The War on HIV/AIDS in Africa: Why We Are Losing and How We Can Win-Kale Kponee
HIV and AIDS in
Africa have and continue to be a cumbrous problem. Sub-Saharan Africa has the
highest HIV/AIDS incidence and prevalence rates when compared with the rest of the world.
According to the World Health Organization (WHO), Sub-Saharan Africa makes up
69% of all affected HIV individuals in the world (1). In Sub-Saharan Africa
nearly 1 in every 20 adults is living with HIV. “Sub-Saharan Africa contains
about 10% of the world's population, yet, in 2001, accounted for over
two-thirds of the 40 million people living with HIV; had 68% of incident HIV
infections and 77% of AIDS deaths; and accounted for more than 90% of AIDS
orphans and children infected with HIV” (67). In an attempt to address many of the HIV related problems in
Africa, Health Organizations such as WHO and UNICEF have attempted to find
clinical mechanisms that seek to reduce both the incidence and prevalence of
HIV and AIDS in Africa.
While the efforts
by many western-based organizations can be applauded for their persistence and
perceived altruism; they fail to ameliorate the problem of HIV in Africa, which
continues to proliferate uncontrollably. In comparison to other western and
developed nations around the world, HIV/AIDS in Africa continues to persist at
an alarming rate. A BBC UK news article reported that in 2009, there was an
estimated 85,000 people living with HIV in the United Kingdom, while affected
African countries like Botswana, Swaziland and Zimbabwe had 1/3 of their population
living with the virus (3). These statistics reflect the unquestionable
disparity of HIV incidence and prevalence rates between the West and Africa.
Although this disparity can be explained partially by economic differences; it
does not explain how England has a lower prevalence of HIV and only spends 2.9
million pounds on HIV prevention each year, while in 2008 15.6 billion pounds
were spent on HIV/Aids prevention in developing countries around the world and
mostly in Africa (478). Despite the vast amount of money invested in public
health interventions to resolve the HIV/AIDS crisis, sub-Saharan continues to
have significantly higher prevalence and incidence rates of HIV infections.
Many of the
failures to resolve the issue can be explained by the erroneous way in which
HIV/AIDs in Africa has been approached. Many of the campaigns to reduce HIV in
Africa are based on outdated and flawed public health models that while
relevant to important health problems, have proven time and time again to be
innocuous to HIV and AIDS in Africa. Efforts to reduce HIV/AIDS in Africa
continue to prove disastrous because they are designed as a “one-size fits all”
solution designed to “treat instead of prevent”, and are spearheaded by
outsiders who lack an in-depth socio-cultural perspective on the vast diversity
that is Africa.
Over-emphasis
on Treatment and Under-emphasis on Prevention in Africa
Bunnell et al. comment that “The
enormous human tragedy represented by more than 2.4 million deaths and 3.2 million incident HIV infections
in sub-Saharan Africa in 2005 highlights the inadequacy of current HIV
prevention efforts in Africa”(856) . A major reason for the failure on the war
on HIV/AIDs in Africa has been the unyielding adoption of treatment over
prevention. Well-meaning health organizations have focused on therapeutic
rather than preventive techniques in Africa. While these techniques have helped
to prolong the life of many individuals affected by HIV in the region, it does
nothing to stop the incidence of HIV in Africa. De Cock et al. note that “the
public health approach of targeted testing and follow-up investigation, typical
of tuberculosis and sexually transmitted disease control, was deemed
inappropriate, and public health and human rights were portrayed as polarized
and even conflicting”(68). Although some of the historical approaches that were
once utilized when dealing with HIV have been rooted out in more industrialized
countries; they remain in Africa. HIV/AIDs in Africa still remain a stigmatized
topic, in which the policy is to “treat” rather than “discuss”.
The
treatment rather than prevention of HIV/AIDS in Africa turns the battle against
of the disease into a defensive rather than offensive one. Well-meaning
organizations like UNICEF are attempting to reduce the mortality of HIV in
Africa by setting up treatment centers geared towards treating mothers infected
with HIV and also towards preventing mother-to-child transmission on HIV(2). The problem with this approach is that
there is not enough focus on preventing behaviors that can obviate treatment of
HIV; rather there is more focus on trying to resolve HIV after it has already
occurred. Recent statistics reveal that 29.2 percent of young pregnant women
are HIV positive, and that young women between the ages of 15 and 19 are the
fastest growing age group for new infections (57).
