS International Collaborative Studies.
Requests for reprints to: Dr Christina P: Lindan, Center for AIDS Prevention Studies, University of California, 74 New
Montgomery Street, San Francisco, CA 94105, USA.
© Rapid Science Publishers ISSN 1350-2840
S69
S70
AIDS 1995, Vol 9 (suppl 1)
rate social and economic conditions [11]. These women
tend to be young (less than 20 years), from impoverished
families of Northern Thailand and Myanmar, have little
education and often speak local dialects and little Thai
[12]. The turnover of women within brothels is high;
within a year as many as 50% may move to another
brothel or out of the sex industry [13]. Having earned
sufficient money or having paid off the debt to a brothel
owner incurred by her family, a woman may return to
her village or seek other employment [14].
In 1989, in response to the escalating HIV epidemic
among sex workers and their clients, public health offi
cials in Chiang Mai implemented a variety of programs
to increase the use of condoms. Radio and television
media campaigns were initiated along with traditional
health education measures such as posters, pamphlets and
lectures at sexually transmitted disease clinics; the lat
ter met with very limited success, possibly due to their
didactic nature and the resulting low participation of
sex workers and clients. Consequently, the Chiang Mai
Provincial Public Health Office, in collaboration with
the Program for Appropriate Technology in Health, de
signed and implemented a multifaceted intervention that
targeted nearly all sex workers in the urban area, as well
as brothel owners and clients. We describe this program
in detail including educational approaches, problems as
sociated with implementation, methods of assessing effi
cacy and an evaluation of the program’s impact on con
dom usage.
In 1991, the Thai National AIDS Committee adopted an
official policy, the 100% condom program, to encourage
condom use in the sex industry [15,16]. We believe that
the project described here provides an acceptable and
sustainable model for the implementation of this policy
as well as one that may be applicable to the sex industry
in other settings.
Subjects and methods
Overview
This project was a demonstration program that began
in October 1989, with the final evaluation in February
1992. Funding was provided by the Chiang Mai Provin
cial Public Health Office (Ministry of Public Health)
and the Program for Appropriate Technology in Health
under a grant from the USAID/Thailand Mission. The
project had two main components called ‘superstar’ and
‘model brothel’ (Table 1), which targeted sex workers
and also owners/operators of commercial sex establish
ments with the objective of increasing the consistent and
correct use of condoms with all clients. The intervention
strategy involved elements of education, motivation, re
ward and support.
Preintervention interviews
In order to identify factors associated with a low usage
of condoms and to help guide development of the in
Table 1. Components of 1 2-month condom promotion program.
Preintervention interviews with sex workers and clients
'Superstar* component
Identify 'superstars', (experienced) sex workers who serve as peer
educators
Small group training sessions for all sex workers at brothels every 3
months
Improve knowledge and perceived risk of AIDS, motivate consistent
cpndom use, teach strategies for handling difficult clients
On-going discussion groups with sex workers to improve program
'Model brothel' component
Identify influential brothel owners to help organize brothels
Encourage all brothel owners/operators to establish policy of manda
tory condom use by sex workers
Cost-benefit approach used as motivation
Supply of free condoms to brothels
All clients must have a condom before entering room of sex worker
On-going discussion groups of owners/operators to resolve problems
tervention, informal open-ended discussions were con
ducted with clients and sex workers. A convenience
sample of approximately 100 clients from a majority of
Chiang Mai brothels underwent individual interviews
before they engaged sex workers. None of the men
who were interviewed were overtly intoxicated. The in
terviews were conducted by the Principal Investigator.
These clients frequently reported that condoms were in
convenient or difficult to obtain. Common beliefs ex
pressed were that ‘real men do not use condoms and that
men were quite capable of selecting ‘clean’ or HIV-free
sex workers.
Individual interviews with approximately 50 direct sex
workers revealed that although most had heard of AIDS,
few clearly understood the information provided in pre
vention campaigns. For example, many did not believe
themselves at risk due to multiple sex partners because
they understood this to mean having sex with more
than one person at the same moment. The vast majority
feared that if they refused clients who would not use
condoms, this would create unacceptable problems with
the brothel owners and reduce their income.
'Superstar' program
Sex workers
The ‘superstar’ component of the intervention targeted
all direct female sex workers in the urban area of Chiang
Mai. Direct sex workers carry out their work in brothels,
in contrast to indirect sex workers who work in estab
lishments where the primary service offered is not sex
ual; they may be hostesses in cocktail lounges, waitresses
or masseuses in massage parlors; sexual encounters are
individually negotiated by either the client or the sex
worker. Street walkers meet prospective clients along the_
streets; this group constitutes only a small proportion of
the total number of sex workers in Chiang Mai. A census
in 1989 by public health officials recorded 1881 female
sex workers in 109 sex establishments in the Muang
District of Chiang Mai (Chiang Mai Provincial Public
Health Office, unpublished information, 1994). Of these
I
Intervention for sex workers in Chiang Mai Virutaratna et al.
women, approximately 500 worked in 43 brothels in the
urban area.
Women were recruited by first obtaining permission
from owners or managers of brothels and sex establish
ments and then approaching all women in their place
of work. Public health workers went to the sex estab
lishments and spoke directly to the women to explain
the intervention and request their participation. Nearly
all the women approached agreed to become involved;
consent to participate was obtained verbally.
The small-group training that targeted sex workers was
undertaken in four phases: November 1989, February
1990, September 1990 and December 1990. In order to
x provide sufficient staff, several other governmental ork
ganizations including Nakorn Ping Provincial Hospital,
4^ the Sexually Transmitted Disease Center, the Faculty of
Medicine at Chiang Mai University and the Communi
cable Disease Control Office (Ministry of Public Health)
were also invited to join the project, a collaboration that
was met with enthusiasm. Each organization assembled
a training team responsible for a certain number of sex
establishments. The core project staff operated train-thetrainers workshops to standardize the educational pro
gram and approach.
'Superstars'
‘Superstars’ were volunteer sex workers who were
trained to aid communication among their peers, pub. lie health workers and brothel owners. These women
were selected by project staff on the basis of their ex
perience in the sex industry, leadership potential and
acceptability as role-models. One to three ‘superstars’
were selected at each sex establishment; new ones were
chosen at each successive small-group training session if
the previous ‘superstar(s)’ had moved out of the brothel.
Their main role was to motivate and encourage other
women in the brothel, especially those who were new
to the brothel. They assisted in educating their peers
'
about AIDS, condom use and managing uncooperative
clients. Focus groups of‘superstars’ were used to identify
techniques for dealing with difficult clients who were
drunk, refused to use a condom or had a prolonged ejac
ulation time. These techniques were incorporated into
the training sessions given by the public health workers.
' Educational component
Fifteen teams of three or four public health workers con
ducted 2-h training sessions with small groups (five to
10 sex workers) every 3 months for 1 year during the
intervention period; each team was assigned to six or
eight sex establishments. The curriculum of the sessions
was specially designed to be additive; new information
was given during each sequential training session, but
each session also reiterated the information given in pre
vious sessions. This reinforced the initial messages and
also provided basic information to those who came into
the program later (due to turnover of sex workers). Using this approach, the women were able to practise new
skills between training sessions and gain personal expe-
rience with risk reduction. Information covered during
the sessions included education on HIV transmission and
AIDS, efforts to improve the concept of personal risk,
instruction in and demonstration of the proper use of
condoms and coaching on how to convince a reluctant
client to use a condom.
The training sessions were conducted at the womens
place of work and times were adjusted to suit the needs
of each brothel. The small-group approach gave the
women a rare opportunity to ask questions and express
their concerns. Following each session, discussion groups
were held to allow the sex workers to identify additional
problems that needed to be addressed.
Methods used to convey information were designed to
be appropriate to the sex workers, most of whom had
little education. While AIDS educational materials were
available in northern Thailand, none were geared to
ward sex workers. Videos were available but could not be
shown as very few sex establishments owned the neces
sary equipment. Therefore, simple and clear flip charts
using pictures were created to explain the modes of HIV
transmission and symptoms of HIV disease. Focus groups
revealed that most sex workers did not know how to
use condoms properly, and most broken condoms ap
parently occurred from incorrect use. Wooden models of
penises were employed for demonstration and practice.
Interaction and discussion were encouraged and efforts
were made to make the sessions enjoyable and fun. All
women were given small gifts such as combs or mirrors
for participating.
A positive approach based on hope for a better future,
rather than fear of AIDS, was used to motivate women
at small-group training sessions. The economic factors
that drive young women into prostitution were openly
acknowledged. Most sex workers did not want to be in
that occupation for their entire adult lives. Consistent use
of condoms was offered as a means of achieving their
long-range goals which invariably involved leaving the
sex industry. Behavioral change was self-reinforcing as
the women became advocates for AIDS prevention.
Special games were developed to help the young women
understand difficult concepts. We describe two of these
here. In the ‘pop-up’ game, designed to develop the con
cept of personal risk, 10 male dolls representing clients
were constructed with a moveable barrel hiding their
genitalia. When the barrel was lifted, a moveable penis
sprang up. On two of the 10 dolls, a red ribbon was tied
to the penis, symbolizing HIV infection (20% prevalence
rate). The sex workers were divided into two teams:
one team always ‘used condoms’ and the other team
‘used condoms’ only when they thought a doll/client
was HIV-infected. Each team took successive turns se
lecting a doll/client. The team that always ‘used con
doms’ received points for all dolls selected. The team that
wasn’t required to ‘use condoms’ lost points for choosing
a doll with a red ribbon, while receiving more points
for choosing a doll without a red ribbon. After each
sex worker had chosen many times, it became clear that
S71
S72
AIDS 1995, Vol 9 (suppl 1)
those on the team not ‘using condoms’ could be exposed
to HIV even if only two in 10 men were infected. Im
plicit, of course, was the message that while a sex worker
might forego the revenue from a client who refused to
wear a condom, and thus earn less money, she would
stay healthy longer and make more money in the long
term.
The jigsaw game’ was designed to teach recognition of
the symptoms of HIV disease and to reinforce the fact
that persons without symptoms (sex workers and clients
alike) could be HIV-infected. Thirty cards were designed
with pictures of people with symptoms of HIV disease:
10 with advanced symptoms, such as Kaposi s sarcoma,
oral Candida or pneumonia; 10 with early symptoms,
such as weight loss, diarrhea or dermatitis; and 10 with
no symptoms. The fact that the asymptomatic period of
HIV disease is often the longest was explained by the
public health workers. The object of the game was to
arrange the cards into sets, and to name or describe the
symptoms.
'Model brothel' program
Brothel owners/operators
The ‘model brothel’ program was developed to promote
cooperation amon;ig brothel owners and encourage them
to establish a policy of universal condom use. To induce peer pressure., we approached those brothel owners
known to be most influential in organizing neighboring
brothels in their subdistricts. Their cooperation was en
listed in encouraging the owners of surrounding brothels
to institute a condom only policy. Within 1 month, all
direct sex establishments were participating. Workshops
and focus groups were held during which previously un
involved brothel owners were invited into the program
and given an opportunity to discuss concerns and find
ways of resolving them.
A cost-benefit approach was used as motivation for
policy change. With a condom only policy in place, it
was estimated that a brothel with 30 women could save
approximately 5000—6000 baht/month (US$200—240)
on treatment of sexually transmitted diseases, a cost
generally borne by the brothel owner. A potential loss
of clients would be balanced by the sex workers’ ability
to work longer and more consistendy if free of disease.
If the sex workers felt supported in insisting on condom
use and believed the owner to be concerned about their
health, these improved relationships could improve the
women’s self-esteem and self-efficacy.
The brothel owners and operators also supported a sys
tem to help sex workers refuse clients who did not want
to use condoms. Every brothel in the program posted
a sign saying, ‘We only welcome guests who use con
doms’. The mama san (brothel manager) would talk to
all clients about condom use before they entered the sex
workers room, explain that he must use a condom and
ask to see if he had one. If the client had no condom, a
free one from the Ministry of Public Health was offered
or other name brands were provided for sale. If a sex
worker was still unsuccessful in persuading the client to
use a condom, she was instructed to give an excuse to
leave the room, allowing the mama-san or a bouncer to
intervene and manage the situation. These interventions
were particularly important during the initial months of
the project before the condom use policy came to be
accepted by clients.
Condom supply
Before this intervention, few brothels had condoms
readily available. Sex workers or clients had to pur
chase them at drug stores or obtain them through family
planning or sexually transmitted disease clinics. Another
study in this area had revealed that 70% of men who used
brothels never or rarely brought condoms with them
[11]. As part of this project, the Chiang Mai Provincial
Public Health Office, with support from the Ministry
of Public Health, supplied condoms to all sex establish
ments free of charge, approximately 60 000 per month to
brothels and 36 000 to sex workers in indirect establish
ments. Either the brothel owner/manager or ‘superstar’
could pick up a supply of condoms twice a week at the
public health office.
Survey of condom use
Several convenience subsamples of sex workers were eva
luated before and after the intervention to estimate the
extent of actual condom use. A baseline evaluation was
conducted in February 1990 in which only 11 of the
43 brothels in the intervention were evaluated due to
limited resources. In February 1991 and again in April
1992, two postintervention evaluations were conducted,
this time in all 43 brothels.
To conduct our evaluation survey, we used 20 specially
trained volunteers who posed as ‘clients’. These volun
teers were young men from local trade shops and small
businesses who were reimbursed for their participation
in the study. The volunteer ‘clients’ surveyed one in five
women at each brothel. Surveys at a specified brothel
were conducted simultaneously.
'
1
The condom use evaluation involved three steps. Ini
tially, the ‘client’ would note whether the sex worker
asked him to use a condom; second, he would insist on
not using a condom and observe whether the sex wor- %
ker refused; third, he would offer the sex worker three
times her customary fee if she would have sex without a
condom. If the sex worker insisted that he use a condom
under all circumsunces, he would pay her customary fee
and leave. If at any point, the sex worker consented to
have sex without a condom, the ‘client’ would make up W
an excuse for leaving (e.g. he didn’t have the time or
changed his mind) and depart. In all cases, the sex worker
was paid her customary fee.
Results
Participation in the intervention
Owners of sex establishments were initially reluctant to
take part in the ‘model brothel’ program; they feared a
Intervention for sex workers in Chiang Mai Virutaratna et al.
(
♦
loss of clients if condom use was made mandatory. The
sex workers also feared loss of income, did not believe
they could refuse clients insisting on sex without con
doms and felt that brothel owners would not support
mandatory condom use and would reprimand them if
they insisted that clients use condoms. It became clear
that uniform support and involvement of brothel owners
and managers was critical to a successful intervention.
in all three steps of the evaluation. A year later, when
another sample of 69 out of 361 women was surveyed,
56 (80%) refused sex without a condom during all three
steps of the evaluation.
Through outreach and net-working with brothel own
ers, universal participation of brothels was achieved. Sub
sequently, almost all sex workers who were approached
willingly agreed to take part in the program. In Novem
ber 1989, 501 women attended the small-group training
sessions; 491 in February 1990, 482 in September 1990
and 478 in December 1990. Differences in the numbers
of sex workers at each stage of the intervention were due
to fluctuations in the total population of sex workers.
