Uganda: Case Study of Successful Behavioural Change

for HIV Decline

Uganda: Case Study of Successful Behavioural Change

for HIV Decline

Geoffrey Setswe, PhD.Capacity Building Workshop

Gallagher Estate, Johannesburg 30 November 2009

What happened ?What happened ?

• HIV prevalence declined from 21.1% (1991) to 9.1% (1998): over 50% reduction in less than a decade

• Declines in incidence occurred before resources allocated for formal interventions (pre- condoms, VCT, etc)

“The scale of changes was equivalent to a vaccine of 75% efficacy.” …Stoneburner, WHO 2000

Why did it happen?Why did it happen?

• Basic behavioural response to avoid HIV risk associated with multiple partners

• Substantial decline in sexual partners was by farbiggest difference across age groups

• Reported changes:48% men & women – “stuck to one partner”11% men, 14% women - “chose to be sexually inactive”12% men, 3% women – “used condoms”

Reported Reductions in Sexual PartnershipsReported Reductions in Sexual Partnerships

How did it happen?How did it happen?

• Community & political efforts reinforced each other, but impetus came from communities

• Changes made were not piecemeal, life did notcontinue as before

• Gov. comm. programme: direct & focused* risk avoidance #1- “zero grazing”* main messages directed at men

• Communicating HIV/AIDS effectively shifted from formal to informal

Uganda-style media messagingUganda-style media messaging

Beyond messages, media & public health campaigns: 3 key features of Uganda communications

Beyond messages, media & public health campaigns: 3 key features of Uganda communications

1. Communication through personal sources

* PLWHAs toured country, told stories.* Cultural, community & religious leaders fully engaged

(musicians, DJs, craftsmen, chiefs,teachers, pastors, etc)

“It was not so much individual or partner communication but rather community level communication processes

within social networks that was significant in influencing behavioural norms”

(Anglican Bishop on Uganda AIDS Council)

2. Great transparency about disease.

• Campaigns captured realism of HIV/AIDSdid not gloss over or down play the experience

(balanced healthy living & widespread suffering)

• Real efforts made to personalise epidemic,to create rippling social pressures

3. Communication promoted attitudeof care

• First Lady urged support for families, orphans

• Promotion of “shared confidentiality” – openness of HIV status with a limited circle of trusted people

• Concentrated on building social capital for managing epidemic (TASO care networks)

Top 3 lessons from UgandaTop 3 lessons from Uganda

1. Primary behavioural change on a large scale is possible

2. Reduction of sexual partners, most esp. concurrent partners, can have a huge impact on HIV at the population level

(due to break up of scope & connectivity of sexual networks)

Even Low degree sexual networks create a transmission coreEven Low degree sexual networks create a transmission core

In largest component: 2% 41% 64%10%

Mean: 1.74

Mean:

1.80Mean:

1.86

Largestcomponents

Mean: 1.68

Number ofPartners

Bicomponentsin red

Source: Martina Morris, Univ. of Washington, used with permission from a presentation given at a meeting on concurrent sexual partnerships and sexually transmitted infections at Princeton University, 6 May 2006.

3. Behavioural change succeeded because it made people think about

a) their sexual behaviour b) the consequences

c) avoiding risks they were able to avoid

The “social vaccine” or the “silent cure” for HIV/AIDS found within communities offers the best hope for long-term sustainable solutions to this crisis

Thank you