Focus on PSI's AIDS programme

On a warm dusty Friday morning, a Maputo market was the improbable setting for a piece of theatre on how to prevent infection by HIV, the virus that causes AIDS. The actors presented their play in Shangaan, the local language most commonly spoken in the Mozambican capital, amid laughter and comment from an audience of some 50 or 60 people who had paused to watch the 30-minute production. The play was one of seven commissioned by Population Services International (PSI), an American non-profit voluntary organisation, for its HIV/AIDS prevention and awareness programme in Mozambique. An estimated 12.2 percent of Mozambican adults are HIV-positive. The infection rates, however, vary from region to region. The country's central region has the highest HIV-prevalence at 16.5 percent, followed by the three southern provinces with 13.2 percent, and 5.7 percent in the remote northern third of the country, according to the Ministry of Health. PSI has been working in Mozambique since 1994, in response to the growing HIV epidemic, using what it calls social marketing. "Social marketing is a comprehensive approach to behaviour change that delivers branded health products and services to those least able to afford them," the PSI country director in Mozambique, Jill Schumann, explained. CREATING DEMAND But first demand must be created. PSI helps to create the demand "through innovative communications", Schumann said, adding that "the creative use of mass media and interpersonal communications across local communities is the key to generating demand". On the supply side, PSI launched the JeitO brand of condoms in 1995. Jeito is a Portuguese word meaning "skill" or "flair". So the advertising slogan "Fazer amor com JeitO" (make love with JeitO) very quickly caught on among radio and television audiences, particularly in the urban areas of Mozambique. The condoms are distributed through about 4,000 sales outlets, most of which are informal and small scale, such as market stalls and kiosks. PSI says that these outlets provide the best access to the product for most people. For condoms to be truly available, they must be affordable. PSI's branded condoms are sold at 1,000 meticais for three, the equivalent of about 1.3 US cents each, compared to a current average price on the global market of 2.5 US cents apiece. "Clearly PSI is a non-profit organisation," Shumann commented. The PSI programme has three main activities, run from offices in every province. The first is called "crossfire" where social agents specially trained in interpersonal communication mediate discussions with groups of 20 to 25 people on the risks associated with HIV and the options for prevention. If condom use is an option, then it is demonstrated. They also discuss how to talk to one's partner about risk avoidance. "That's tough stuff", Shumann commented. Eighty of the 128 districts in Mozambique, those most at risk from the spread of HIV, have social agents trained by PSI, and each is expected to conduct 15 group discussions a month in the district. The second component of the programme is theatre and discussion. There are nine theatre groups, presenting a repertoire of plays, each directed towards a specific target group: women, students, miners, voluntary counselling and testing centres, workers in their workplaces and high risk men. The last group includes long-distance truck drivers, because of the role of the transport corridors in the burgeoning HIV epidemic. On any given day, 40 crossfire group discussions are held and five theatre plays are presented. The play in the Maputo market targeted women, with a message on how to negotiate condom use with their partners. Ezequiel Mingane, the director of the theatre group in Maputo province and city, noted that there was a significant difference between audiences in the city and those in the more rural districts. "People in the city are already changing their cultural habits and they are more receptive to new messages and more open to discussion," Mingane said. Indeed, many of the women who had gathered to watch were ready with comments when a PSI social agent asked if anyone knew about methods of avoiding infection from HIV. "Reduce the number of partners," called out one woman in the audience. But the woman who said "I prefer condoms because you can trust them" was seconded by several voices at once. DOES IT WORK? But what measurable impact has the programme had on behavioural change? Towards the end of last year, PSI conducted a nationwide survey to evaluate how successful its programme in Mozambique had been. Using indicators established by the World Health Organisation, PSI asked people to name two methods of preventing the sexual transmission of HIV, how many casual sexual partners, if any, the respondent had over the previous 12 months, and whether the respondent had used a condom in the last casual sexual contact. Comparing last year's survey, with 1996 baseline data, PSI was looking for an increase of 25 percent of people who could name two methods of HIV prevention, but found an increase of only 6 percent. With regard to the number of casual sexual partners, PSI hoped to find that the number of people reporting irregular partners would fall by 25 percent, but found a decline of 15 percent. The results relating to condom use were more encouraging. The target for PSI was a 50 percent increase, which in reality turned out to be 48 percent. Commenting on the results, Shumann said the low increase in the number of people who could name two methods of HIV prevention was probably because "it's really high already, and an external evaluation of our programme found our target here to be unrealistic". There could be a link between the other two indicators. "Perhaps some people prefer to use condoms rather than reduce the number of partners, but that's only a possibility and would need to be tested," she told IRIN. With regard to behaviour change, PSI found the results relating to young people aged from 15 to 24 years most encouraging. The use of condoms increased faster among the younger groups than their older compatriots. Young persons also showed a decline in reported symptoms of sexually transmitted diseases and seek counselling and testing services more often. Do these results call into question the efficacy of the PSI programme? For Shumann, "behaviour change is a very complex question, and it's harder to bring about change in older people, who are more set in their ways".