Only a very small number of sex workers were away
from the brothels during the training sessions. Once the
program was well established, neither the owners nor the
sex workers reported a decline in the number of clients
or in net income.
We have described a multifaceted intervention program
that encouraged the universal use of condoms in Chi
ang Mai brothels. This program was a demonstration
project launched partly in response to the Thai Govern
ment’s HIV-control program. The broader government
program focused largely on the purchase and distribution
of condoms; it also proposed sanctions against sex es
tablishments where condoms were not used consistently,
and included a media campaign targeting clients. In con
trast, our program specifically focused on sex workers at
their places of work and acknowledged the importance
of targeting clients and brothel owners.
Evaluation of condom use
Before the intervention, a convenience sample of 24 out
of 131 women (18%) from 11 brothels (approximately
one in five women from each brothel studied) were eva
luated by volunteers posing as clients (Table 2). Of these
women, 42% succeeded in refusing a client who offered
three times her customary fee to have sex without a
condom. In contrast, 2 months after the intervention
was completed, 26 out of 28 women (93%) of a different
sample from the same subset of brothels refused clients
in a similar scenario. This number diminished somewhat
1 year later at which time 13 out of 17 women (76%)
who were sampled successfully completed all three steps
of the evaluation.
Concomitantly, a postintervention evaluation of condom
use was conducted with a convenience sample of 50
out of 349 women from the remaining 32 (out of 43)
brothels in Chiang Mai. This gave similar results to the
evaluation of the other 11 brothels. Two months after
the intervention, 46 out of 50 women (92%) succeeded
Discussion
There were several important factors in the acceptability
and sustainability of our program. First, universal en
dorsement by brothel owners was essential to supporting
the womens’ right to refuse clients. This was obtained by
educating owners on the economic advantage of main
taining the health of the women. Second, we gained the
full participation of sex workers; this was accomplished
by appealing to their almost universal hope of return
ing to their homes and raising a family, which could
occur only if they remained healthy. Third, the use of
selected women as ‘superstars’ contributed to the sus
tainability of educational messages. Acknowledgement of
these women increased their role as opinion leaders and
allowed the use of peer pressure to promote behavioral
change. Most important, these women were successful
in teaching survival skills to sex workers who were new
to the brothels.
Measuring the impact of our program on condom use
was a difficult task given the overlap of other govern
ment prevention campaigns and the increasing stigmati
zation of sex workers. However, we feel confident that
our assessment of rates of condom use, as measured by
Table 2. Insistence on condom use by sex workers as assessed by volunteer 'clients'.
Sex workers who passed assessment (no., %)
Sex
workers
Evalated
(no.)
(no.)
Step 1
Step 2
Step 3
24
28
17
17 (71%)
27 (96%)**
14 (82%)
12 (50%)
27 (96%)'
13 (76%)
10 (42%)
26 (93%)—
13 (76%)*
50
69
49 (98%)**
64 (93%)*
47 (94%)***
63 (93%)***
46 (92%)***
56 (81%)***
Brothels with pre- and postintervention (n = 11)
Preintervention
131
Postintervention (1991)
138
Postintervention (1992)
115
Brothels with postintervention only (n = 32)
Postintervention (1991)
349
Postintervention (1992)
361
Step 1: sex worker asked client to use a condom; Step 2: sex worker refused client's request for sex without a condom; Step 3: sex worker refused
sex without condom when client offered three times customary fee. *P<0.05, **P<0.01, ***P< 0.001, Fisher's exact test for the differences in
proportion of women who passed each step in the preintervention evaluation compared to each postintervention evaluation.
S73
)
S74
AIDS 1995, Vol 9 (suppl 1)
volunteer ‘clients’, was accurate. It is unlikely that the
sex workers were aware that they were being evaluated;
the use of volunteer ‘clients’ was neither announced nor
known to the sex establishments beforehand; all broth
els were surveyed more or less simultaneously. Different
volunteer ‘clients’ evaluated women in the same brothel
so that the offering of more money for sex without a
condom would not give away their purpose. In fact, our
initial survey of clients had revealed that it was common
practice for clients to offer more money for sex without
a condom.
We believe that our volunteer ‘client’ method of deter
mining condom use is more accurate than self-reporting
by sex workers or clients. Social desirability may lead
to exaggerated rates of reported condom use. In a 1989
study in Chiang Mai, self-reported condom use by sex
workers was close to 90%, yet HIV seroconversion and
sexually transmitted disease rates remained high [16]. In
an intervention targeting sex workers in another north
ern Thai province during the same period of time, con
dom use was reported as increasing from 14 to 50%, yet
only 17% of women said they would refuse to have un
protected intercourse if a client insisted [17]; in contrast,
we found that 42% of sex workers that we surveyed in
sisted on condom use with volunteer ‘clients’ before the
intervention. In 1991, 2 months after the intervention,
92-93% of all sampled sex workers refused volunteer
‘clients’ insisting on sex without a condom; 1 year later,
this had decreased to 80%.
Following the relative success of a number of differ
ent demonstration projects, like the one described here,
the Thai National AIDS Committee adopted the 100%
condom program as official policy [15,16]. Under this
policy, brothel owners are required to provide condoms
to all clients and to advertise that only clients using con
doms will be entertained. However, it does not specify
any education or training program, or a plan for im
plementation or evaluation; it is up to officials in each
province to devise their own strategies. As a result, any
evaluation of the program has been indirect, such as
monitoring condom usage through reports from male
sexually transmitted disease patients who have had con
tact with sex workers. Self-reports of condom use by sex
workers have increased since the campaign began [16].
However, HIV infection rates among military conscripts
continue to rise, and HIV prevalence among sex work
ers, despite turnover, continues to be high [9,10]. Thus,
although the government’s 100% condom program may
be affecting condom use to some degree, HIV transmis
sion between sex workers and clients is continuing.
The demonstration project described here provides a
specific strategy for increasing condom usage within
brothels. However, there is no quick fix. Interventions
targeting behavioral changes require a clear commitment
by public health officials to maintain them on an ongo
ing basis in order to prevent relapses and to sustain the
change [18]. Our program was dependent on ongoing
outreach activites to reinforce messages, engage new peer
leaders and insist on the support of the brothel owners.
The program was staff-intensive, requiring the recruit
ment of workers not only from the Health Department
but also from other governmental organizations in which
this assistance was not a mandated part of the job. Thus,
as a result of budgetary and staffing requirements, the
Public Health Office fully supported the project for only
a short period of time once the initial funding was ex
pended. It is likely that the absence of an ongoing in
tervention in the face of the continual turnover of new
sex workers explains the drop-off in condom usage over
time that was evident in this study.
In addition, dependence on a free supply of condoms
may result in relapsed behavior if these condoms become
unavailable. This may partly explain immediate increases
in the prevalence of sexually transmitted diseases during
periodic failures of stocks of free condoms in Chaing
Mai in the middle of 1990 (D. Douglas, personal communcation. Program for Appropriate Technology and
Health). As a result, other condom interventions in an
other province promoted by the Program for Appro
priate Technology and Health used a system of direct
sales from drug stores to brothels to avoid being depen
dent on a free supply and to ensure sustainability of the
program.
The present report covers brothel-based sex workers, but
our program also targeted indirect sex workers through
small-group training sessions. Indirect sex workers dif
fer from brothel-based women in several ways. They
are generally more highly paid, have fewer clients per
day [19,20] and have been considered at lower risk of
HIV infection. In 1989, according to government serosurveillance studies, 5% of indirect sex workers in Chiang
Mai were HIV-infected compared to 44% of women in
brothels [5]; this increased to 7.5% in 1993 [6]. Paradoxi
cally, women in indirect establishments appear to be less
likely to use condoms than brothel-based sex workers
[7], and may have less freedom to negotiate and insist
on their use. It is likely that with increased stigmatiza
tion of direct sex workers and sanctions against brothels,
more young women will move out of brothels to work
in places like coffee houses or massage parlors. It will
therefore be important to specifically target indirect sex
workers in AIDS prevention campaigns.
The alarming situation of HIV infection in Thailand
necessitates the continuation and expansion of thought
ful behavioral and public health interventions. So long
as the sex industry remains one of the few means by
which young women can obtain rapid economic im
provement, and since social norms allow both single and
married men to visit sex workers, the goal of proper
and consistent condom use in the sex industry must
be a national priority. The intervention program de
scribed here demonstrates a means by which this goal
may be achieved. The components of this project that
contributed to its success, in particular universal sup
port by brothel owners, an educational outreach to all
sex workers, ongoing supplies of condoms and specific
)
♦
(
Intervention for sex workers in Chiang Mai Virutaratna et al.
&
targeting of clients, should be incorporated into other
prevention programs in Thailand.
6.
<a
Ik
i
Acknowledgements
We thank David Celantano for reading the manuscript;
Anan Labsomtob, Anussorn Sithirat and the staff of
the Chiang Mai Provincial Public Health Office; Niwat Pruthithada and the staff of the Venereal Disease
Control Center of Region 10; Chawalit Natpratan and
the staff of the Department of Communicable Dis
ease Control Region 10; Petchsri Sirinirund and the
staff of Nakorn Ping Hospital; Decha Kuwudyakorn,
Watchara Sonthichai and the staff of Chiang Mai Mu
nicipal Health Department; Waraporn Siriswang and
Boonsiree Khochasin of Chiang Mai University for ex
tensive support and participation in each step of this pro
gram; Pawana Wienwarie and Don Douglas, formerly
of Program for Appropriate Technology and Health for
technical support of this project, especially media pro
duction; Win McKeithen of the USAID Mission, Thai
land; and all sex workers and brothel owners who took
part in this program.
8.
9.
10.
11.
12.
13.
14.
15.
16.
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STD/HIV intervention with sex workers
in West Bengal, India
Smarajit Jana, Nandinee Bandyopadhyay, Sadhana Mukherjee*,
Nayanita Dutta, Isika Basu and Amitrajit Saha
AIDS 1998, 12 (suppl B):S101-SI 08
Keywords: Self-esteem, social empowerment, networking, socail mobilization
I
Prevalent perceptions about sex, sexuality
and sex workers in India
In dominant discourses in India the term ‘prostitute’ is
rarely used to refer to an occupational group who earn
their livelihood through providing sexual services. Rather
it is used as a descriptive term denoting a homogenized
category, usually of women, that poses threats to public
health, sexual morality, social stability and civic order
[1]. Within this discursive boundary, sex workers
systematically find themselves to be targets of moralizing
impulses of the elite, through missions of cleansing and
sanitizing, both materially and symbolically [2J. If and
when sex workers figure in the political or developmental
agenda, they become ‘beneficiaries’ of projects which
aim to rescue, rehabilitate, reform, discipline, control or
police them. They get ‘saved’ and put in ‘safe’ homes by
charity organizations for their moral improvement.
Developmental nongovernmental organizations (NGO)
tend to ‘rehabilitate’ them through alternative employ
ment generation activities which invariably yield too
meagre an income for them to sustain themselves and
their dependants.The police regularly raid their quarters
and extract payments from them in the name of
controlhng'immoral’ trafficking. In addition, they remain
labelled as‘fallen’ women, seldom gaining acceptance in
the society.
The prevailing discussions on sexuality and sexual practices
frame the sex act as a necessary evil which can only
become socially acceptable if it is practised within mar
riage for purposes of reproduction. Such understanding
refuses to acknowledge sexual pleasure and an individuals
right to that pleasure. The existing gender ideology that
organizes the relationship between men and women
further limits the recognition of a woman’s sexual needs.
Thus, attempts are made to ignore the implications of
the social role that the sex workers play and to leave the
prevalent inequality within the political economy of
sexuality unquestioned.
Even when sex workers happen to be described in less
negative or even sympathetic terms in popular discourses,
they stall do not get exempted from stigmatization or social
exclusion. When they are represented as objects of pity,
they are seen to be powerless, abused victims of aberrant
male lust, who have ‘fallen’ into prostitution without any
choice or hope, when no other recourse is left for them.
Otherwise they make their appearance in the popular
imagination as the self-sacrificing supporting cast of
characters in literature and cinema, atoning their moral
guilt by ceaselessly giving up their hard earned income,
their clients, their ‘sinful’ ways and finally their lives to
ensure the well-being of the hero or the society he
represents. In either case they are refused enfranchisement
as legitimate citizens, and are banished to the margins of
the story and history. It is against this background that
the HIV/sexually transmitted disease (STD) intervention
programme was launched in Calcutta, India, targeting sex
workers, considering them as the major source of
infection.
STD/HIV intervention project with sex
workers
The baseline survey
The rationale behind the survey was to design an STD/
HIV control programme in Sonagachi, the red light district
in Calcutta, West Bengal, India, as the control of STD in
prostitutes is considered to be an effective public health
intervention as far as controlling HIV is concerned [3].
Sonagachi is a sex workers district in Calcutta having an
estimated number of 4000 sex workers residing in 370
From the Sonagachi STD/HIV Intervention Project and the *Durbar Mahila Samanwaya Committee (DMSC).
Requests tor reprints to: Smarajit Jana, Sonagachi STD/HIV Intervention Project, 8/2 Bhawani Dutta Lane, Calcutta 73, India.
© Lippincott-Raven Publishers ISBN 0-41283-650-5 ISSN 1350-2840
si 01
SI02
AIDS 1998, Vol 12 (suppl B)
brothels. Each brothel has about 5-50 sex workers under
one madam and one room is occupied by one to three
sex workers. The baseline survey was conducted by the
All India Institute of Hygiene and Public Health (AIIH
& PH), Calcutta, in collaboration with local NGO and
community-based organizations (CBO). The survey
looked into issues of social demography of the locality,
mapped the sexual behavioural practices among sex
workers, their clients and partners and assessed the
prevalence of STD and HIV among them.
Methodology of the baseline survey
Frcm April to June 1992, the baseline survey was
conducted in the Sonagachi area following a pre-designed
methodology.To ensure proper representation, multistage
sampling was performed. A sample of 450 sex workers
was selected at random to represent a reasonable estimate
of the prevalence of STD among sex workers. Floating
sex workers were excluded from the survey, as their
temporary stay in the locality and their rapid mobility
made it difficult to enumerate them [4-6]
For convenience, sex workers were stratified into three
categories mainly on the basis of the professional rates
they charged (category A, >Rs. 100.00; category B,
Rs.50.00-100.00; category C,<Rs.50.00;all rates charged
per client). Access to water and sanitation services and
possession of assets such as an electric fan, radio, television
and furniture were also considered while categorizing
the sex workers.The number of sex workers selected from
each category was proportional to the total number of
sex workers in them. About 12% of the total number of
sex workers living in the locality were surveyed (Tables 1
and 2).
Table 1. Number ot sex workers (SW) surveyed.
