This article was downloaded by: [University of Leeds] On: 05 February 2015, At: 05:47 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
HIV/AIDS in Africa a
D. Wilson & S. Lavelle
a
a
Department of Psychology , University of Zimbabwe , PO Box MP 167, Harare, Zimbabwe Published online: 25 Sep 2007.
To cite this article: D. Wilson & S. Lavelle (1990) HIV/AIDS in Africa, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 2:4, 371-375, DOI: 10.1080/09540129008257756 To link to this article: http://dx.doi.org/10.1080/09540129008257756
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
371
AIDS CARE, VOL. 2, NO.4,1990
HIWAIDS in Africa D. WILSON& S. LAVELLE
Downloaded by [University of Leeds] at 05:47 05 February 2015
Department of Psychology, University of Zimbabwe, PO Box MP 167, Harare, Zimbabwe
Introduction The VIth International AIDS Conference presented starkly different prospects for rich and poor countries. In the former, those with access to health services may receive an increasing array of effective treatments (Delaney, F.plenary presentation; Fischl, Th.plenary presentation), increased length and quahty of life (Hessol et al., ThC33; ThC621; Volberding et al., ThB17) and the possibility of a vaccine t h ~ sdecade (Berzofsky, F-plenary presentation; Clerici et ul., ThA332; Koff et al., ThA330). The latter, whether in Africa (De Cock et al., FC103; Kamenga et ul., ThD127; Katabira. F.plenary presentation; Kiereini, W.plenary presentation; Ntaba, S.plenary presentation), Asia (Bhargava et al., SD50; Bhimani et d., ThDll7; Thanprasertsuk, FC99) or Latin America (Chequer et al., ThC40; OmelasHall, Th.plenary presentation), face uncertain access to limited care, destitution and the apparently inexorable march of HIV through their communities. As Jonathan Mann reiterated inside (Splenary presentation) and outside the conference halls, the greatest challenge facing AIDS workers is to ensure that the scientific advances reported or in sight reach all who need them. Promoting this objective is as necessary a task for AIDS workers as promoting behavioural risk reduction. The following review s w e y s work either from, or germane to, AIDS prevention
in Africa. Campbell covers counselling and care elsewhere in this volume.
Epidemiological research with implications for intervention This conference was spared the numbing sero-epidemiologies of urban, convenience, samples presented at the Marseilles IVth AIDS in Afnca Confmence. However, the HIV epidemic is poorly understood in many rural areas in Africa and the San Francisco meeting shed little further light here. There were numerous transmission dynamics studies, which, in general, confirmed the association of non-circumcision and ulcerative STDs with HIV transmission, but, more decisively than before, implicated non-ulcerative STDs as co-factors (Bassett et al., ThC581; Bulterys et al., ThC576; C h pangwi ef al., ThC98; Duerr ef al., ThC575; Laga et al., ThC97; Moss et al., ThC750; Nzila et al., ThC579; O’Farrell et al., FC604; Plourde, ThC571; Serwadda et al., FC100; Zeking et al., FC598). These data have clear implications for interventions. Attempts to interfere with HIV transmissibility by controlling STDs should focus on several STDs, not just ulcerative ones. Similarly, efforts to select those STD patients who most need intensive HIV prevention counselling should not focus exclusively on ulcers. An intact foreskm was implicated as an
Downloaded by [University of Leeds] at 05:47 05 February 2015
372
S A N FRANCISCO SUMMARIES: D.WILSON & S. LAVELLE
based activities was underscored by a French survey (FD847), which found that the massmedia can impart factual information, but interpersonal communication has greater impact on behaviour. Sherr (SC688) also reported that health advertising, a pillar of mass media campaigns, increased awareness, but had little effect on behaviour, among British drug users and members of the general population. Zambia’s Chikankata hospital remains a model for community-based activity and their presentations focused on home-based, paediatric care (Chela et al., FB479), the use of volunteer educators and care-givers (Mwilu et al., FD780), the role of the church in AIDS work (Campbell et al., ThD818) and overcoming impediments to the implementation of community-based projects (sexual Rader er al., FD783). A singular feature of this groups’ work was a willingness to draw on their rich, programmatic experience and cogent qualitative insights, without KABP props. Several other community programmes are discussed in Mass media and complementary various categories below. community programma Television and video may seem massAfrican AIDS prevention activities, initiated media approaches. However, because of their by governments in a region where few in- rarity in Africa, they are keenly anticipated, digenous PVOs exist, lean heavily on mass viewed communally, often with vociferous media approaches (Rukarangira et al., audience involvement, and animatedly disFD844). A Zimbabwean study of adolescent cussed afterwards-which makes them an condom use argued that the predictors of ideal focal point for community-based intended condom use identified in their re- group, activities. A Zairean study (Kyungu search (belief in the efficacy of condoms, et d., FD846) reported widespread viewing having talked about AIDS with a partner, and retention of televised AIDS information friend or teacher, lack of anxiety about up- among Kinshasa adults. In Kigali, Rwanda, setting one’s partner by suggesting condoms AIDS knowledge and intention to adapt and