HIV/AIDS in
Africa has been approached from a clinical perspective rather than from a
preventative and public health perspective. Many of the organizations present
in try to prolong the survival rate of individuals affect with HIV/AIDS instead
of trying to prevent the phenomenon in the first place. There is little emphasis on finding ways
to address the socio-cultural and environmental factors that play into the
development of the disease, rather many efforts in Sub-Saharan Africa as a
whole focus prescribing instead of preventing. This approach of treatment over
prevention is problematic because it doesn’t reduce the incidence of HIV/AIDS
in Africa; rather it perpetuates the disparities of HIV/AIDS in Africa.
Reliance
on Flawed Individualized Public health Models
One of the public
health models that are applied to treat HIV/AIDS in African countries is the
health belief model. This model is based on the assumption that “health and
health related behaviors are predicated on an individual’s ability to acclimate
to the Eurocentric value system of health” (247). Treatment centers built by
UNICEF and other health organizations assume that all mothers individually want
to seek help and prevent transmission of HIV to their children. They assume
that this intention will drive mothers to come to the treatment centers and get
the help that they need, without accounting for other barriers that might
prevent access to treatment.
The health belief
model does not account for the fact that African nations may not have the same
access to knowledge about HIV/AIDs as their European counterparts. Friedman
writes that the health belief model is “rational-cognitive model and assumes a
rational decision-maker. Most
adolescents and many adults do not seem to approach the AIDS issue from such a
logical perspective, but seem quite capable of discounting risks and
optimistically perceiving themselves as invulnerable to harm” (101). Many Africans possesses a religiously
ingrained optimistic bias that leads them to think they are immune to harm and
HIV. The health belief model assumes that persons inflicted with AIDs in Africa
will rationally weight the perceived benefits of getting treatment at Centers
in Africa versus the cost and then actively make a decision to seek help. It
does not take into account the optimistic bias problem.
Another flawed
public health model applied to HIV prevention in Africa is the theory of
reasoned action. This theory assumes that individuals are also rational in
their decision making, a presumption that “may not be entirely relevant for
AIDS-related behaviors that are heavily influenced by emotions” (153). Many
individualized health models like the ones described above and others have been
applied to solve the HIV crisis in African nations and have failed countlessly
because they do not acknowledge the irrationality and unpredictability of human
behavior. Also they fail to view the problem of HIV/AIDS from a group perspective
and rather focus on individual behaviors which are counterintuitive to the
collectivist nature of many African countries. Setting up centers to treat rather than prevent the problem,
and assuming that African individuals will seek treatment based on the theories
in many of these euro-centric public health models is flawed. It is flawed
because many health organizations that want to combat HIV/AIDS in Africa base
their solutions on individualized and “rational” public health models that do
not take into account the underlying socio-cultural, environmental, and
behavioral factors that may hinder an individual’s ability to seek help.
One-Size
Fits all Mentality that Hinders Efforts to Incorporate Population-Based Health
Models.
“Approaches
to the prevention and control of the HIV/AIDS epidemic in Africa have been
heavily based on early experiences and policies from industrialized countries,
where the disease affects specific risk groups. HIV/AIDS has been dealt with
differently from other sexually transmitted or lethal infectious diseases,
despite being Africa's leading cause of death” (1125). These approaches that
are tailored to fit the experiences of industrialized countries do not account
for the diversity of Africa or the different social norms and values in African
countries. The public health attempt to prevent HIV/AIDS in African countries
does not incorporate specific theories that can motivate African inhabitants to
change the way they view HIV/AIDS. In addition to that, many public health interventions
that seek to reduce the incidence of HIV/AIDS in Sub-Saharan Africa do not take
into account the uniqueness of different cultures in many African countries.
Public
health interventions in Africa must be tailored to the specific needs of different
countries in Africa. To actualize these, it is important to treat HIV/AIDS in
African countries by a case by case method. Estimates of the yearly number of
new HIV infections and HIV incidence rate show that there are 100,000 or more
cases each year in African countries like Nigeria, Tanzania, Mozambique, and
South Africa; while there are 1,000-10,000 new cases a year in other African
countries like Rwanda, Somalia, Senegal, Benin and Burkina Faso (478). The
diversity of incidence rates in these and many other African countries suggests
that there are different factors at play in these countries that can explain
the irregularity in incidence rates. These irregularities exemplify the fact
that HIV prevention in Africa cannot be generalized.