Category
A
B
C
Total
Brothels
(n)
Brothels
selected
(n)
78
187
97
362
12
28
25
65
SW selected
SW in all
and
brothels examined % Of
(n)
(n) surveyed
724
1772
1168
3664
>
11.1
11.7
13.7
12.2
81
209
160
450
Category A, >Rs. 100.00 per client; category B, Rs.50.00-100.00
per client; category C, <Rs.50.00 per client.
Table 2. Sexually transmitted disease infection among sex workers.
Sex workers
Infections
n
%
Single
Double
Multiple
186
91
13
51.7
25.3
3.6
In general, six to seven sex workers were selected from
each of the 65 brothels of Sonagachi. If any brothel had
less than six or seven members, the deficit was compen
sated for from more populated adjoining brothels. Non
responders were also similarly replaced.
Laboratory results
Out of 450 sex workers surveyed, blood samples and
vaginal smears were collected from 360. Smear exami
nation of endocervical specimens showed 10.5% were
positive for Neisseria gonorrhoea and on culture 4.9% were
positive. Trichomonas vaginalis was detected in 11.1% and
Candida albicans in 23.2%. Serological tests conducted for
syphilis found 58.8% reactive by Venereal Disease Research
Laboratory (VDRL) test and 63% by Treponema pallidum
haemagglutination (TPHA) test. Out of 360 sex workers,
80.5% were found to be infected with one or more STD
causative agents. Among the 151 asymptomatic cases
detected, 124 (82%) were infected with one or multiple
STD causative agents. Five out of442 serum samples were
positive for HIV infection, the positivity rate being 1.1%.
Four of these had syphilis also.
The premises of a local youth club in the heart of the
red-light area was turned into a clinic for the duration ot
the survey (8 weeks).
Initiating the project as an operational
research programme
Findings from the baseline survey
Sociodemographic aspects
Of the sex workers surveyed, 85% were between the ages
of 15 to 29 years.The lowest recorded age was 13 and the
highest 45 years. Literacy rates were very low and alcohol
abuse common among those surveyed. Poverty was the
dominant reason cited for entering prostitution. Of the 450
sex workers surveyed, 40% had children, 45% used
contraception in some form and only 27% used it regularly.
Only 2.7% used condoms always or often; 69% of the sex
workers had some knowledge about STD and 31% had
heard of HIV/AIDS. As for sexual practices, 98.7% practised
penovagmal sex; 78% also practised oral sex.
Initiating the project
There are various models of targeted STD/HIV
intervention for sex workers, from mandatory screening
to giving sex workers themselves a central role in health
promotion [7].The Sonagachi intervention programme
attempted to give sex workers a central status within the
programme right from the beginning.The leadership tried
to imbue a genuine spirit of partnership between the
project team and the community of sex workers they
worked with. The very strategy of the intervention was
considered at a point when there were no such tried and
tested designs or established strategies of empowering sex
workers. However, in Thailand, a model was tried invol-
)
I
Intervention with sex workers in West Bengal Jana et al.
-.•r
k
ving brothel owners in overall planning and design [8].
The brothel owners and their associates who control the
trade were given authority to run this programme.Though
this programme was successful in increasing condom use,
its sustainability and replicability were not tested. The
conceptual basis of the Sonagachi model is different from
chat of the Thailand model on three counts: (1) in the
Sonagachi model sex workers’ needs and interests were
given prime importance as opposed to the Thailand
model. They were given the central role in planning and
designing the intervention programme; (2) the strategy
of the Sonagachi model was to give decision-making
power to sex workers themselves; (3) part of the strategy
of the Sonagachi model was to address the structural issues
for which the project activities had to move beyond the
geographical boundaries of the red-light area [9].
peer educator, a sex worker had to be in the profession
for at least a year and she had to have proven communi
cation skills. The project also looked for elements of
leadership quality, which could then be further enhanced
through orientation and training.
Right from the beginning, the programme management
decided to adopt a very flexible approach so that the pro
gramme could easily be adapted to the changing circum
stances and could be remodelled with the shift in percep
tions of the programme workers as their experience of
working with sex workers increased. In fact, one of the
desired outcomes of the programme was to come up with
a model for such work which could then be replicated with
local variations in different red-light areas. The principal
emphasis of this model was real and active involvement
of the sex workers at every level of the programme.
Training module for peer educators
At the initial stage, those selected as peer educators were
given 6-week training with components of class-room
teaching as well as field-based orientation, on the issues
of HIV/AIDS.
Basic approaches of the intervention programme
.The basic approaches that the intervention programme
adopted can be summed up as three‘R’s: respect, refiance
and recognition. That is, respect towards sex workers,
reliance on them to run the programme and recognition
of their professional and human rights [10]. In practice,
the project focused on translating this approach into a
relationship of mutual trust and rapport between the
community of sex workers and the staff members of the
project. From the very beginning, as already mentioned,
there was a very real acceptance of sex workers as sex
workers, with no desire to‘rehabilitate’ them. As no move
was made to disrupt the on-going sex trade or motivate
the sex workers to switch to other occupations, the pro
gramme did not pose any immediate or ostensible threat
to the local power-brokers of the sex industry who, in
turn therefore, did not hinder the programme. With the
local controllers of the sex trade, negotiation and high
lighting of mutual benefits and shared interests was found
co be a strategically effective approach. More importantly,
the programme recognized and actively addressed the issue
of ‘empowermg’ the sex workers of every status within
the industry as an essential component for sexual behav
ioural change and improvement of their health status.
Designing the peer education programme
Selection criteria
Peer educators were selected from among the community
of sex workers on the basis of certain criteria. To be a
It was found that sex workers who had children were
more eager to become peer educators, in order to give a
more socially acceptable identity to their children who
can claim that their mothers are workers in a statesponsored programme. Those who had Babus (or regular
partners) were also more keen as the Babus wanted their
partners to gain in status through this involvement.
However, once the project took off, more and more sex
workers became eager to be peer educators, even the
ones who had very busy professional lives.
The structure of the training module was deliberately
kept open-ended and flexible to allow for autonomy of
thought and to facilitate appreciation and accommodation
of the existing skills and knowledge of the peer educators.
Over and above the technical training, emphasis was given
to further developing the leadership qualities of the peer
educators to encourage them to take up initiatives within
the community and the project beyond the narrow roles
as extension workers.
Going beyond the behavioural change model
Very early in the life of the Sonagachi project, the peer
educators, with the empathetic support of the project
management, recognized that even to realize the very
basic programme objectives of controlling transmission
of HIV and STD it was crucial to view sex workers in
their totality (as complete persons with a range of emononal and material needs, and not merely in terms of their
sexual behaviour) as it was essential to address the range
of issues that determine the quality of their Lives and to
locate these issues in the broader context within which
they live.
Sociostructurai barriers
In Sonagachi, as in any sector of the sex industry, the sex
workers are in a situation of powerlessness which is both
extreme and brutal. Within the well-marked hierarchy of
the sex industry, sex workers have much less power than
the pimps, madams, landlords and other interest groups
of the locality and of the wider society. While, traditionally,
sex workers can move around within the red light area
without any restriction, except for the more highly priced
workers during business hours for the sake of maintaining
their ‘exclusivity’, contact between sex workers from
different brothels is covertly restricted by the power-
SI 03
S104 AIDS 1998, Vol 12 (suppl B)
brokers of the industry by inducing a cUmate of mutual
suspicion and competition. The peer educators first had
to break down these barriers of suspicion between sex
workers and allay their doubts and cymcism that was also
extended towards any new ideas.
While promoting the use of condoms, the peer educators
soon realized that, in order to change the sexual behaviour
of sex workers, it was not enough to enlighten them about
the risks of unprotected sex or to improve their communi
cation and negotiation skills [11]. Sex workers first needed
to value themselves enough to think of taking steps to
protect their health and their lives. Even when fully aware
of the necessity of using condoms to prevent disease
transmission, individual sex workers may feel compelled
to jeopardize their health for fear of losing their clients to
other sex workers in the area unless it was ensured that
all sex workers were able to persuade their clients to use
condoms for every sexual act. Some sex workers may not
even be in a position to try negotiating safer sex with a
client as they may be too closely controlled by exploitative
madams or pimps. Moreover, if a sex worker is starving,
either because she does not have enough clients or because
most of her income goes towards maintaining a room or
meeting the demands of pimps, madams, local power
brokers or the police, she may not be in a position to
refuse a client who cannot be persuaded to use condoms.
In order to motivate the larger body of sex workers to
change their sexual behaviour and also to enable and
encourage them to participate in project activities and
take best advantage of the services provided by it, the
peer educators had to ensure that the entire body of sex
workers in the locality developed a positive self image,
had self-esteem and confidence and had an increased
access to power so that they can articulate their needs
and have an interest in investing in and planning for their
future [12].They also realized that given the asymmetrical
power relations within the sex industry and their social
exclusion, the only way the sex workers could gain greater
control over their own bodies, sexuality, income, health
or fife was through mutual support, collective bargaining
and united action.
Thus the project, by its very design, went beyond the
‘behavioural change model’ and instead concentrated on
the broader and more fundamental issue of social power
relations which shape people’s ‘behaviour’ and adopted
strategies for empowerment of sex workers.
Consequences of the intervention project
Formation of the sex workers' organization
The most important direct fallout of the intervention
was the establishment of the Durbar Mahila Samanwaya
Committee (DMSC) as a forum of sex workers, distinct
from the tunded project. While working on the issue of
STD/HIV, the peer educators soon reaHzed they cannot
do so in isolation, without addressing the other issues
related to the lives and profession of sex workers. In order
to do so, they formed an inter-Unk committee with the
representatives of 12 red-light areas of Calcutta, which
later developed into DMSC. In less than 2 years from its
inception this forum now has about 1000 fee-paying
members and about 25 000 associate members who are
all either sex workers or children of sex workers. DMSC,
at its present formative stage, is primarily involved in crisis
management on behalf of its member sex workers and
has been taking steps to improve their immediate working
conditions. The members of the committee have
organized rallies and demonstrations against specific
instances of trouble caused by local hooligans, against
extortion and harassment by the local police, protested
against forcible AIDS surveillance (for example, in
September 1993, a group of doctors, working under a
state institution in collaboration with an NGO, entered
the Sonagachhi red-light area with police protection, and
forcibly drew blood samples from 50 sex workers in the
name of surveillance) and unauthorized vaccine trial (for
example, in 1995, an HIV vaccine was tested on sex
workers in the Bowbajar red-light district, Calcutta,
without informing them or without their consent; it was
also learnt that this vaccine did not have technical
clearance from the World Health Organization or the
Food and Drug Administration, USA) and have stopped
eviction of individuals or entire groups of sex workers
from their homes or localities. In November 1997, DMSC
convened the First National Conference of Sex Workers
in India, on the theme ‘Sex work is valid work, we want
workers' rights’. The conference was attended by 5000
sex workers from all over the country [13].
The long-term goals of the committee are to fight for
full legal recogmtion of prostitution as a profession and
demand decriminalization ot adult prostitution.They also
demand abohtion of existing laws controlling the sex trade
as these laws have historically acted against the interest of
sex workers rather than penalizing those who exploit
them. Finally, the DMSC aims to work towards forming
a self-regulatory body made up solely ot sex workers,
along the lines of other professional bodies such as the
Indian Medical Council or the Bar Association, which
will act as the principal arbitrator of the sex industry.This
professional body of sex workers would be responsible
for ensuring that the industry abides by some minimum
guidelines to safeguard the interests of working sex
workers and also to prevent the forcible entry ot unwilling
women and minors into the profession.
Mobilization of sex workers
Currently, the committee is in the process of recruiting
brothel-based as well as floating sex workers from all redlight districts of Calcutta and other parts of West Bengal
and plans to start its branches in all areas where there are
sex workers, in order to reach out their services to as
4^
)
Intervention with sex workers in West Bengal Jana et al.
many sex workers as possible and also to consolidate their
numerical strength to fight out their long-term political
battle. Within a year they could open 50 branches of
DMSC throughout the state of West Bengal.
♦
<
Extending the domain of preventive care
Recently, the peer educators who formed the committee,
with the help of the project, have started operating a HIV
help-line, mainly for helping HIV-seropositives and AIDS
patients and their families to cope with the social and
psychological traumas associated with being HIV-positive.
When they come to know of individuals who have
contracted HIV/AIDS, teams from the committee visit
them in their locality to extend moral and material support
and also to sensitize the local community.The significance
of this service is not restricted to affected sex workers
alone but has broader implications. The thrust of this
initiative is to challenge social constructions about AIDS
patients in general, and the misconceptions and apathy
among the health professionals in particular.
State-wide expansion of the programme
In 1995, peer educators carried out a rapid assessment of
the sex trade in West Bengal under the supervision of the
Project in order to map out a state-level intervention
programme. They idenufied 254 red-light districts and
areas in the state [14]. For the first phase, 30 red-light
areas were selected on the basis of a linear scale for early
intervention with the help ot the UK Department for
International Development (DFID;formerly the Overseas
DevelopmentAdministration, ODA) and the government
ofWest Bengal. For various reasons the programme could
not be taken up in more than one area. However, DMSC
itself has started intervention initiatives in the other
selected red-light areas since then, and within 6 months
they could expand programmes to 30 other red-light
districts in the state ot West Bengal.
Political economy of sex workers'
cooperative
One of the most significant steps that the members of
the committee have taken to increase the economic
security of its members is to register a consumer co
operative (Usha Multipurpose Co-operative Stores Ltd)
in their own name in August 1995. They had to fight a
long battle with the concerned authorities to force them
to accept their professional status as sex workers rather
than hiding behind the more ‘virtuous’ label of housewife,
as was suggested by the officials involved. Through this
cooperative they plan to start a creche facility for children
of sex workers during business hours which will also give
employment to out-of-work sex workers. They have
already started a savings and credit scheme for the co
operative members. Recendy they have also undertaken
social marketing of condoms in Calcutta and other districts
of West Bengal through a special team of members, the
Basanti Sena.They are very emphatic that the cooperative
is not meant for economic‘rehabilitation’ of sex workers
who are in the trade, but is designed to provide a financial
resource for them to fall back on in moments of crisis, to
minimize their economic desperation and create a space
for negotiation. Moreover, they hope that the Basanti Sena
will not only travel around different parts ot the country
for social marketing of condoms, but will also help in
acquainting more and more sex workers with the aims
and objectives of the committee.
The registration of the cooperative also marks an
important strategic advantage for the DMSC in their
struggle to re-frame the definitions and meanings of their
occupation. Members of the committee hope to use the
fact that a state institution,The Ministry of Co-operation,
Government of West Bengal, has formally recognized
prostitution as the cooperative member’s profession, as a
leverage in their campaign for complete legalization ot
prostitution.This they see as a crucial gain as they realise
that, to improve the material circumstances of their lives
and their working conditions, they have to negotiate with
and contest the ways in which dominant discourses
describe them.
