The cornerstone in the fight against HIV/AIDS is the combination of treatment and prevention. But with treatment still in short supply in many developing countries, prevention programs bear a great burden. Nevertheless, a new book says prevention programs can fail if they fall prey to the age-old concerns of power, politics and sex.
South African Catherine Campbell is the author of “Letting Them Die: Why HIV Prevention Programs Often Fail.” The social psychologist at the London School of Economics and the University of Natal saw the failure of a prevention program first hand. Between 1997 and 2000, she was part of an effort to curb the spread of HIV/AIDS among gold miners.
"This was a three-year study in the gold mining community of Summit Town, which is near Johannesburg. We got a lot of foreign donor funding to set up a state of the art HIV prevention program. And the program really was, on paper, an extremely good one. It used community based peer education. It was community wide. The program was managed by a very representative group of stakeholder partners and we really were expecting the program to be very successful. And unfortunately after the three years we found not only did the program not succeed, but in fact levels of sexually transmitted infections among some groups actually got worse," she says.
Dr. Campbell says problems in the prevention program actually started “early on.”
"The different stakeholders had very different analyses of HIV. What was causing the problem, what ought to be done. There were quite different levels of commitment among the different stakeholders. So, you had a very uneven situation where you had this group of people trying to work together, but in some sense there were no common understandings underpinning their work. And secondly, some were more committed than others to addressing the problem."
And there were power imbalances. She says the more powerful stakeholders -among academic researchers, the gold mining industry and the health department - viewed HIV/AIDS strictly as a bio-medical problem. She says they believed it should be fought primarily through clinics treating sexually transmitted diseases. They were less committed to the other parts of the program, alienating those promoting social and community aspects of prevention.
She says, "You know, they said HIV is caused by weak-willed individuals who will not abstain from sex. Or, HIV is caused by a whole series of medical problems without looking at the wider context. And I supposed that’s one of the points I tried to make in the book – you can’t expect individuals to change their sexual behavior unless you create community contexts that support sexual behavior change."
The social psychologist also warns that promoting abstinence-only prevention programs – as is being done in some quarters today - is not realistic.
"The reality is there will always be a group of sexually active young people. There will always be a group of people who have more than one partner in America or South Africa or anywhere. And those are the people who are at risk of HIV. And if one preaches an abstinence message, one excludes the people you’re trying to reach. While this might be unpalatable to some people for kind of moral reasons it’s the reality. And we ignore it at our peril," she says.
Catherine Campbell says because of the differing viewpoints and lack of social concerns in the Summit Town project, the very people that were supposed to be helped, gold miners, were excluded.
"People with AIDS in South Africa are a hidden constituency because of the tremendous taboo and stigmatization around having AIDS or having someone with AIDS in your family. People are very often reluctant to disclose they have the problem. And that’s a context where it’s very difficult for people with AIDS to get together and become a strong lobby group."
She says for prevention programs to succeed, HIV/AIDS must be fought on three levels.
"You know, in a short-term level, we have to see it as a medical disease with STI (sexually transmitted infections) and anti-retroviral drugs. In the medium control, we need to mobilize communities to take control of HIV/AIDS. And in the long term, we need to really work towards fighting and challenging the power imbalances that drive the epidemic," she says.
Ms. Campbell says, “Real partnerships involve sharing decision making, sharing control over resources and giving marginalized members a sense they are equal stakeholders.”