Expecting poor marks for AIDS prevention on the UNGASS report card

African countries have failed to meet prevention targets agreed upon in 2001 at the United Nations General Assembly's Special Session on HIV/AIDS (UNGASS), according to a statement issued recently by over 80 representatives of African civil society. The statement noted that no African country has met the UNGASS goals of reducing HIV prevalence amongst young people by 25 percent or ensuring 90 percent access to HIV/AIDS information and education. These failures are likely to come under scrutiny as government representatives converge on New York at the end of this month to review progress on their 2001 commitments to combating HIV and AIDS. Prevention is central to the UNGASS Declaration of Commitment, [www.un.org] which reads: "As efforts to expand access to life-saving treatments accelerate, success in prevention is essential to make sure those programmes can be sustained for those already infected." At the 2001 meeting, governments agreed to "communicate life-saving information, forge new social norms, promote the benefits of condoms ... and empower people to protect themselves from infection." But figures in official reports submitted ahead of the meeting indicate that in Southern Africa, the region worst hit by the epidemic, condom uptake and knowledge about how to prevent transmission are still disturbingly low. In most countries in the region, less than half of the 15-24 year-olds surveyed reported using a condom during their last sexual encounter with a non-regular partner. In Mozambique, the figure is as low as 31 percent with Zambia and Malawi only faring slightly better with 32 percent and 39 percent using condoms. Knowledge of how best to prevent HIV infection is also disturbingly low in the region. Mozambique is the poorest performer in the area of education with only 27 percent of 15-24 year-olds able to identify ways of preventing infection and aware of major misconceptions about HIV transmission. Mozambique also reported the largest percentage of young men and women who had had sex before the age of 15 (27 percent), often an indicator of high HIV prevalence. South Africa was not far behind with 25 percent.

Mixed attitudes towards condom use Sonny Molamu, a volunteer with SOLOF, regularly hands out condoms to drivers at the taxi rank in Springs near Johannesburg. SPRINGS, A conversation with a group of mini-bus taxi drivers in Springs, about 50km east of Johannesburg, revealed a mixed set of attitudes and behaviour when it came to condom use and HIV. The men were the targets of a condom distribution and awareness-raising programme run by the Save Our Loved Ones Foundation (SOLOF), a local NGO. [More...]

According to Sisonke Msimang, HIV/AIDS programme manager for the Open Society Initiative for Southern Africa (OSISA), the impact of the requirement by countries that are recipients of the United States Emergency Fund for AIDS Relief (PEPFAR) that they promote abstinence over condom use has probably yet to be felt. She attributed southern Africa's poor performance on prevention targets partly to a lack of resources and infrastructure, but also to a lack of action on the part of governments in the area of life-skills education. "One of the easiest and most fundamental things that needs to be done is sex education in schools and not being afraid to talk about issues relating to HIV," she commented. South Africa has significantly more resources available for education and awareness campaigns than most other sub-Saharan countries and, according to figures in its progress report, young people are much better informed about how to prevent HIV infection than elsewhere. But this is not reflected in a correspondingly high use of condoms: only 53 percent of people aged 15-24 reported using a condom the last time they had sex with a non-regular partner. Msimang pointed out that although governments acknowledged the need for condoms, most still lacked condom distribution plans. Dumisani Rebombo, who coordinates male-focused prevention programmes for EngenderHealth, an international reproductive health NGO, does not see the problem in South Africa as one of poor distribution. "In Gauteng Province 12 million condoms a month go out, but how many people actually use them? Why do we still have such high incidence?" The difficulty, he concluded, lay with attitude and behaviour change. "It's not enough just to hand condoms out - you have to have a conversation about it, talk about the barriers and how to negotiate with partners. You might distribute fewer, but it's more useful." According to Msimang, persuading people to use condoms with a new or non-regular partner was not the biggest challenge; convincing them to continue using condoms several months into a relationship was the real problem. "Human beings can learn how to behave differently when they see themselves at risk, but when you're in a loving and trusting relationship you don't see yourself as at risk," she said. A national survey published last year by the Human Sciences Research Council (HSRC) of South Africa highlighted this false sense of security as one of the major barriers to prevention. The study found that half the respondents who tested positive for HIV had not considered themselves at risk of infection, and the main reason they gave for this feeling of invulnerability was not consistent condom use, but faithfulness and trust in their partners. "Condoms, in some cases, are seen as a barrier to intimacy," said Pierre Brouard, deputy director of the Centre for the Study of AIDS at the University of Pretoria. "For some couples, dispensing with the condom is seen as an act of commitment and trust." Brouard added that women might want to use a condom but lacked the power to negotiate it. Female condoms give women more control but, despite anecdotal reports about their popularity, they are much more expensive than male condoms and not widely distributed by South Africa's health department. Only 1.2 million female condoms were distributed in 2004, compared to 346 million male condoms. Instituting the fundamental behavioural changes needed to reverse the HIV epidemic was not a job for governments alone, said Brouard. "Governments need to work with key role players in civil society that shape behaviours and attitudes, like churches, schools and clinics. They need to all be on the same page as far as messages go." Both Brouard and Rebombo pointed to the consistent, integrated approach of Uganda's prevention strategy as the key to its success. In contrast, said Brouard, South Africa's leadership has sent out mixed messages about both the seriousness of the epidemic and how to tackle it. The HSRC study measured knowledge of various government-sponsored prevention campaigns in South Africa and found that awareness of them was often patchy. Echoing the lessons learned from Uganda, the study recommended that future prevention programmes adhere to "an overarching communication strategy that is related to the national comprehensive plan". [UNGASS Prevention Commitments 'At a Glance'] [Southern Africa Country Progress reports]