A rolling stone gathers no moss
A recent development is perhaps the strongest indicator
of how the strategy of empowerment that the intervention
project followed has had far-reaching effects. A group of
six male sex workers operating in, and around, the redlight areas of central Calcutta approached DMSC and
the project representatives with a written petition
demanding that they too be included in the committee
and its programme. The project management and the
committee members responded positively and promptiy.
as the plight of the male sex workers is no less pitiable
than that of the women involved in the trade. Moreover,
their legal status is even more precarious as the Sodomy
Act of the Indian law penalizes anal intercourse. Since
then the committee has involved about 160 male sex
workers as active members who are also accessing services
of the project.
Obstacles encountered
A programme of this kind, working towards empowering
one of the most deprived sections of the society, obviously
encountered various obstacles, both from within the sex
industry and more critically from among the elite groups ot
society who feel threatened by any change in the status quo
and the existing social and political power equanons [15].
From within the trade, the greatest challenge was to instil
a spirit of community among the sex workers and improve
their self-esteem (the broad description of ‘community’
as defined by the Joint United Nations Programme on
HIV/AIDS is ‘a group of people who has something in
SI 05
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AIDS 1998, Vol 12 (suppl B)
common and will act together in their common interest’).
The most difficult task was to evolve an effective strategy
and appropriate work plan to combat the dominant social
discourse regarding them asTallen’. However, the principal
philosophy and strategy of the project of treating sex
workers as responsible workers, both in society and within
the project, and later the formation of DMSC, the sex
workers forum, meant that this issue was adequately
addressed right from the beginning.
The power brokers of the sex industry were other
potential sources of threat to the project.Through strategic
negotiation and emphasizing common interests, these
people could be involved in many cases, though not with
out reservation, in various project activities..
The major obstacle to the project, as identified by the
project staff, are not the local thugs but the power holders
and representatives of the establishment who include
administrative personnel and medical professionals.These
persons obstructed and are still obstructing the policy
and strategy of empowerment in all possible ways. This
section of society feel, that to control disease among them,
the sex workers have to be bullied and coerced but cannot
be given the autonomy or power to take control of their
bodies and health. The project has still a long way to go
and many a battle to fight before it can influence this
deeply entrenched dominant ideology of sexuality and
sexual morality.
Issues of sex and sexuality
The experience of the project shows that the very fact
that the sex workers are given recognition and respect as
legitimate workers challenges some deeply held social
constructs about sex and sexuality, from which obviously
the sex workers themselves are also not exempt. In fact,
ideologies of gender, sexuality and class intersect to create
the conditions of deprivation of sex workers, and the
success of any intervention programme working with sex
workers depends on the possibilities the project can create
for the sex workers to negotiate and re-interpret the
dominant discourses that frame them.
Interestingly, even among feminists, who have historically
challenged, both in theory and practice, many of the
patriarchal biases in dominant discourses and ideology,
there are deep “moral’ dilemmas as far as issues of sex and
sexuality in general and prostitution in particular are
concerned [16].While being ready to grant certain human
rights to the sex workers, many feminists, human rights
activists and the general public alike are still instinctively
unprepared and ideologically unequipped to rethink issues
of sex and sexuality with the urgency and seriousness of
purpose that is required, along with issues of class and
gender equity.The Sonagachi project, through its various
activities, could unravel the importance and impact of
existing ideology and its strength in hindering the health
intervention programme.
Monitoring and evaluation
internal systems
The project has an elaborate and on-going system of
recording the field activines,monitoring the performance
of the project and evaluating its impact. Peer educators
report their activities in a pre-designed format every day.
Social workers who supervise and administer the project
activities give weekly and monthly reports. There are
regular monthly staff meetings, focus group discussions,
meetings of field committees, the project team and
grievance redresser forums, outcomes of which are
recorded and analysed. Apart from serving the purpose
of monitoring the day-to-day developments, these various
structures also ensure democratic functioning of the
project as a whole, giving regular opportunity to project
staff at all levels including the peer educators to assess the
quality and volume of their work and suggest measures
for improvement. This system also ensures that the peer
educators are actively involved in the decision-making
process of the project in real terms.
)
>
For quantitative and technical assessment of the impact
of the project, repeated cross-sectional surveys are carried
out by the project team. Following the baseline survey,
two other evaluation exercises have been carried out. One
of the most important indicators of change is considered
to be condom use practices [17], which were judged
through self-addressed questionnaire in successive surveys
(Table 3).There was a significant increase in condom use
by the clients of the sex workers.
This increase in condom use is not due to information,
education, communication (IEC) activities alone but is
due to ‘peer pressure’ and effective networking among
the sex workers, as can be verified when the increase in
condom use is compared with the duration of the
profession (Table 4).
Sex workers, within a short span of time after joining the
trade, pick up the issue and enforce condom use by their
clients mainly through peer groupings and peer pressure
tactics.
Assessing rates of STD incidence and prevalence is a way
of evaluating the impact of an intervention [19]. It is now
widely accepted that declining rates of STD infection as
a result of an intervention act as a good indicator of the
effect the intervention is likely to have on the HIV
incidence rate [20].The fall ofVDKL seropositivity rate
in 1995 compared to 1992 is an imponant indicator of
behaviour change which is observed in Sonagachi
(Table 5).
The HIV prevalence in the consecutive community level
surveys [21] shows a slight increase over the years, which
is rather expected as the condom use practice was not
100% (Table 6).
h
Intervention with sex workers in West Bengal Jana et al.
Table 5. Results of serological tests for syphillis (1:8 and above dilu
tion) in three consecutive surveys.
Table 3. Percentage of sex workers using condoms (18|.
Usage period
1992 (April-May)
1993 (Nov-Dec)
1995 (Aug-Sept)
Always (%)
Often (%)
Total (%)
1.1
47.2
50.1
1.6
22.1
31.6
2.7
69.3
81.7
Year
Tested (n)
VDRL+ (%)
1992
1993
1995
417
607
475
25.42
28.5
14.1
VDRL+, positive Venereal Disease Research Laboratory test.
Table 4. Correlation between use of condom the previous night with
duration in profession during 1995.
Duration in profession (months)
>6
>2
No. of acts
No. protected
% Protected
75
36
48
102
57
56
196
124
63
External evaluation
In 1995, ODA commissioned an external evaluation of
all aspects of the project [22]. The external evaluation
team found the project to be perhaps one of the best
interventions for sex workers in the world.The evaluation
team particularly appreciated the enthusiasm and intensity
with which the intervention activities are conducted by
the project. The philosophy towards prostitution and
attitude towards sex workers as embodied in the project
was identified as the key factor making the project an
exceptional one. It was felt that to capture the true spirit
and the real impact of the project, the regular evaluation
should broaden its scope beyond measuring the effects
through STD and condom use levels and focus on nonclinical aspects of the project related to the empowerment
of sex workers and develop appropriate methodology and
indicators for this purpose. Also, the evaluation method
ology of the technical components ought to be consistent
and the methods used for assessing condom use or STD
prevalence should not be changed from one survey to
another.The project is now working on these suggestions
of the external evaluation.
Success perceived by the community
One of the major indicators that the sex workers find the
project intervention relevant and useful is the fact that,
during the life of the project, their participation in, and
use of, project components have increased remarkably in
intensity and volume; the peer educators and also general
members of the sex workers community access all the
project services with enthusiasm and appreciation. In
addition to the efficacy of the services, it is the spirit of
respect and democracy and the sensitivity with which
these services are rendered that facilitate greater access
by sex workers.That there have been perceptible changes
in the quality of their fives, since the intervention started,
is indicated by the range of activities they have undertaken;
this suggests an aspiration to improve the quality of their
Table 6. HIV prevalence rate found in three consecutive surveys.
Year
Tested (n)
HIV+ (n)
HIV+ (%)
95% Cl
1992
1993
1995
442
607
582
. 5
7
28
1.13
1.15
4.81
0.15-2.11%
0.3-2.11%
3.07-6.55%
Cl, confidence interval.
lives, and gain greater control over the circumstances that
govern their lives. These activities range from starting
literacy training for themselves, to running creches for
their children and the cooperative and forum operations.
The degree of self-respect, dignity and social identity that
sex workers have acquired through their involvement with
the project is valued by them as the most important
achievement of the project. On the other hand, the project
staff considered that these are perhaps the strongest tool
that the project has managed to develop which will enable
it to achieve its objective of controlling STD/HIV.
Future development
Sustainability
Any sound enterprise craves sustenance; it is crucial to
sustain the project continuously to reap benefits for the
sex workers. With this in mind, the project has considered
certain activities at the social and economic levels.
At the social level, the project has started advocacy and
negotiation with civic bodies demanding proper arrange
ment for basic amenities to improve the quality of life of
the sex workers [23]. Recently the Calcutta Metropolitan
Corporation has donated land for the construction of
the offices of DMSC, the sex workers’ organization.
At the economic level, the following has been planned:
(1) health insurance and social security schemes, which
will provide health services including laboratory services;
it is conceived that money charged for such services will
sustain them; (2) the entire Sonagachi project will be
converted into a centre for sexual health with a
comprehensive research and training wing. To facilitate
the above, restructuring of the orgamzation of the project
is taking place that will be along the lines of a workers’
collective and will include sex workers who will run the
project.
SI 07
si08 AIDS 1998, Vol 12 (suppl B)
Replication
Based on a rapid assessment survey conducted by DMSC
in collaboration with AIIH & PH Calcutta, the DMSC
will expand the programme to all the districts of West
Bengal with or without assistance from external agencies.
The STD/HIV intervention programme will provide
necessary support as a facilitator.
2.
3.
4.
5.
Conclusion
6.
The most important lesson learnt from the project is that
to improve the health status of, and control STD/HIV
infection among, an economically deprived, politically
marginalized and socially stigmatized group such as sex
workers, it is not enough to design a technically sound
and efficient intervention programme. What is crucial for
the success of any such intervention is to contest the social
and structural power relations and ideologies that put such
communities in such a vulnerable position in the first
place. Unless such structural obstacles are challenged at a
much broader level, any micro-intervention cannot hope
to bring about behavioural changes which will result in
disease prevention. While working on STD/HIV with
sex workers, it is of crucial importance to keep in mind
that the issues of class and gender have significant bearing
on their ability to access the intervention services and
take preventive measures [24].The Sonagachi project has
thrown up a whole host of issues about gender, poverty
and sexuality that have to be debated, defined and re
defined within the process of a struggle itself.The exper
ience of the project shows that for a marginalized group
to achieve the smallest of gains, it becomes imperative to
challenge an all-encompassing material and symbolic
order that not only shapes the dominant discourses outside
but, and perhaps more importandy, historically conditions
the way the participants negotiate their own locations.
The significance and historical imporunce of the
Sonagachi project lies in the fact that through its innovative
and flexible approach it has been able to create the real
possibility of such negotiation, through the mobilization
of the sex workers’ community which is bound to have
far-reaching impact not only on the lives of sex workers
but on society in general.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
References
1.
Bhattacharya P: Letter to the editor. Anandabazar Patrika Cal
cutta, December 24, 1997.
24.
The Immoral Traffic (Prevention) Act, 1956 (No. 104 of 1956)
with short comments. Allahabad: The Law Book Company (P)
Ltd; 1993 Section 18(2), 14.
Mark R: Project for sex workers in Europe [editorial]. Cenitourin
Med J Sexual Health STD HIV 1997, 73:155-156
Jana S, Chakraborty AK, Chatterjee BD, Chakraborty MS, van
Dam CJ, Meh ret M: Knowledge, attitude of CSWs towards STD/
HIV and prevalence of STD/HIV among CSWs. IX International
Conference on AIDS. Berlin, July 1993 [abstract WS CO8-4].
Chakraborty AK, Jana S, Das A, Khodakevicj L, Chakraborty MS,
Pal NK: Community based survey of STD/HIV infection among
commercial sex workers in Calcutta (India). Part I. Some social
features of commercial sex workers. J Commun Dis 1994,
26:161-167.
Jana S, Chakraborty AK, Das A, Khodakevicj L, Chakraborty MD,
Pal NK: Community based survey of STD/HIV infection among
commercial sex workers in Calcutta (India). Part II. Sexual be
haviour, knowledge and attitude towards STD. J Commun Dis
1994, 26:168-171.
Day S, Ward H: Sex workers and the control of sexually trans
mitted disease. Cenitourin Med J Sexual Health STD HIV 1997,
73:161.
Rojanapithayakorn W: The one hundred percent condom pro
gramme in Thailand, an update. X International Conference of
AIDS. Yokohama, August, 1994 [abstract 478c, p. 50].
Jana S, Banerjee B (eds): A Dream, A Pledge, A Fulfilment: Five
Years' Stint of STD/HIV Intervention Programme at Sonagachi.
Calcutta: All India Institute of Hygiene and Public Health; 1997.
Jana S, Bailey M: All part of the service. AIDS Action 1994, 26:7.
Dutta N, Singh S, Moulik R, Brahma S, Jana S, Basu I: Enabling
female sex workers to create a milieu of negotiation. XI Interna
tional Conference on AIDS. Vancouver, July 1996 [pub C 1166,
p. 464].
Jana S, Chudhury R, Banerjee B, Mukherjee M, Basu I: Putting
barricade against AIDS through mobilisation of female sex work
ers in Calcutta. IV International Congress on AIDS in Asia and
the Pacific. Manila, October 1997 [abstract C(P) 118, p. 349].
Durbar Mahila Samanwaya Committee: First National Confer
ence of Sex Workers. Calcutta: Durbar Mahila Samanwaya Com
mittee; November 14—16, 1997.
Mukherjee S, Jana S, Mukherjee M, Choudhury R: Situational
analysis of sex trade with the help of FSWs (female sex work
ers) and their networking. IV International Congress on AIDS in
Asia and the Pacific. Manila, October 1997 [abstract C(P) 117,
p. 349].
Chhabra R: Subversive jargon, societal subversion. Hindistan
Times New Delhi, November 9, 1997.
Shrage L: Prostitution, Adultery, and Abortion: Moral Dilemmas
of Feminism. UK: Routledge; 1994
Jana S, Khodakevich L, Larivee C, Dey I, Sander N: Changes in
sexual behaviour of prostitute in Calcutta. X International Con
ference on AIDS. Yokohama, August 1994 [abstract 346D].
Jana S, Singh S: Beyond medical model of STD intervention Lessons from Sonagachi. Int J Public Health 1995, 39:128
Mertens TE, Low-Beer D: HIV and AIDS: where is the epidemic
going? Bull WHO 74:128
Grosskurth H, et al.: Impact of improved treatment of sexually
transmitted diseases on HIV infection in rural Tanzania:
randomised controlled trial. Lancet 1995, 346:530-536.
Fox R: Redlight on Calcutta: health via schools in Andhra Pradesh
[commentary]. Lancet 1994, 344:1038.
O'Reilly KR, Mertens T, Sethi G, Bhutani L, Bandyopadhyay N:
Evaluation of the Sonagachi Project, October 31-November 14.
Calcutta: All India Institute of Hygiene and Public Health; 1995.
Jana S, Banerjee B (eds): Five Years' Stint at Sonagachi. Calcutta:
All India Institute of Hygiene & Public Health; 1997:22-23.