Much
of the public health interventions employed in Africa to combat HIV/AIDS treat
Africa as a country instead of a continent with different views. This “one-size
fits all” mentality is the cause of the high prevalence and incidence of HIV in
the African continent, and the inconsistent results around the continent. While
countries like Uganda have lowered the incidence and Prevalence of HIV/AIDS in
their citizens, through condom education and de-stigmatization of sex, other
countries in have while employing those same methods have not been as
successful (340). This is simply due to the fact that there are many cultural
and religious differences between African countries. African countries are
influenced by the cultural and religious beliefs of their society. These beliefs
are reflected in many of the behaviors actualized, especially when dealing with
attitudes towards sex and HIV. Public health interventions against AIDS/HIV in
Africa do not work because they fail to recognize the cultural differences
between African nations.
Many of the
public health interventions that have been applied to preventing HIV/AIDS in
Africa have lacked the cultural relativism needed to be able to effect change
that could be administered through population-based health models. A lack of knowledge
about different socio-cultural norms in many African countries has prevented public
health interventions from using population-based public health models and
theories that require in-depth knowledge about the population that it is trying
to affect. Population-Based health
models such as the Diffusion of Innovation Theory, Agenda Setting Theory,
Marketing Theory and Advertising theory could be applied to HIV/AIDS in Africa
(54) if public health practitioners took the time to learn about the dynamic and
nuances between Africa countries.
The inability to apply these theories to
fighting HIV/AIDS in Africa is big reason why prevention efforts haven’t been
as successful in Africa when compared to other European countries. Theories
like the Diffusion of Innovation Theory require that there is concrete
knowledge about what a specific population is doing over time; when this
knowledge is acquired public health interventions can be applied based on
knowledge on what appeals to that specific African population (42). Many of
these group based public health models require that the scope of public health
intervention in Africa acknowledges the irrationality of specific African
populations, the group mentality of different African countries, and the social
and cultural norms of each population. What is normative in South Africa may
not be normative in Nigeria and it is extremely important that public health
interventions are applied with this knowledge in mind. A lack of acculturation
to distinct African cultures by Public Health Practitioners hinders progress in
the war against HIV/AIDS in Africa.
My
Public Health Intervention
To
combat HIV/AIDs in Africa a continent wide world campaign must be implemented
to resolve the problem. My proposal involves teaming up with the African Union
to garner funds that would start a “United for Survival” Campaign in all of
Africa. The campaign would be made “by Africans and for Africans”, creating a
sense of familiarity and solidarity with the population we are trying to
affect. This Campaign would focus on 2 key elements in the war against HIV/AIDS
in Africa. There would be a portion of funds that would strictly be reserved
for emphasis on prevention of HIV/AIDs that would be tailored to fit the needs of
different African countries. This budget for prevention would focus on using
group level health models, advertising theories, and socio-cultural relativism
to reach citizens in Africa and attempt to curb the incidence of HIV in Africa.
The “United for Survival” campaign against AIDS in Africa would tap into
Africa’s sense of pride, unity and struggle. Prevention efforts in different
countries would be focused on reaching out to the distinct populations that
were at highest risk. It would focus on the de-stigmatization of previous
ideologies about sex and empowering African populations with the autonomy and
freedom to pave their own future.
The campaign would become a brand that each separate country would
recognize as a testament to Africa’s perseverance and ability to survive
against HIV/AIDS.
The other portion of the funds would be
reserved for the screening and treatment of HIV/AIDs in high risk populations.
These screening efforts would be unique to the needs of the distinct African
countries and would be geared to first targeting the highest risk populations
in specific countries. Treatment centers would be mobile and stationary. The
mobility of these treatment centers would ensure that rural populations are
being reached, and that the screening centers are visible enough to stimulate
discussions and actions among the people. Overall the “United for Survival”
Campaign would combat HIV/AIDs in sub-Saharan Africa by using prevention models
that utilized efficient Public Health models and advertising theories,
addressing the distinct treatment needs of specific African countries, and
uniting the continent as a whole in the fight against HIV/AIDs.