perceived normative support for con- HIV-preventive practices increased markdom use) could best be modified using com- edly after exposure to an AIDS education munity-based, small-group, face-to-face, video (ThD781). However, the value of this participative, approaches. The presenters medium is vitiated by the exiguity of suitnoted that, while lip-service is unswervingly able material. Thus, Stone et d ’ s (ThD906) paid to community work, few funds ever description of a meticulously developed, reach communities lrectly and it remains dramatic film on AIDS for Ugandan workeasier to secure funding for outside, ‘expert’, places, by Riber, the producer of the repersonnel or IEC materials than for tran- spected teenage pregnancy film, Consesport or part-time salaries for community quences, was welcome. One quibble: a focus educators (Wilson et al., ThD53). The ur- beyond the workplace might have been pregent need for complementary, community- ferable for a trailblazing production in a
HIV risk factor at the Washington IIIsd Intnnational AIDS Conference 3 years ago, with many odds-ratios reported then or since far exceeding those associated with behavioural interventions, yet there have apparently been no anthropological studies of cultural attitudes or obstacles to infant circumcision, nor attempts to introduce it as a long-term preventive measure. While circumcision arouses fierce e h c feeling in Kenya, It seems to be regarded largely with indifference in central and southern Africa, where its promotion is arguably warranted. This raises larger questions about the practical utilization of research. Dallabetta (ThC574) reported that 9% of primiparous and 15% of multiparous women had used vaginal tightening agents in the last 3 years and that one agent, stones, increase susceptibility to HIV. This practice must be urgently addressed by researchers and interventionists.
AIDSINAFRICA
country and region with so few adults in formal employment. Nonetheless, this drama will admirably complement Born in Africa, the superb documentary on the late Ugandan musician, PWA and hero, Philly Lutaya. A generic African AIDS video has also been commissioned by AIDSTECH.
Downloaded by [University of Leeds] at 05:47 05 February 2015
Condoms
373
Prevention forwomen The female condom and anti-viral spermicides are the only preventive measures directly controlled by women. Evidence showing the female condom to be an effective and acceptable barrier to the exchange of sexual fluids was presented (Leeper, SC758). Field trials are urgently required in Africa, where female subordination and male resistance to condoms underpin desperate need for a female condom. However, given it’s likely cost, its utility in Africa is likely to hinge on whether it is safely re-usable-which it apparently was not intended to be. Discouraging data were presented for nonoxynol-9. A Rwandan study found it to be ineffective against HIV (Allen et al., SC35) and a sample of Canadian prostitutes reported vaginal irritation and inflammation during intercourse and oral side effects including burning and stomach cramps during oral sex when nOnO~ynOl-9lubricated condoms were used (Rekart et al., SC36).
Remarkable strides have been made in the distribution of subsidized, (with partial cost recovery) condoms among several groups in Kinshasa and other regions of Zaire (Ferroros et al., SC697; Payanzo et al., ThD782; Payanzo et al., ThD783; Spilsbury, SC696), where condom sales rose from 935,515 in 1988 to 4,140,000 in 1989, an increase of 443%. A similar cost recovery programme is underway in Tanzania (Strand et d.,FD60). However, notwithstanding increased sales in Zaire, condom use remains low. It would also be helpful to know the estimated number of condoms used by different groups each month, the cost of a condom in relation to the minimum wage, Focused interventions the cost of a loaf of bread, or a prostitute’s fee, the time period for which price stability RoninCtes is assured and whether withdrawal of subsidies is envisaged. Cost recovery cannot en- Little work on prostitute interventions was sure a self-sustained programme, since costs presented presumably because these are are recovered in local currency and condoms established, long-term, programmes, which must be procured in foreign exchange, which have been described before. Interventions most African countries desperately lack. for prostitutes were published from Kenya (Similar problems beset free services, such (Ngugi et al., 3033) and presented from as Zimbabwe’s, which face burgeoning de- Nigeria (Williams et al., SC717). The latter mands for condoms to prevent STDs.) The drew upon fertile programmatic experiences quality of condoms supplied to Africa (both and insights-a focus Wrely to be developed ex-factory and after storage), a subject of further at the forthcoming Kinshasa Vth frequent complaint, was not addressed. Since AIDS in Aj%a meeting. Moses et al., latex condoms may degrade in tropical Afri- (FD837) estimated that an intervention for can temperatures, great hopes rest on plastic 1,OOO prostitutes in Pumwani, Nairobi, precondoms, which are presently being tested vents 12,OOO HIV infections annually, at a cost of U S 6 per infection prevented, which by Family Health International. Unexpectedly high and sustained rates is highly cost-effective. Eke ((SC718) reof condom use were reported among discor- ported that role plays were useful in promotdant couples in Rwanda (Tice et al., SC694) ing behaviour change in a small sample of .Kinshasa prostitutes. Corby et al. (SC714) and Zaire (Jingu et al., SC695).