Daily J, Farmer P, Rhatigan J, Katz J, Furin J: Women and HIV
infection: a different disease? In: Women Poverty and AIDS:
Sex Drugs and Structural Violence. Edited by Farmer P, Connors
M, Simmons J. Monroe, Mains: Common Courage Press; 1996.
Pergamoo
0277-9536(94)00165-0
Soc. Set. Me(j yo| 40 No 7 pp
Copynght 0 1995 Elsevier Science Ltd
i„ Great BnUttr All ri|hlJ
0277-9536i95 S9 50 + 0.00
T"XRsXcXPNRED?v=^^
Lori L. Heise* and Christopher Elias’
H-lih. ,730 Rhode lsland
The Populauon Counc.1, ol'e Dag Han^a^d
n^*1'
women. Disproportionately poor and with little power to negotiate the terms^ °f
°f lhC world’s
often cannot avail themselves of these life-savi™ strategic! Women
encounters’ *omen
Key worth-women, AIDS prevention, human rights, community organizing
INTRODUCTION
to dominate women is considered the essence of
maleness itself. Culturally created norms tolerate,
As currently conceived, the global AIDS prevention
indeed encourage, sexual behavior by men that puts
strategy consists primarily of three interrelated tactics: both them and their panners at risk. New norms must
(1) encouraging people to reduce their number of
be established—through education and advocacy—
sexual partners; (2) promoting the widespread use of
that stress mutuality, responsibility and equality
condoms; and (3) treating concurrent STDs in
between men and women.
populations at risk of HIV. Together, these strategies
By its very nature, however, this type of
constitute the backbone of the 96 million the U.S.
fundamental social change takes time—time that
government spent on AIDS prevention in developing
women at risk of HIV today do not have. The AIDS
countries in fiscal year 1992 [1]. This three-pronged
epidemic therefore creates two imperatives: to begin
attack, however, is inadequate for meeting the
in earnest to work on changing the underlying
protection needs of many of the world’s women.
causes of women’s vulnerability and to pursue
Disproportionately poor and with little power to
vigorously every means possible to strengthen
negotiate the terms of sexual encounters, women often
women’s immediate ability to protect themselves in the
cannot avail themselves of these life-saving strategies. face of the economic and cultural forces currently
Women need both a new commitment to addressing
allied against them. This, in turn, means placing
the underlying inequities that heighten their risk, and
greater emphasis within existing AIDS programs on
new technologies that provide them with a means of
empowering women and committing major resources
HIV protection within their personal control.
to developing new prevention technologies—like
Ultimately, empowering women to have more
vaginal suppositories or foams lethal to the
control over their sexual lives will require a
virus—that women can use without their partner’s
fundamental change in the dynamics of male/female
knowledge or consent.
relations and a concerted effort to eliminate the
This article makes the case for restructuring AIDS
inequities that leave women economically dependent
prevention by describing the growing risk of HIV
on men. In large measure, women’s vulnerability to infection faced by women throughout the world,
HIV infection derives from their low status in society.
examining the serious limitations of the contemporary
Reducing their vulnerability will mean changing the
AIDS prevention strategy in meeting women's needs,
cultural beliefs and gender stereotypes that perpetuate
and by exploring how new approaches—including a
the belief that women are inferior to men.
shift toward a more ‘community organizing’ approach
Empowering women will also require redefining
to AIDS prevention—could help women exert more
what it means to be male. In many societies, the right
control over their sexual and reproductive lives.
931
932
Low L. Heise and Christopher Elias
WOMEN AT RISK
between one-quarter and one-third of all women aged
9 had become infected in some large urban centers
in East and Central Africa [2]. In some cities, between
15 and 34% of pregnant women presenting at prenatal
care clinics are HIV-infected (Table 1).
In industrialized countries, such as the United States
and the nations of Western Europe, the primary
populations affected by HIV contmue to be gay and
bisexual men and intravenous drug users, the majonty
of whom are male. But here too, women now compose
The early and persistent stereotype of AIDS as a
gay male disease has perpetuated the notion that
women are not at risk for HIV infection. The reality
is that m sub-Saharan Africa and other regions of the
world where HIV is predominantly transmitted
through heterosexual intercourse, there are as many
^fected *omen as there are men. As of early 1992, the
World Health Organization (WHO) estimated that
over three million women in sub-Saharan Africa had
been mfected with HIV, along with half a million
Aine
population of persons living with
infants who contracted the virus before, during or AIDS and HIV infection [5]. AIDS became thc leading
shonly after birth [2], Worldwide, by the year 2000 the cause of death for African American women aged 15
annual number of AIDS cases in women will equal or
513165 °f NCW Y°rk and Ncw Jers
«y
987, andr became the fourth leading killer of
all U.S.
exceed the number in men [3, 4]
________
Surveillance data reveal the degree to which HIV Th" ° r'pr°duct7 *8' in 1993 [6],
has penetrated vulnerable female populations
|’ ' '
Amons
,
' C Ural and econ°mic factors
female sex workers, whno
.8
onsPirc l° he’ghten women’s vulnerability to AIDS in
whose contact with multiple
sexual partners increases their risk of having sex with comparison to men’s. For example, it is likely that
someone who is mfected, rates of HIV infection exceed per-exposure transmission from man to woman during
heterosexual intercourse is up to 2.5 times more
50/« in some urban centers (Table I). Sex workers
however constitute only a small percentage of the 7CuTvthan frOm W°man lo man f8’ 91-Thc efficiency
women affected by HIV. Studies show that by 1992, o HIV transmission appears even greater if the
woman or her partner has another sexually
Table I. Percentage of women who are
_______
Cameroon
Douala (1992)
Yaounde (1990)
Central African Republic
Bangui(1989)
Congo (1987)
Pointe Noire
Ethiopia (1989)
Addis Ababa
Kenya (1992)
Nairobi
Malawi (1990)
Rwanda (1989)
Kigali
Tanzania
Arusha (1988)
Tanga (1988)
Female sex
workers
HIV positive, selected countries
Female STD
patients
Pregnant
women
45.0
9.3
17.0
2.0
8.0
8.0(1990)
64.1
18.2
10.3
36.8
85.5
15.0
55.9
61.0
23.3
74.0
31.6 (1992)
75.0
52.6
5.5
7.0
Uganda
Kampala (1990)
54.6
Zambia (1990)
Northern Province
Lusaka
India
New Delhi (1988)
Bombay (1992)
Thailand
Northern (1992)
Haiti: (1989)
Port-au-Prince
Source: Center for Intcand No. la" S bXu
------ TT-
34.0(7]
71.0
69.0
30.1
41.2
36.9
9-30
24.5
0.0
0.8
2.8
41.9
______ ______________________________ 116
N°" N° ‘
Transforming AIDS prevention to meet women s needs
933
transmitted infection. Evidence suggests that the prostitutes, is that the mass of women iM
in need of
presence of a concurrent STD increases the risk of HIV
protection are not sex workers, but women
1 with one
transmission at least 3- to 5-fold [10]. Because the same
partner—their husband or the man with whOm they
STDs that generally cause burning and itching in men live. In Sao Paulo, Brazil, married women who have
are often asymptomatic in women, female patients are only one sexual partner constitute 49% of a||
less likely to seek treatment [11]. Others feel too AIDS cases among women [ 13]. Likewise in the new
embarrassed or ashamed to seek care at an STD States, one recent article estimates that a womanUnited
’s t
clinic—facilities frequented primarily by men and of contracting an STD is determined at least as much
female sex workers [12]. As with health care in general, by her partner’s sexual behavior as by her own
women are often too busy, too modest, or too poor to nonmonogamous behavior. In the author's high end
seek treatment for STDs.
model, women are almost twice as likely to contract an
The precarious state of women’s reproductive STD due to their partner’s sexual behavior than due
health in the world’s poorer nations also places women to their own [14].
at an augmented risk. Chronic iron deficiency,
Unfortunately, many of the most popular
malaria, complicated pregnancies and lack of access to AIDS prevention messages—‘Stick to Your Partner,’
safe and legal abortion predispose women to the need ‘Love Faithfully’—give women the mistaken im
for blood transfusion, a major pathway for HIV pression that if they remain monogamous, they will be
infection. While much blood is now tested in the safe from HIV. Data from around the world, however,
capital cities of the developing world, adequate quality indicate
that
--------- it.j isnot safe for women, or for AIDS
assurance procedures are still evolving, and the prevention programs, to make this presumption.
equipment necessary to screen blood is often Monogamous women are increasingly at risk of AIDS
nonfunctional and generally not available in smaller through both the heterosexual and homosexual
cities or rural areas.
behavior of their steady male partners. To date, AIDS
LIMITATIONS OF EXISTING AIDS PREVENTION
STRATEGY
1
The first line of defense in many AIDS prevention
campaigns has been to counsel individuals to avoid
exposure to HIV by limiting their number of sexual
partners. Teenagers are told to abstain from sex until
marriage, couples are exhorted to remain monog
amous, and others are encouraged, at the very least, to
reduce their number of sexual partners. There are a
number of realities in women’s lives, however, that
limit the utility of this prevention advice. First, for
many of the world’s women, monogamy is a largely
irrelevant strategy because they are already monog
amous. It is the sexual or drug-using behavior of their
sexual partner that puts them at risk. Second, for a
significant portion of those women who are not
monogamous, having multiple partners is not a
pleasure-seeking strategy, but a way to gain access to
resources that only men control. These women cannot
easily reduce the number of their sexual partners;
multiple partners are their key to survival. Third,
partner-reduction messages assume that women are
always in control of when they have sex and with
whom. As data on rape and coercive sexuality indicate,
however, this is far from the case in many sexual
encounters.
The danger of relying on presumptions of monogamy
What has been forgotten in the rush to ‘educate’
populations considered to be at ‘high risk,' such as
•The following focuses on data from communities where
polygyny is not a formal social institution. For an
evocative discussion of the influence of formal polygyny
STDs? see
on the transmission of HIV, as well as other STDs,
[21].
prevention programs have not included these women,
leaving them without adequate information or skills to
protect themselves from infection.
In many cultures there persists a sexual double
standard that gives men license to be sexually
adventurous while restricting female sexuality.* As a
result, many surveys of sexual behavior document a
higher rate of partner change among mamed and
single men than among women (although under
reporting by women and overreporting by men
probably contribute to these results) [15-18]. In
Thailand, for example, 28% of a stratified random
sample of men nationwide admitted to having sex
outside of their marriage or steady partnership within
the last year, compared to only 1% of women [16].
Likewise, an island-wide random survey of men and
women on Barbados showed that during the age
period 25-34, men had five sexual partners on
average, while women had only one. (Not sur
prisingly, sticking to one sexual partner did not reduce
a woman's odds of reporting a history of STDs
[15].) Results from a six-country, WHO-sponsored
survey on African sexuality found that more than
twice as many men than women reported extramarital
affairs in the 12 months prior to the survey.
Men also reported significantly more lifetime sexual
partners [19].
A study from Kigali, Rwanda [20] illustrates starkly
the danger women face in assuming that monogamy
‘protects’ them from AIDS. Of 1458 women aged
18-35 years attending the outpatient pediatric and
prenatal clinics at the Centre Hospitaller de Kigali,
86% reported being married or in a common-law
union with a man. All but 10 reported being
monogamous, although only 496 (34%) felt certain of
thefidelity
**- of their partners. Overall, 24% of. women
who thought they were in mutually monogamous
934
Lori L. Heise and Christopher Elias
oEi"“X:
the' prCSSUr
pressure* tO
to have chi,dren
children ,s
is acu
acute,
i—men
----- \
partner—their husband—21 % were infected
te, many
The tendency for young girls to be partnered with engage in homosexual
h°rnosexual activity
act‘v>‘y nonetheless marrj
have steady female sexual partners. This sets the st
men five to ten years their senior increases the
for increasing AIDS incidence among women .
likelihood that they will be exposed to HIV. This age
children, a pattern already documented in Trini.
gap is likely to increase as older men seek out younger
and younger partners in the hopes of avoiding and Tobago, Brazil, the Dominican Republic .
AJDS a Pattcrn already documented in parts of other Latin American countries [32]. As of IS
Africa [22], It will also increase as harsh economic bisexuality was the risk factor for 28% of AIDS ci
times lengthen the time it takes for African men to among men in both Brazil and Mexico* [33, 34].
Unfortunately, men who engage in bisex
accumulate the ‘bridewealth’ they must pay a woman’s
behavior
are very hard to reach with AIDS prevent
family to secure her hand in marriage [23].
messages
because many do not consider themsel
Mathematical models of the AIDS epidemic show
gay
or
bisexual.
’ In Brazil, for example, only n
that a woman’s risk of contracting HIV increases
who
take
the
receptive,
passive role in anal sex
dramatically as her age at first intercourse goes down
considered
homosexual;
the
man who ‘inserts’ is s<
and/or the age difference between her and her partner
as
masculine
regardless
of
the
gender of his sex
goes up [23, 24]. Older men have had more sexual
partner [35], Research from Rio de Janiero docume
partners and, therefore, have a greater chance of being
infected with HIV or other STDs. It has also been that as of 1992, unprotected penetrative intercou
was still dangerously common among men having
suggested that early intercourse may represent an
with
other men, especially among those who repor
additional, independent, risk [25-27]. Dau suggest
sexual
contact with both women and men.f Fully 5(
that if a young woman is exposed to HIV before genital
of bisexual men had engaged in anal intercourse w
maturation is complete, she may face a greatly
l
’
a male partner during the last six months, 43% withe
augmented likelihood of HIV infection. This dyna^c
may account for the very high rates of clinical AIDS a condom. Of the 100% who also had vaginal sex w
a woman, 89% did not use a condom with their fem.
among young women that have been found in areas
partner
[35]. Not surprisingly, the male to female ra
where sexual initiation with older men occurs at a very
among
reported
AIDS cases in Brazil decreased fre
early age [28].
30:1 in 1985 to 6:1 in 1991 [36].
Regretubly, many women feel incapable of
These examples emphasize the importance
challenging their husband’s infidelity—to do so places
reaching
all women with AIDS prevention messag
their relationship, their economic security and their
not
just
those
who themselves engage in ‘high rii
physical safety at risk. During focus-group discussions
activity.
In
fact,
it is precisely those women w
m Zambia, for example, many women felt powerless
appear
least
at
risk
of contracting HIV—marri
over their partner’s sexual behavior. “I can be faithful
to my husband, but my husband will not be faithful to women who have no outside partners and do not u
me,” observed one woman. “There are very few men drugs—who are left exposed due to the failure of me
AIDS prevention campaigns to reach out to wornwho are faithful to their wives” [29]. Likewise
other
than those who identify themselves as s
preliminary dau from research projects on women
workers.
Women’s risk of HIV is also exacerbated I
and HIV m India, Brazil, South Africa and
the failure of most programs to target men. As tl
Guatemala, reveal that an overwhelming number of
epidemic proceeds, sexual partners of men at high ri:
women report being monogamous themselves but
aware that their partners are not [30]. These women are destined to make up an ever larger share
individuals contracting AIDS.
expressed a sense of helplessness over their ability to
change their partner’s sexual behavior.