Primary
Emphasis on Prevention
Unlike
many of the flawed public health interventions in Africa that focused primarily
on treatment; the “United for Survival” campaign would focus primarily on the
prevention of the disease in the first place. This “prevention first” mentality
would be successful because it attempts to decimate HIV from its root and it
also takes an offensive rather than defensive stance against the disease. Prevention
over treatment is a superior method that has been proven to be effective
numerous times. An example of the effectiveness of HIV/AIDs prevention is the
decline of the incidence of HIV among youth in South Africa (2). Before serious prevention efforts in
South Africa, new HIV infections had reached a peak of 1,000 with nearly 1,000
deaths from AIDS every day. Also, around 5.2 million South Africans were living
with HIV, the highest number of any country in the world (3). After serious
intervention efforts by the government that focused primarily on prevention
through youth campaigns and education, the HIV prevalence in children fell from
5.6 percent to 2.5 percent, and the incidence of HIV among youth was halved (2).
The prevention efforts against HIV/AIDs were responsible for the drop in
incidence and prevalence rates in high-risk populations in South Africa.
Mead
writes that “AIDs treatment alone will not materially slow the spread of HIV
infection. Indeed, unless prevention efforts are strengthened, the commitment
to universal access will become more expensive with every passing year, as new
infected AIDS patients become eligible for medication and are added unto those
that are already using it” (7). The
“United for Survival” campaign will be more successful because it taps into the
knowledge of Mead and other researchers when trying to approach the heavy
burden of reducing the prevalence and incidence of HIV/AIDS in Africa. This
prevention over treatment approach in our campaign is important because it is
backed by research and studies that conclude that treatment alone cannot
eliminate HIV/AIDs in Africa.
The fact that our campaign has a strong
emphasis on prevention makes our efforts more efficient for HIV/AIDs in Africa
because it shifts our focus to education and empowerment. More developed
and rich western nations like the UK have been successfully in blockading the
rise of HIV in their nations because they have chosen to treat it as public
health concern. When asked while HIV/AIDS prevention was successful in the UK,
Norman Fowler the then health and social security officer responded by saying;
“"We did it in an extremely pragmatic way, we treated it as a public
health issue” (1). Whereas as other public health
interventions like UNICEF focus on the treatment of pregnant women and mothers
infected with HIV/AIDS; the “United for Survival” campaign takes that effort
one step further by focusing on the education and prevention of the disease in
those populations in the first place. By doing this the campaign is empowering
affected populations as well as prolonging quality of life by preventing the
disease from occurring at all.
Utilization
of Irrational, Group- based Public Health Models
Many
of the public health interventions that have been attempted in Africa have been
flawed because they are still utilizing Eurocentric individual public health models.
Our campaign will be effective because those models are not utilized at all.
Instead of utilizing individualized public health models that are too linear
and heavily based on the assumption that behavior is rational (31); our
campaign uses models that account for the irrationality of humans and more
specifically Africans. The “United for Survival” campaign focuses on using
alternative models that take advantage of irrational health behaviors.
My campaign uses
group model theories like the Diffusion of innovation theory to effect change
on a population based model. The Diffusion of innovation theory is effective
because it includes communication channels than can diffuse new ideas and
effectively change the mentality of an entire population (6). In terms of
HIV/AIDs, our campaign utilizes the diffusion of innovations theory to spread
knowledge about HIV/AIDS prevention in a contextual way that spreads and grabs
the interests of the populations in Africa. This theory is important because
graphically, it understands the irrationality of human behavior from a group
level and gives public health practitioners the ability to insert new
prevention techniques that are grounded in the diffusion of innovations
framework (18).
