Evaluation of HIV/AIDS Communication Campaigns: The importance of critique

1. Evaluation of HIV/AIDS Communication Campaigns: The importance of critique Centre for AIDS Development, Research and Evaluation www.cadre.org.zaWarren Parker • warren@cadre.org.za

2. HIV/AIDS Campaigns • HIV/AIDS campaigns are formal organised activities, typically utilising various forms of communication to achieve objectives related to prevention, care, treatment, support and rights • There are hundreds of campaigns operating at national and sub-national level in South Africa • National campaigns incorporating programmatic activities include Khomanani, Soul City, Soul Buddyz, loveLife, the school-based life-skills programme, TAC, condom social marketing • Educational programmes – Tsha Tsha, Gazlam, Beat It • Focused campaigns around condoms, STIs, VCT, TB

3. HIV/AIDS Campaigns • Sub-national campaigns include activities of provincial and local governments, NGOs, community-based organisations, sectoral organisations (eg. Workplaces, faith-based organisations), etc • HIV/AIDS communication also occurs outside the domain of formal campaigns and is influenced by• News, features, documentaries, talk-shows• Interpersonal communication• Knowing people who are living with HIV or who have died of AIDS• Being directly affected by HIV/AIDS (eg. Living with HIV, family affected, orphaning)

4. Have campaigns worked?

5. Yes… For example: • Progressive increase in reported last intercourse condom use• 1998, DHS, females, 15-19, 21.2% (unmarried partner)• 2000, BAC, males and females, 15-30, 52%• 2002, NM/HSRC, females 15-24, 46.1%; males, 57.1%• 2003, RHRU, females 15-19, 55%; males, 57% • Increase in perceived ease of access• 2000, BAC, males and females 15-30, 75%• 2002, NM/HSRC, males and females, 15-24, 95% • Increased public sector procurement • Demand-based logistics system, widespread access (including commercial and social marketing availability) • Quality control of product

6. Why… • Cumulative effect of campaigns over past decade • Cumulative effects of social and individual responses in the context of a growing epidemic • Normalisation / social acceptance of condoms • Progressive improvements in public sector condom quality control • Progressive improvements in condom distribution • Demand-based logistical system • Increased annual budgets and procurement Successful as a result of the interplay between• Multiple and sustained campaigns• Quality of product/resource• Efficiency of service/system• Sustainability (budget)

7. But… Why is prevalence increasing? • HIV prevention through condom use is only one prevention strategy – insufficient on its own • Perceptions of availability, and reported use are high butimpact may be reduced as a result of• inconsistency of use• incorrect use – when to put condom on – what to do if breakage – causes of breakage• lack of use in high risk contexts – sex work, truck driving – lesser availability in under-serviced contexts - informal settlements, rural areas• limited locus of control (gender, economic, institutional, coercion, violence) • Further research is needed to build on successes and consolidate condom promotion as a strategy

8. What about HIV prevention campaigns targeting youth?

9. Well… • Youth focus has been based on assumptions that:– Youth prevalence drives adult prevalence– Controlling youth prevalence has a positive ‘knock-on’ effect on individual HIV risk later on in life– HIV prevalence amongst youth can be rapidly reduced through intensive campaigns • Most campaigns in South Africa include a youth prevention focus– massive budgets allocated to youth HIV prevention by government and through funders including Global Fund, bilateral agencies, foundations– great deal of overlap, but little co-ordination • Campaign evaluations show some impact on knowledge, attitude and behaviour indicators…

10. But… • Youth antenatal prevalence has remained much the same over the past four years • Population-based studies show high prevalence, and disproportional effects on young females (RHRU 2004)Males 15-19, 2.5%Females 15-19, 7.3%Males 20-24, 7.6%Females 20-24, 24.5% • Teen pregnancyrates have increased, eg.15-19, DHS 1998,RHRU 2004

11. And… • HIV prevalence in young adults and adults escalates rapidly from early 20s (NM/HSRC 2002) – little apparent ‘knock-on’ effect.

12. Can campaigns actually make a difference to youth prevalence?

13. Points to consider… • Campaigns are mainly about promoting knowledge and awareness– Communication should be focused, clear and simple– Little evidence that indirect focus on ‘consumerism’, ‘aspiration’ and ‘healthy lifestyle’ amongst youth will lead to sexual risk reduction • Rational volitional model of sex is problematic– Sexual relationships are relative to partner dynamics– Risk may be influenced by physical power [male/female], cultural power [age/gender], economic power [poverty/reification of consumption], abuses of institutional power [schools]– Sex includes emotional and irrational elements • Prevention should not be separated from the continuum of treatment, care, support and rights– Integrated approaches incorporating community-level mobilisation, eg. Gay community response in US, community-level response in Uganda– support services important

14. What’s missing? • Lack of direct focus on communication about key epidemiological drivers– Early sexual debut– Age differentials between partners– Multiple partners– Coercion (as a product of power differentials)– Violence (rape, statutory rape) • Lack of focus on youth risk as a product of vulnerability:– Specific risks to young females– Children affected by HIV/AIDS in their families (orphaning)– Poor promotion of grants and assistance to vulnerable youth– Inadequate promotion of rights and legal framework– Little emphasis on young PLHA

15. Where to from here?

16. Expand prevention focus… • Epidemiological drivers affecting all age groups– Children under 14– Young adults and adults 25-35 – Older adults (50+) • Contexts of risk • mobility in the context of work (eg. Truck driving) • labour migration and workseeking (feminisation of migration), informal settlement • Sex workers, gay men, IDU (emerging) • A focus on PLHA is virtually absent

17. Extend focus… • Address information needs along the continuum– ‘Treatment seeking’, STI, PMTCT, PEP, TB, ARV – universal precautions overlooked– ’Support seeking’, counselling, VCT, grants– Care including palliative care– Support to PLHA, affected families, orphans– Legal recourse in relation to law and rights

18. A coherent approach… • There is an urgent need to develop an overarching strategy that sets the agenda for campaigns. This strategy should:– Address overlap and improve co-ordination between campaigns– Focus intensively in key areas– Use research to inform campaigns– Ensure accountability of campaigns to national indicators • The broader context should also be taken into account– Resource and service environment • Formal health system • NGOs and CBOs with HIV/AIDS focus • Civil society organisations • Businesses • Social mobilisation and grassroots response– Political environment– Macro-economic system

19. Our actions count…