Elsewhere, other ‘low-risk’ women are contracting Sexual networking as an economic strategy
HIV through the hidden homosexual behavior of their
Many partner-reduction messages arc based on tl
male partners. To date, this phenomenon has been
premise that individuals seek multiple partners I
studied primarily in Latin America and the Caribbean
although similar patterns are now being documented further their own pleasure; reducing one's risk is thi
other places, such as Thailand [31]. Because only a question of exerting self-control. While pleasui
is surely a factor in many cases, there is also a need I
replace partners lost through separation, divorce, c
death. Likewise, for many women, having more tha
one partner is an economic survival strategy that
'SSSSE-3...... .......... ....
" leVeU of condom
*■“> ‘hdr
partners compared to their male panners.
children.
Stick to One Partner’ slogans ask many wome
living on the edge to forego income vital to meetin
today’s needs to avoid an ill-defined risk of AIDS 1
years hence. Increasing poverty, especially amon
Transforming AIDS prevention
women, has made this type of balancing act ever more
present in women’s sexual decision-making. In the
decade pnor to 1990, three-fourths of the world’s
women lived in countries whose per capita gross
aomestic product either declined or increavd hv
to meet women's needs
935
the fees and expenses that allow her tn
,
Each year, thousands of schoo! " °s ’
SCh0°L
forced to drop out of school becaus! . " ^"0 aF
as al result of providing ~
sexual
favors to
to older men .n
Aua* »avors
exchange for school money [47], Many of tb
women are tu------- *
n
study of nrostitutp? in
r
_i..
°r. One
Nairobi study is just one
one-fourth to one-third of all the world’s households
[40] Given women’s lack of access to wage
employment and their responsibility for child care and
family upkeep, it is not surprising that ho^holdt
J T eSpeclally for women who have been
commSvD nd.°ned by their h^bands. family Or
of Z, p, Depend,n« on the cult^e. a w,de variety
°
t/ansgress.ons’can prec.p,tate repudiat,on-
headed by females are disproportionately poor. Data
from five Latin American c.^at ffir'T/afple3
document that the median monthly income of non
households headed by women is consistently lower
than that of households headed by men [41]
With few marketable skills, many\vomen havecome
ffifertft' e-d d!VOrce’ unwed Pregnancy, AIDS,
th^^’^.^
3 «l*’ A study by
I
Housewiv« Federation, for example
samffie were
pros,i,utes in ‘heir
aft(.P u
W^en CaSt 0Ut from their communities
a^doneT
The m'grati°" °f
Xa^trsusSei"^
t^C^
these women are abandoned due to infertilhy'c’aused
by
an STD acquired from their husbands.
women often have relationships with more than one
As
these examples suggest, cultural and economic
man to gain access to resources—resources they do not
constraints
make it difficult for women who have no
command themselves because of entrenched gender
discrimination in access to education, to credit and to husbands to survive wuhout multiple sexual partner
the formal wage economy [42-44], These women ships and the added nsk they entail. Research in both
Uganda and Rwanda, for example, has shown that
Oners'35'redU“’ ‘he nUmber °f the,r sexual
women who are separated, widowed or divorced have
In urban areas of Africa, for example, it is not Significantly higher levels of HIV infection than do
uncommon for women to form relatively stable unions married or cohabitating women [20,51], Although
with several partners, each of whom contributes in most women marry early in developing countries,
some way to the maintenance of their families. These divorce, male outmigration, w.dowhood and abanonment mean that many will have to survive at least
relationships may and often do involve affection, but
heir primary motive is economic. A woman may have part of their lives on their own. In some developing
countries, more than half of all marriages will be
ties to several long-distance truck drivers, for example
whom she sees on occasion when they pass through dissolved by the time a woman reaches her forties [521.
t0*n- Jhey m turn, help buy groceries and pay the Some of these women will remarry and others will be
school fees for her children. These women-known as supported by an eider son, but many will find
themselves alone with few skills and little education to
spares ln Zimbabwe, ’deuxiemes bureaux’ in
fall
back on. One researcher estimates that there are
Francophone Africa, and ‘girl friends’ or ’town wives’
roughly
10.5 million widows in India who are either
elsewhere in Africa-draw strong distinctions between
without adult sons to support them or have been
explicit exchange of money for sex [45]
Women clerical workers, school girls and female
traders are examples of the larger population of urban
women who occasionally barter sex for the resources
and upward mobility that older men can provide [46],
It is quite common for secondary school girls, for
example, to take up with a ‘sugar daddy’ who helps pay
.
..
------------------------------- ered sexual relauonslups.
access to economic resources is often a factor in the
decision to take on additional partners. Among the
Yoruba of southwestern Nigena. Orubuloye and
colleagues found that, in contrast to men. married
women who had affairs seldom said it was for their
own pleasure; rather, it was in exchange for some form
of economic assistance or support withheld by their
husbands (54]. Likewise, Rwabukwali and colleagues
1,71 argUC thal among womcn in Kampala, Uganda
T°?C neCeSS‘,y WaS the Pnmar>
sexual
nsk taking among 72% of HIV + women and 54%
936
Lori L. Heise and Christopher Elias
of matched controls. Both authors conclude that
sexual networking is in fact a form of economic
networking, making it difficult for women to eliminate
outside partners without access to alternative forms of
income.
These examples demonstrate the difficulty of
applying Western categories—‘prostitution,’ ‘multiple
partners,’ ‘monogamous relationship’—to the
reality of third-world women’s lives. Such labels do not
begin to capture the subtlety or fluidity of sexual
networks under conditions of economic scarcity,
do they acknowledge the degree to which
vulnerability shapes the sexual decisionaking of third-world
------ ----- 1 women. Until women have
J al‘,St‘C elOr°mlC ^"raatives, many will be unable to
heed AIDS prevention messages that advocate
‘partner reduction’ as a means to protect oneself from
AIDS.
-an—-
increasing risk of contracting HIV or some other STD.
A recent study from Zimbabwe documents the rising
concern among health workers about the number of
children they are seeing who have contracted STDs or
HIV through sexual abuse [60].
Limitations of condom promotion strategies
Another major thrust of AIDS prevention programs
has been the promotion of condoms as a way to protect
availability impair the implementation of this
important AIDS prevention strategy. Greater pLitiwl
commitment and community leadership are needed to
make the use of condoms widely acceptable to
individual men and women throughout the world.
Along with this commitment must come increased
Non-consensual sex
resources for improved condom design, procurement
and distribution.
Partner reduction messages are only actionable
As a strategy for women, however, condom
m-so-far as women are truly free to control when and
promotion has some major limitations that highlight
with whom they have sex. The pervasiveness of
the need for complementary, female-controlled,
nonconsensual sex in women’s lives is a reality that
prevention technologies. Condoms are a technology
prevention programs have yet to confront, despite its
that women may influence, but ultimately do not
ability to undermine significantly the effectiveness of
control. This means that women’s safety is often
conventional AIDS prevention strategies.
predicated on their ability to ‘negotiate’ condom use
Rape is an extreme example of the type of sexual
with an often unwilling partner. There are a variety of
coercion that women confront daily in both the
powerful forces—social, economic, cultural and
industrialized and developing world. In the United
emotional
that limit women’s ability to negotiate
States, for example, population-based surveys suggest
successfully on their own behalf.
that one in five American women will be the victim of
For a condom-based strategy to work,women must
a completed rape in her lifetime [55]. Studies first feel able to discuss sex and condom use
with their
1 matters,
however, is not a part of many relationships. A survey
popular perception, the majority of rape survivors
of spousal communication in Asian countries, for
(60-78%) know their assailants, a reality confirmed by
example, found that close to a third of the women
surveys and service statistics from rape crisis centers in
Chile, Malaysia, Mexico, Panama, Peru and the interviewed in the Philippines never talked to their
United States. Also, a large percentage (36-58%) of husbands about sexual matters, nor did 47% in
Singapore or 53% in Iran (61 ]. Caldwell and colleagues
rapes are perpetrated against girls 15 years and under,
[62] report that frank discussion between partners
with a disturbing percentage of assaults against girls
about sex is uncommon in many parts of sub-Saharan
younger than 10 [56].
Africa as well. Elsewhere, strong cultural factors work
Regrettably, there is ample evidence as well that
early forced sex is an afl-too-common dimension of against the open discussion of sex. In traditional
growing up female. Especially vulnerable are young Latina culture, for example, a “good woman” is
girls who are forced to have intercourse by a male expected to be naive about sexual matters; knowledge
able or assertive women are considered to be “loose”
relative or are foisted prematurely into the world of [63]
.
adult sex after being married off as a child. In the
There are also strong emotional barriers that
Maternity Hospital of Lima, Peru, for example, 90%
prevent
women from raising the subject of condom
of young mothers aged 12-16 had been raped by their
use.
Especially
in the context of an ongoing
father, stepfather or another close relative [57]. In
relationship,
discussion
of condoms often raises
Jamaica, 40% of pregnant girls aged 11-15 reported
painful
issues
of
fidelity
and
trust that many women
the reason for their first intercourse as “forced” [58]
And m India, close to 26% of 133 postgraduate, and men would rather not confront. In focus-group
middle and upper class students interviewed reported discussions in places as diverse as the Caribbean,
having been sexually abuse by the age of 12 [59]. Given sub-Saharan Africa and Sri Lanka, men and women
uniformly said that use of condoms symbolized
the widespread prevalence of STDs
.
and HIV among distrust between partners, rather than care and
many adult populations, sexual abuse victims
-s are at concern [64]. Not surprisingly, these beliefs make the
>
Transforming AIDS prevention to meet womens needs
937
discussion of condom use an emotionally loaded topic,
especially in the context of a valued relationship.
Experience has shown that women also suffer
abandonment, physical abuse and accusations of [46]).
M (quotedin
infidelity by bringing up condom use. The family
Indeed, it is clear from conversations with u
planning literature documents how for some men, the
in
both the industrialized and developing worlds°^
desire to use any form of birth control signals a
many
feel unable to influence their partner’s behat
woman’s intentions to be unfaithful. (Their logic is
with
respect to condom use. In focus-g^
that protection against pregnancy allows a woman to
discussions,
women m rural South Africa felt it wa<P
be promiscuous.) Where children are a sign of male
waste
of
time
” to bring up condom use with their
virility, a woman’s attempt to use birth control may
husbands;
they
strongly emphasized the need for a
also be interpreted as an affront to her partner’s
preventive
method
they could use without their
masculinity. In focus-group discussions with women
in Mexico and Peru, for example, many women were partner’s knowledge [68]. Partners of intravenous
afraid to bring up birth control for fear of being drug-using men in New York City expressed similar
beaten, deserted or accused of cheating on their frustration at being made to feel responsible for men’s
sexual behavior. “The men decide what is going to
partner [65, 66]. The connection to infidelity is even
happen sexually”, they said. “If the staff wanted men
stronger for condoms, which are widely associated
with promiscuity, prostitution and disease in many to^wear condoms, they would have to talk to the men”
parts of the world. By bringing up condom use, women
Consistent condom use appears to be difficult to
either insinuate their own infidelity or they implicitly maintain even
with substantial outside support and
assert the right to protect themselves from husbands
where one partner had
ur.z • - . In Zaire couples
•
who have outside relationships. This assertion may counseling.
HIV
infection
needed
frequent
home visits as well as
trigger violent reactions.
clinic
counseling
to
help
them
use
condoms regularly.
Besides fear, complex psychological factors often
Despite intensive counseling, infection or pregnancy
keep women from raising the topic of condom use with
occurred in nearly 10% of couples followed for six
months or more (701. Likewi*^ in
a me
"»=.^
7
where strong emotions often supersede the tug of
supersede tne
nf These studies suggest the magnitude of the task women
reason. Many a teenage pregnancy has been born of
the belief that only ‘other people’ get pregnant, or ‘it face in negotiating consistent condom use each and
every time they have sex.
can t happen the first time.’ Likewise, many a married
For women living with abusive or alcoholic
woman has undoubtedly clung to the belief that her
partners, the task of enforcing consistent condom use
partner is faithful, even when evidence suggests the
contrary. A study of women’s risk perception in is even more problematic. Studies of natural family
Mexico, for example, found that while two-thirds of planning in the Philippines, Peru and Sri Lanka [72]
and sexual attitudes among women in Guatemala [73]
women thought married women should use condoms
because Mexican men have affairs, the vast majority note the frequency of forced sex by men, especially
of women did not perceive themselves to be personally when husbands arrive home drunk. The summary
document of the Guatemalan focus groups observes
at risk [67]. The understandable need women have to
It is clear from the replies the women gave ... that
believe that their partners are faithful works to their
being
forced through violence to have sex by their
disadvantage, especially in cultures where male
partner
is not an uncommon expenence for
infidelity is the norm.
Guatemalan women.” Since women have little say
Even when women are able to raise the issue of
condom use, they often face entrenched male over their partner’s sexual behavior outside of
resistance to their use. Because women are often marriage, their lack of control over the sexual
dependent on men economically and socially, they encounter within marriage is even more problematic.
This is not to say that all women are powerless in
have little leverage for gaining male compliance [29].
sexual
situations that put them at risk. Kline and
The more limited the options a woman has outside of
colleagues [74] report that many of the low-income,
a particular relationship or sexual encounter, the less
»hc can afford to lose her partner or her paying minority women they interviewed in New Jersey were
able to exert considerable power in their relationships
customer. A woman’s cultural conditioning may also
by
withholding sex if a partner refused to use condoms.
imit her ability to assert dominance in the sexual
Generally, these women were involved with drug
ealm, a domain largely controlled by men in most
using men who contributed little to the family’s
arts of the world. As the consensus statement from economic support.
ie First International Workshop on Women and
Orubuloye and colleagues [75] also report that
IDS in Africa observes: “Forces ranging from early
among the Yoruba of southwest Nigeria, women have
uldhood training to state laws governing marriage.
been able to refuse sex, without violent reprisal, if their
938
Low L. Heise and Christopher Elias
partner is known to be infected with a traditional STD. with steady lovers or spouses [15, 37]. Similarly, se
(Only 36% of women said they would consider using workers who regularly use condoms in their professio
a condom in place of abstinence.) The authors note have proven unwilling to introduce them into thei
that Yoruba women have certain advanuges when it private lives [78-80, 88]. This appears to be related t<
comes to controlling their sexuality; they tend to be the need to distinguish work or recreational sex fror
financially independent, their famihes welcome back relationships that have more emotional significance
wives in cases of conflict, and they traditionally have In many different contexts, a willingness to engage ii
had the role of enforcing abstinence during pregnancy, unprotected sex has become a cultural marker o
menstruation and up to two years postpartum. intimacy [80].