Another
group-level public health model that our campaign uses is advertising theory in
our prevention efforts. Our campaign against AIDs is grounded on the promise
that we can give Africans everywhere autonomy and control over HIV/AIDS. The
campaign uses advertising theory to advertise that victory over HIV/AIDS will
lead to health, longevity, and happiness. This approach is important and
effective because we are tapping into the core values of African countries
everywhere and we are using advertising theory to promise change through the
eradication of HIV/AIDS. The campaign uses advertising theory to make a large
promise that is backed up with imagery of freedom, unity, and life. Using advertising is important because
evidence has shown that it appeals to the deeper to the needs and desires of
the consumer and when applied properly can get a consumer to purchase any idea
(52). This campaign utilizes advertising theory to appeal to the core values of
Africans in distinct countries, and by doing so gets them on board with the
fight against HIV/AIDs. Advertising theory allows us to use what Africans care
about the most, to do what they need the most to survive: fighting HIV/AIDs.
Our
campaign also uses the social expectations/social norms theory. This theory is
based on the belief that you can you can create massive change dramatically on
a mass level simply by changing social norms (8). The campaign uses this theory
by tapping into the culture values of specific African countries and then
effecting change by changing the social norms of that specific country. Using
group based theories have been successful in Africa countries like South Africa
where a new campaign was started to reach out to the youth using target
theories using this theory. This theory tapped into the social expectations of
sex in youth in South Africa and changed their mindset by instilling the
beliefs that condoms and open discussions were important for the de-stigmatization
of sex and of HIV/AIDs. The campaign taught youth to value a bright future and
an education over unprotected sex and fleeting pleasure. This utilization of
the Social Expectations/Social Norms theory of that campaign in South Africa
has played a role in the reduction in the incidence of HIV among the youth (9).
Utilizing
group based health models in our techniques will prove more successful because
it is predicated on the fundamental assumption that humans are irrational, have
deeply ingrained desires, and are motivated to action through their social
norms/expectations. Our campaign uses these group health models to channel
these assumptions into a viable HIV intervention tactic that effectively
instills knowledge about HIV prevention in the minds of citizens in African
countries.
Use of Cultural
Relativism Tailored to Impact Distinct African Countries
The “United for Survival”
campaign is superior to previous public health interventions because it does
not treat Africa as one big country, but rather as a large continent with
distinct cultural norms and values. The social norms in Nigeria are not the
same as the social norms in Ethiopia; therefore the campaign applies the Social
Expectations or Social norms theory in Nigeria differently than it would in
Ethiopia. By doing this our campaign is eliminating the “one-size” fits all
mentality that has previously been used in HIV/AIDs interventions in the past. Previous
studies have shown that when the same HIV preventions that worked well in
countries like Uganda have been applied to other African countries; they are
not as successful (1147). This is because many of these interventions lack the
cultural relativism to acknowledge the uniqueness of different countries in
Africa.
The “United for
Survival” campaign is different in that it utilizes knowledge about distinct
social norms in different African countries to instill prevention techniques. The
campaign is funded in such a way that separate countries are given funding and
are encouraged to use these funding to tackle the needs of their population. An
example would be Nigeria using celebrities to spread the word about HIV/AIDs in
their country, while Botswana might utilize bill boards and television ads to
do the same thing. Another way in which our campaign adapts to the social
behavior in different countries is that it may approach a country that has
higher incidence of rape and violence different than it would approach another
country with higher mother to child HIV transmissions. The key here is that the
campaign is tailored to fit the needs of specific African countries, and by
doing that it ensures that our overall outcome of reducing HIV/AIDs in
sub-Saharan Africa is met.
Conclusion
The
War against HIV/AIDs has been unsuccessful in the past because of the
application of outdated methods and approaches. In the past HIV/AIDs in Africa
has focused primarily on treatment, individualized public health models, and
“one-size fits all” methodologies that have proved ineffective. These
approaches have been the reason why the incidence and prevalence rates of
HIV/AIDs in Africa continue to spiral out of control and lead to preventable
deaths. For HIV prevention to be successful in Africa it is important that
there is more emphasis on prevention, utilization on irrational group-centered
public health models, and distinct approaches for different countries that
incorporate cultural relativism. These methods are important because they rely heavily
on an in-depth knowledge of values and beliefs of the population we are trying
to impact and the irrationality of behavior in said population. Through these
methods we can ensure a significant reduction in the incidence and prevalence
of HIV/AIDs in Africa as a whole. To start the journey of resolving HIV/AIDs in
Africa it is important that we eradicated outdated models and adopt novel ways
of dealing with the problem so that we can change the rates of AIDS/HIV in
Africa.
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Labels: Cultural Issues, Green, HIV/AIDS
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