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 Many of the campaigns to reduce HIV in Africa are based on outdated and flawed public health models that while relevant to important health problems, have proven time and time again to be innocuous to HIV and AIDS in Africa.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.
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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