Polygamy and a tolerance of male infidelity also mean
Moreover, like men, women can find condom
that men can seek pleasure elsewhere. The authors unpleasant because they reduce sensation and interfen
note, however, that refusal is likely to be tolerated only with notions of spontaneous or ‘natural’ se:
until the man is treated. Long-term refusal, as would [29, 74, 78]. As one female informant noted in th«
be required by HIV infection, “would likely result in study of sexuality among fish traders in northwesten
the husband driving away the wife ... or becoming
I____
Zambia: “If there is no sperm, I can’t enjoy sex. If
threatening or violent, in which case the wife would am in love with you, I have also accepted the risk o
leave.”
disease—even death" [29]. Similar concerns abou
Several studies have shown that sex workers seem to interrupting the passionate flow of lovemaking have
have more leverage than women in the general been mentioned by low income, minority women in the
population when negotiating condom use, probably United States [74], Elsewhere, female sex workers have
because bargaining is already an explicit pan of the expressed dislike for condoms because they prolong
sexual encounter and the balance of power is more intercourse, which can lead to painful and dangerous
equal between buyer and seller. Most peer-education friction sores (81). Clearly, a condom-only’ approach
programs for sex workers have shown that condom use to AIDS prevention must overcome resistance on the
can increase substantially if women are educated part of both women and men.
about their risk and taught how to use condoms
properly [76-78]. But here too, women experience c__
difficulty getting_clients to comply. Six separate studies STD COntro1
A/DS Prevention strategy
reported at the Fifth International AIDS Conference
Recently, the strategy of preventing and controlling
found that the main reason sex workers did not use
other sexually transmitted infections has been
condoms was male refusal [78]*.
accepted as a major component of the global
It is not always men, however, that stand between AIDS response. After considerable debate, most
women and condom use. Among women, the fact that researchers now agree that STDs, particularly genital
condoms prevent pregnancy is also a major barrier to ulcer diseases, significantly augment the sexual
their use. In many cultures, childbearing is a woman’s
transmission of HIV [82]. In fact, a recent review
only route to status, and having children is an
suggests that, on a population basis, much of the
important way for women to gain power within the
risk of HIV transmission in Africa may be
narrow political realm of the family. Pregnancy is attributable to the presence of other STDs [83]. Many
often the primary motivation for sex: “If a man uses
programs have thus come to see STD control as a
a condom on me, I cannot even become pregnant, and priority public health intervention in the fight against
what is the use of sex without conceiving?” asked a key AIDS.
informant in the Zambia study cited above [29].
Prior to the AIDS era, STD control programs were
Also operative in women’s resisunce to condoms
among the most poorly funded of all health-sector
appears to be the symbolic significance of unprotected activities. Strengthening district, state and national
se* a sign of intimacy with which condoms interfere. STD control programs will require additional
One of the strongest and most consistent findings to
resources to train providers, establish diagnostic
emerge from AIDS research to date is that women and facilities and develop clinical infrastructure. Given
men alike have proven far more willing to use condoms these challenges and existing resource constraints,
with prostitutes, clients or casual sex partners than initial efforts at improved STD control have been
As a consequence, many AIDS prevention programs in
developing countries have begun to place greater
emphasis on targeting men. This is a welcome shift from
placing all responsibility for changing male behavior on
women. It would be a mistake, however, to switch entirely
pXXmtafg^17Xc7us.velyk"Sm"nd
could evolve from disillusionment over women’s ability to
influence their partner’s sexual behavior. Such a
exhO,SdIe shlft WOUld leaVC women unacccPtably
Xp°
highly targeted, concentrating primarily on ‘core’
groups, such as sex workers, their clients and men with
repeated STDs. A programmatic bias toward targeting
has been reinforced by econometric modeling that
suggests that targeted interventions are considerably
more cost-effective (in terms of ‘healthy years of life
' “““ “■u“-oa!>cu c‘lo"s
generaj
saved’) than broad-based efforts aimed at the general
P°Pulatl0n (84l- In keeping with this logic, the bulk of
STD invcstmcnl has gone toward improving the
easting network of STD clinics (whose clientele are
primarily men and, in some settings, sex workers) and
I
Transforming AIDS prevention to meet women's needs
939
establishing new services for reaching these core
promoted as part of the global AIDS
groups.*
Prevention
strategy.
While such highly targeted efforts may make sense
in the short term, given existing resource constraints,
the long-term reproductive health of women and men
STRENGTHENING WOMEN’S ABILITY TO PROTFrr
depends on a commitment to promote an expanded
themselves
t
development budget that affords reproductive health
As the previous section demonstrates, the existing
services, including routine STD
treatment,
services for
>r women in
m the
fc general population will need
,tor
'•»
to be integrated with other health services, because
5 condom use, and they have too little power outside of
women are seldom willing to endure the stigma these relationships to abandon partnerships that put
attached to attending an ‘STD clinic.’ The develop- them
_n at risk. Given this reality, what can be done to
ment of integrated services, in turn, will require
reduce women’s risk?
reorientation of service providers, improved clinical
An important first step is to recognize that women’s
facilities and practical research aimed at identifying
low status is a critical obstacle to AIDS prevention. It
effective and sustainable service models [87].
As outlined in the proceedings of a recent meeting is women’s subordination, not merely their lack of
knowledge, that is their primary risk factor for HIV
on reproductive tract infections,! co-sponsored by the
[91], Strategic interventions to promote gender equity
International Women’s Health Coalition and the
deserve a central focus in national AIDS plans.
Rockefeller Foundation, the establishment of ade
Governments can help eliminate the financial
quate services for the recognition and appropriate
inducements to multiple partnerships by revising laws
treatment of STDs in women will require a significant
and labor codes to guarantee women the right to own
investment of resources [88]. This investment is
and inherit property, to earn salaries on a par with men
essential, given the considerable morbidity and
and to have equal access to credit and training. They
mortality that women experience as a result of these
infections. While the AIDS epidemic has attracted can improve women’s ability to protect themselves by
expanding female education, educating women about
global attention, in most parts of the world
their rights, fighting the cultural beliefs and biases that
reproductive tract infections caused by pathogens
denigrate women and value boy children over girls,
other than HIV still account for the bulk of
and helping women organize on their own behalf.
reproductive morbidity suffered by women [89, 90].
Until women become part of the dialogue that
Given the current economic and political climate,
establishes policy and distributes resources, women's
however, it appears unlikely that governments will
issues will remain vastly underattended. And until
commit to the type of expanded budget that would
women share power more equally with men—in both
allow for the development of comprehensive repro
the public and the private sphere—they will remain at
ductive health services capable of reaching the
heightened risk of AIDS.
majority of the world’s women. As a result, it is
Policy makers must also begin to consider law
unlikely that most women will directly benefit in the
reform and investments outside the health sector as
short term from the *STD control’ measures currently
legitimate and important AIDS reduction strategies.
Subsidizing the uniform and s
girls in Africa might actually do more to reduce HIV
An interesting and potentially important exception to this
transmission—by eliminating the need for Sugar
rule is the innovative strategy of providing STD treatment
through social marketing approaches currently being Daddies—than the most sophisticated ‘peer edu
initiated by Population Services International (PSI) In a cation campaign. It would also reduce unwanted
demonstration project in Cameroon, PSI is developing an pregnancy, raise the age of marriage and decrease
STD ‘kit’ containing antibiotics, educational materials infant mortality, not to mention promoting gender
and condoms which will be marketed for men through
existing private sector distribution channels. These kits equality. One benefit of women-centered AIDS
will include information regarding the need to refer strategies is that they have positive backward links to
female partners for clinical evaluation [86].
many other development objectives.
tThe term ‘reproductive tract infection’ refers to sexually
Short of transformational change, there is much
transmitted infections of the female reproductive tract, that can be done to empower women within existing
those caused by the oveT^Xh^^o^smsVomaUy ^D,S Prevention Programs. Promising projects
w r. -j —J in
found in the genital tract of healthy women e g.
bacterial vaginosis and candidiasis) and iatrogenic
present with similar clinical syndromes (e.g. vaginal
discharge, itching or lower abdominal pain), the broader
serric^°re accuratc,y descnbcs women’s need for clinical
SSM 40-7—F
Thailand, the Dominican
------ j Republic and Nigeria, for
sample, have helped sex workers enforce condom use
by
assertion and negotiation skills,
implementing ‘condom-only’ policies in brothels, and
giving women more power through self-organization
[92]. A -project
in Calabar,. -Nigeria has helped ™
sex
workers change the basic economics of their trade [93],
Together, these women decided to raise their fee for sex
940
Lori L. Heise and Christopher Elias
so that they could afford to refuse clients who would and recommended holding a community meeting
not use condoms. Project organizers also persuaded discuss the dangers of the new disease. The on
hotel owners not to raise the price of the rooms that difference was that the women in the latter group hi
the women use for clients, arguing that ‘safe sex’ was
participated in a community organizing project for s
in the owner’s long-term financial interest. The years where they had learned to analyze their situatic
project, which was started by a group of volunteers, is and seek individual and collective solutions to the
now largely self-supporting, with the women them
problems. When asked about beatings or abandoi
selves taking over most of the organizing functions.
ment, the members of the second group acknowledge
The key to the Calabar project’s success is that it that before they participated in the project, they woui
built upon women’s capacity for collective action.
never have had the power or confidence to raise sue
Women throughout the world have a history of a delicate topic.
rallying together to solve common problems—a
This film shows that women who feel powerless an
strength that has yet to be widely utilized by AIDS resigned can be helped to feel entitled and empowerec
prevention programs (e.g. successful campaigns But ultimately, even these women must rely on
against male alcoholism in India and community
technology—condoms—that men control. Althoug
policing against wife battering in Peru) [94, 95]. As
technology development is not a solution in itsel
behavioral scientist, Priscilla Ulin [46], observes,
women's overall vulnerability to HIV would be great!
"Women’s collective perception of their ability to act
reduced if they had access to a prevention technolog
on AIDS prevention messages could be a critical within their control. In this respect, women ar
determinant of both male and female behavior
uniquely vulnerable. If men choose to ignore behavio
change.’’ To date, there has been little effort to initiate
change messages to reduce their number of sexua
dialogue among women about the strategies they have
partners, they still have a technology—condoms—1<
used successfully to change their own or their partners’
protect themselves. If injection drug users continue t<
behavior. Nor have most projecu sought to organize
inject, they have a technology—clean needs and/o
women to exert collective pressure on men to change bleach—that is both effective and within their persona
their ways.
control. Only women who confront centuries of socia
The Calabar project also benefitted from its use of
conditioning that grants sexual license to men, an
a ‘community organizing’ approach to social change
expected to protect themselves with a technology tha
rather than the ‘health beliefs’ model that currently is outside of their personal control.
dominates AIDS interventions. AIDS projects could
Scientists have concluded that developing a female
profit greatly by importing some of the lessons learned
controlled microbicide’— a vaginal product similar tc
from popular education efforts in other sectors.
today’s spermicidal jellies or foams—could be
Change requires not only new knowledge but a new
developed in 5-10 years if made a priority for research.
analysis of the problem and an empowered sense that
(The feasibility of bringing such a product to market
action, on an individual or collective level, can make
has recently been reviewed [97]. Such a product would
a difference. ‘Organizing,’ as opposed to information
allow women to protect themselves from HIV without
and counseling, helps build group consensus and
their partner’s knowledge or cooperation. It may also
imparts a unified sense of purpose and possibility.
be possible to develop a microbicide effective against
Especially among women and other oppressed groups,
HIV that would not be a spermicide, thus providing an
an on-going process of action and reflection can
HIV prophylactic for women desiring to conceive.
impart a new sense of entitlement and renewed faith
Although critical in the short term to reducing
in the possibility of change [96].
women's risk, hopes for a new female-controlled
Often the benefits of organizing and consciousness
technology should not be allowed to divert attention
raising around one issue ‘spill-over’ into areas
from the underlying (and far more difficult) task of
unrelated to the initial intervention. A dramatic
changing the power balance between men and women.
example of this ‘secondary empowerment’ comes from
Ultimately, a technology that allows women to
a film on women and HIV, entitled Positively Women
circumvent their lack of power in sexual relationships,
produced and directed by Nalini Singh with backing
is no answer, but merely a ‘bandaid’ for deeper
from the United Nations Development Program. The
problems
in need of redress. Nonetheless, without a
film includes conversations with two groups of women
such
a
bandaid,
many women will bleed to death
from nearby villages in Rajasthan India about their
before long-term strategies can take hold.
ability to protect themselves from HIV. Prior to the
In sum, making AIDS prevention relevant to the
filming, neither group knew anything about HIV or
reality of women’s lives will require policy revisions in
condoms; but the demeanor and response of each
three important areas: a greater commitment to
group were entirely different. Women from the first
identifying practical strategies for equalizing econ
group were withdrawn, embarrassed and said they
omic and social power between men and women; more
would be afraid to raise the issue of condom use with
attention
to group process and empowerment within
their husbands for fear of being beaten or humiliated.
existing
AIDS
programs; and a concerted effort to
By contrast, women in the second group felt capable
develop microbicidal products for intravaginal use.
and entitled to discuss condom use with their husbands
Only a persistent and conscious neglect of women’s
Transforming AIDS prevention to meet women’s needs
needs will explain continued inattention to these
important and, to date, underattended areas.
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Declining risk for HIV among injecting
drug users in Kathmandu, Nepal:
the impact of a harm-reduction programme
Aaron Peak*t, Sujata Rana*, Shiba Hari Maharjan*,
Damien Jolleyt and Nick Croftst
Objective: To measure changes in self-reported risk behaviour for HIV infections
and HIV seroprevalence among injecting drug user (IDU) clients of an outreach
harm-reduction programme in Kathmandu, Nepal.
Methods: The Lifesaving and Lifegiving Society (LALS) of Kathmandu began providing
sterile injecting equipment and education to Nepalese IDU in 1991. A sample of these
IDU were interviewed and tested for HIV each year from 1991 through 1994.
Results: Indicators of unsafe injecting fell, as knowledge of HIV rose more in 1994
for those who had been in touch with LALS for longer. Indicators of unsafe sex did
not change. HIV seroprevalence remained low, 1.6% in 1991 and 0% in 1994.
Conclusion: We conclude that programmes for the prevention of HIV spread among
IDU are possible and effective in Asia, and are urgently needed.
AIDS 1995, 9:1067-1070
Keywords: Injecting drug use, HIV, Nepal, harm reduction, Asia
Introduction
Over the bst two decades, there have been large increases
in the number of people regularly using opiates in Asian
countries, many of whom have more recently turned
from smoking or inhaling opium to injecting heroin [1].
In many of these countries, associated with changes in
the patterns of opiates consumption, there have been
explosive epidemics of HIV infection among injecting
drug users (IDU) since the late 1980s [2]. These epi
demics continue unabated in most countries in Asia in
which they occur. Few local initiatives exist to slow or
prevent the spread of HIV among IDU in these coun
tries; in general, efforts are targeted at drug use itself.
In many cases these efforts are extremely repressive, and
current evidence suggest that they are having little effect
other than to further disenfranchise the drug users and
drive them underground. Strategies which can prevent
the further spread of HIV among IDU in Asia in realistic
timeframes are urgently required [3].
Injecting drug use is a relatively recent phenomenon
among Nepalese people in Kathmandu. Syringes are
available from pharmacies, but are expensive relative to
income, and become more expensive or unavailable if
the pharmacist knows that the purchaser intends to use
them to inject illicit drugs. In a small city such as Kath
mandu this knowledge is common among pharmacists,
as it is among the police, who can use possession of a
syringe as an excuse for arresting or intimidating IDU.
A syringe and needle usually retails for approximately
10 rupees, compared with the average cost of a meal of
about 20-25 rupees and a packet of low-quality heroin
at 200 rupees. Knowing that the purchaser is IDU, the
pharmacist can charge up to 10 times the usual price.
There are six drug treatment centres in Kathmandu,
most of which do not admit IDU or HIV-positive indi
viduals. Fees are very high, as is the relapse rate.
The Lifesaving and Lifegiving Society (LALS) of Kath
mandu began distributing sterile injecting equipment in
exchange for contaminated equipment in 1991 among
IDU in Kathmandu. LALS has grown from one outreach
worker to eight Community Health Outreach Workers
(CHOW) in 1994. CHOW also distribute other ma
terial for HIV prevention, including sterile water, con
doms and bleach, and provide education, counselling and
primary health care for their clients. It is estimated that
From the ’Lifesaving and Lifegiving Society, Kathmandu, Nepal and the tMacfarlane Burnet Centre for Medical Research,
Melbourne, Victoria, Australia.
Sponsorship. Supported by the Research Fund of the Macfarlane Burnet Centre (N.C.). The Lifesaving and Lifegiving Society
has received support from the Wbrld Health Organization, the American Foundation for AIDS Research and the Point
Defiance AIDS Project.
Requests for reprints to: Nick Crofts, Head, Epidemiology and Social Research Unit, Macfarlane Burnet Centre for Medical
Research, PO Box 254, Fairfield, Victoria 3078, Australia.
Date of receipt: 13 February 1995; revised: 20 June 1995; accepted: 26 June 1995.
(0 Rapid Science Publishers ISSN 0269-9370
1067
068
AIDS 1995, Vol 9 No 9
LALS staff are in regular contact with about 750 IDU of
an estimated total of 1500-2000 IDU in the Kathmandu
valley. Syringes are exchanged on a one-to-one basis,
with no limit on the number exchanged at any contact.
By the end of 1994, there had been 57734 exchanges,
rising from 4506 in 1991 (an incomplete year) to nearly
30000 in 1994. As well as syringe exchange, CHOW
provide many other services, including distribution of
information and educational material, condoms and pri
mary care services. Of 48386 client contacts up to the
end of 1994, only half involved syringe exchange, and
6847 primary health care.
LALS is a unique program in Nepal, and to our knowl
edge in Asia. It was therefore imperative that the need
for its services and the impact it was having on the HIV
risk behaviour of its clients be continuously assessed. We
also wished to monitor the rate of HIV infection among
those IDU with whom we are in contact, to ensure that
HIV is not spreading, and to attempt to provide appro
priate services to those found to be HIV-infected.
Methods
Each year that LALS has been operating a sample of the
clients with whom it is in contact have been interviewed
and blood samples taken. This research programme has
been aimed at discovering the needs and behaviours of
our clients in relation to the risk of HIV infection in par
ticular, through both their injecting and sexual contacts.
Briefly, in each year of operation, consecutive IDU
clients of LALS were asked to participate if they had
injected within the preceding 30 days, or if they had
participated in a previous interview. Sample size was
constrained by available resources, but participants were
enrolled in all years on a first-come basis. A question
naire was completed by CHOW, who had previously
established a relationship of trust with the client. For the
most part, clients were interviewed in a private setting
in the field; no identifying information was collected,
although clients were asked if they had previously par
ticipated in this research programme. At the same time
as the interview, a blood sample was taken by CHOW,
with provision of pre-test counselling for HIV testing.
All sera were tested in Kathmandu using conventional
methods for the presence of antibody to HIV, hepatitis B
surface antigen and antibodies to syphilis using the Vene
real Disease Research Laboratory (VDRL) test. Those
with reactive VDRL results were followed and treated
by staff nurses from LALS or referred for treatment when
appropriate; HIV and hepatitis B virus results were de
livered with post-test counselling.
Statistical analysis
Data were entered into a database built using Epi Info
version 5.1 (Centers for Disease Control and Preven
tion, Atlanta, Georgia, USA). Comparisons were made
between demographic characteristics of the samples, self-
reported behaviours and seroprevalences between dif
ferent annual samples and between those in the 1994
sample, who were interviewed for the first time and
those who had been previously interviewed. Statistical
techniques used in analysis included Kruskal-Wallis and
Mann-Whitney tests.
I
1
1
I
Results
1
1
In 1991, 127 IDU were enrolled, interviewed and tested
from a total of approximately 150 with whom LALS
was in contact. In 1992, 59 were interviewed of whom
20 had previously been interviewed. In 1993, 200 IDU
participated out of a total of about 600; 59 individuals
were interviewed for a second time, 14 of whom were
interviewed first in 1991. In 1994, 200 IDU participated
out of 750 with whom LALS was in contact; 83 had
previously been interviewed (Table 1).
I
I
1
1
I
1
Table 1. rNumber of interviews and reinterviews of injecting drug
I
users in touch with the needle and syringe-exchange
u programme
r _a _......... .. in
.j
Kathmandu, Nepal, 1990-1994.
I
Previous interview year
Year of
First
interview
interview
1991
1992
1993
1994
Total
127
39
141
117
424
1991
20
14
4
38
1992
45
12
57
1
1993
Unknown
Total
66
66
0
0
0
1
1
127
59
200
200
586
!
I
I
I
I
There was no difference in demography between the
samples to suggest that the groups of IDU LALS was
in contact with were substantially different over time
(Table 2). The proportion of men, average age at in
terview, average years of schooling, the proportion who
had never married, and median income stayed substan
tially the same between 4-yearly samples, and in 1994,
between those interviewed for the first time and those
re-interviewed. In all subsamples, median age at first in
jection was 22 years, although, as would be expected, the
median duration of injecting increased to some degree
over time and with continued contact with LALS.
If indicators of injecting behaviour are compared be
tween groups, it can be seen that injecting safety in
creased over time and for those interviewed in 1994 who
had been in contact with LALS longer (Table 3). First,
the number of times LALS clients had been injecting
drugs each week decreased from about 21 times in 1991
to about 15 times in 1994, both for people interviewed
for the first time and for those who had been interviewed
before. There was also a decrease in the number of times
people shared injecting equipment in the previous week
— from about 14 times per week in 1991 to once pct
day or less in 1993 and 1994; therefore, the frequency ot
e
Needle exchange in Kathmandu Peak et al.
Table 2. Demographic profiles of injecting drug users interviewed in
Kathmandu, Nepal, in 1991 through 1994, by first or subsequent inter
view (in 1994).
Year of first interview
Table 4. Knowledge and attitudes about HIV, serostatus for HIV, hepatitis B and
syphilis among injeaing drug users in Kathmandu, Nepal, in 1991 through
1994, by first or subsequent interview (in 1994).
n (%)
1994 interview
Year of first interview
1991
Number enrolled
Men (%)
Average age of men
(years)
Schooling (years)
Never married (%)
Median income
(rupees per week)
Duration of
injecting (years)
Average
Median
127
90
1992
39
1993
First
Subsequent
92
141
95
117
97
83
93
25.7
5.5
54
26.8
5.6
64
25.0
6.6
54
26.4
8.4
58
27.3
7.1
46
700
700
600
700
500
2.4
1
4.3
4
3.2
2
3.9
3
4.5
4
1991
Know about
HIV/AIDS
73(58)
Perceived to be at
risk of HIV
18(25)
Risk source (%)
Prostitutes
Syringes
Other
HIV*
2(1.6)
HBV*
7(5.5)
VDRL-reactive
18(14.2)
1994 interview
1992
1993
First
Subsequent
37(95)
120(85)
114(97)
83(100'
11(30)
54(45)
47(47)
39(47)
9
73
27
1 (2.6)
19
91
9
0(0)
13 (9.2)
20(14.1)
32
65
6
0(0)
8(6.8)
6(5.1)
33
87
3
0(0)
5(6.0)
4(10.3)
7(8.4)
HBV, Hepatitis B virus; VDRL, Venereal Disease Research Laboratory test tor
syphilis.
Median age at first injeaion was 22 years for all subjects.
sharing was less in 1994 for those who had been in con
tact with LALS longer. Most of those who were re-interviewed in 1994 reported not sharing at all in the previous
week. The number of sharing partners remained stable
across the years, but were smaller in those re-interviewed
in 1994 compared with those interviewed for the first
time that year.
Table X Injecting behaviours among injeaing drug users in Kathmandu,
Nepal, m 1991 through 1994, by first or subsequent interview (in 1994).
Year of first interview
1994 interview
1991
1992
1993
First
Subsequent
No. respondents
127
No. injeaions per month
Average
23.7
Median
21
39
141
117
83
18.9
20
<0.0001
16.7
14
17.0
15
17.5
15
No. times shared needles
per month
Average
12.7
Median
14
Pt
No. people shared
needles with
Average
2.8
Median
2
Pt
11.3
11
0.0003
2.9
2
NS
7.3
4
2.4
2
7.6
5
2.9
2
6.1
2
2.1
1
NS
0.06
0.024
•For difference between 1994 samples. tFor differences over time. NS, Not
significant.
Knowledge of the existence of HIV infection and AIDS
increased dramatically from 58% in 1991 to almost 100%
in 1994; also, an increasing proportion of those inter
viewed perceived themselves to be at risk of HIV in
fection, from 25% in 1991 to 47% in 1994 (Table 4).
This risk was increasingly perceived to be associated with
both injecting behaviour and conuct with sex workers,
although the former was seen to be more significant. In
1994, those who were re-interviewed were significantly
more likely to recognize the risk from injecting than
those being interviewed for the first time.
The same degree of change in relation to sexual be
haviour was not apparent, with an increased proportion
having ever had contact with a sex worker, but similar
high proportions reporting condom use with sex work
ers only half the time or less (Table 5). However, 49% (89
out of 183) of first interviewees failed to answer ques
tions about usual condom use, so these results may be
misleading. There were 33 responses from female IDU
overall, ot which 27 were first interviews (13, three,
seven and four in 1991 through 1994, respectively). Six
indicated ever having accepted money for sex, all of
whom were interviewed in 1994: two first and four re
interviews. Of the six, three reported never and three
rarely using condoms.
Table 5. Sexual risk behaviour for HIV infection among male injecting
drug users (IDU) in Kathmandu, Nepal, 1991 through 1994, by first or
subsequent interview (in 1994).
Year of first interview
1994 interview
1991
1992
1993
First
Subsequent
No. male IDU
114
36
Never had sex (%)
26
25
Never with prostitute (%)
40
28
No. men reporting ever having
sex with a prostitute
38
17
Any condom use (%)
100
35
No. condom use
always/mostly (%)
4(11) 1 (17)
134
16
33
113
19
28
77
9
38
68
35
60
43
41
46
1 (4)
4(15)
3(16)
Athough the proportion positive for hepatitis B surface
antigen remained relatively constant, the overall sero
prevalence of HIV did not change significantly, and al
though HIV was discovered at low rates in 1991 and
1992, no new HIV-infected individuals were identified
in 1993 or 1994. Overall, there were almost 195 personyears (PY) of follow-up on those interviewed more than
once, a seroincidence of zero per 100 PY [upper 95%
confidence interval, 0.1 per 100 PY]. The level of past
exposure to syphilis, as measured by VDRL reactivity,
was high, ranging from 5 to 14% of the yearly samples.
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AIDS 1995, Vol 9 No 9
Discussion
The sharing of contaminated injecting equipment
among IDU is a major risk for transmission of HIV, if
it is present, whether in the West [4] or in Asia [5,6].
Despite the presence of HIV among IDU in Nepal since
at least 1991, these data suggest that to date, HIV is not
spreading among those IDU who are in contact with the
LALS. The data presented here from 4 years’ monitoring
of the first needle and synnge-exchange programme in
Asia show that there have been significant changes in
self-reported injecting behaviour in relation to HIV risk
among IDU in Kathmandu from 1991 to 1993. This
change has been even greater among those who have
been in conuct with the needle exchange through this
time than in those who were interviewed for the first
time in 1993, but there were also significant changes in
this latter group as well. This suggests that LALS has
had a significant effect in promoting and supporting safer
injecting practices among its clients, with some spread
of this effect beyond those in immediate conuct with
LALS.
cant social desirability bias with clients of the exchange
learning the correct or desired responses to questions,
may have some force but does not affect the fact of
lack of HIV spread as determined by serology or of the
increasing distribution of sterile equipment. Again, the
possibility of selection bias affecting the results is mini
mized by the consecutive enrollment of clients, the only
proviso being that they had injected in the previous 30
days.
In a context where there has been explosive spread of
HIV among IDU in Nepal’s neighbouring countries,
China [7] and India [8], and in virtually every other
country in Asia where HIV has appeared among IDU,
including Thailand [9], Malaysia [6] and Myanmar [10]*
this lack of spread among IDU in Kathmandu over a
4-year period is remarkable. Conclusions based only on
this evidence cannot be firm, as factors other than the
impact of the harm-reduction programme may play a
part. It may be that there is some self-selection for time
of entry into these studies, with subjects more compliant
and easier to find if recruited early; however, the lack
of significant differences between those interviewed for
the first time in 1994 and those being followed-up in
that year suggests that this is not the case. It is possible
that HIV is spreading among IDU not in conuct with
LALS in Kathmandu; if this were the case, then the lack
of spread in this group is even more remarkable. Finally,
it is possible that when an IDU becomes infected with
HIV he or she is more likely not to come into contact
with LALS; however, for the vast majority of IDU in
Kathmandu it is only through LALS that they have access
to HIV testing.
This evidence is therefore strongly suggestive that harm
reduction programmes can be implemented and effective
in controlling the risk of HIV infection among IDU
in Asia. Many programmes that have been effective in
preventing the spread of HIV among IDU in western
countries are often said to be inappropriate for Asia on
cultural, political, economic or religious grounds. LALS
demonstrates that this is not necessarily the case. What
works in preventing the spread of HIV among IDU is
now well known from many different cultural and so
ciopolitical settings [11,12]. What is needed, in Asia as
elsewhere in the world, is the will to do those things
which we know will work (including needle/syringe
exchange and distribution and peer education), and to
carry them out early enough and on a scale sufficient to
have an impact on the HIV epidemic among IDU.
I
Acknowledgements
I
LALS wishes to express its gratitude to its many support
ers, especially Dave Purchase of the Point Defiance AIDS
Project; Gene Vadies and Dr Robin Biellik from the WHO
Global Programme on AIDS, the American Foundation for
AIDS Research; Dr Benu Bahadur Karki, Chief of the Na
tional STD and AIDS Prevention Centre for Nepal; Rabi
Raj Thapa, Senior Superintendent of Police in the Narcotic
Drug Control Unit in Nepal; and Dr Iswar I-al Srestha,
Consultant Pathologist.
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