374
SAN FRANCISCO SUMMARIES: D.WILSON & S. UVELLE
presented quasi-experimental evidence of the effectiveness of including condom use and skills training in HIV-prevention counselling among Californian prostitutes. Those working with prostitutes should note disturbing reports of police in Brazil and the U.S.A. identifying street-kids and prostitutes from possession of condoms or bleach and harassing them (Clay et al., ThD780; Luna et al., SC573).
Downloaded by [University of Leeds] at 05:47 05 February 2015
STD patients There is consensus that HIV-prevention counselling for STD patients is (a) essential and (b) difficult to do effectively, as the recidivism rate attests. In Africa, the problem is compounded by the lack of proper clinics in many areas and by the insupportable ratio of health staff to patients where affordable treatment exists. Regrettably, no detailed approaches to this vexed issue were presented, but Cohen et al. (SC678) reported that STD patients exposed to two group-based interventions recorded 50% and 65% fewer reinfections than controls who received individual counselling. Groupbased, sUs-orientated, participative, approaches, which have proved effective in many different contexts, should be examined in African STD clinics. If they show promises, the challenge will be to train health staff to lead such groups.
Adolescents
Despite the early onset of sexual activity re’ported (Dupree et al., ThD858; Kapiga et al., SC45; Matondo, FC749; Ouedruoga et al., FC595; Wilson et al., ThD53), few comprehensive school programmes were described. An exception was Malwi (Dupree et al., ThD858), where, with government support, multisectoral support was secured, focus groups were held with pupils, parents and teachers and materials, including teacher’s guides and student handbooks, were developed and pre-tested. Teachers will be
trained to teach others, so that all 3,000 Malawian public sector teachers will be able to teach, answer pupils’ questions or refer the pupils appropriately. Kambamba et al. (FD910) inserted AIDS education messages-derived from attitudinal research-in notebooks that Zairean pupils buy at subsidized prices. In South Africa, where the numbers with HIV are doubling in 6 to 8 months, teachers have been trained to educate ‘mixed race’ pupils about AIDS (Englebrecht et al., 4049) and community educators are used to reach youths outside schools (Greathead et al., 4097; Ramakhula et al., SD62). Despite these efforts, it seems that a minority of African countries have comprehensive national programmes for adolescents.
Workplace programmes Rwakagiri et al. (ThD212) outlined a programme, conducted through the Federation of Ugandan Employers, in which trained peer educators distribute condoms and literature in worksites. Long-distance transportation workers were again identified as a vulnerable occupational group, with 23% of a sample of 237 drivers tested near Nairobi, Kenya, seropositive (Omari et al., FC729), but none of the several interventions underway for this group were described in any detail. No prevention activities were presented for another vulnerable occupational category, the uniformed services, for whom the most intensive interventions are direly needed.
Involvement of PWAs Cranston et al. (SC724) reported that interventions involving PWAs had greater impact on attitudes than knowledge or skills-based approaches, but the value of PWA participation was most vividly depicted by Staley of ACT-UP’S stirring address, McKusikick’s moving personal perspectives on AIDS (both W.plenary presentations), and above all, activists outside the convention centres.
AIDSINAFRICA
AIDS is, in so many ways, the affliction of the voiceless and we all-AIDS administrators, doctors, educators, researchers-need PWA activism and participation to keep us accountable. In Africa, following Philly Lutaya’s lead and notwithstanding cultural obstacles, we must recognize the pivotal role of PWAs in AIDS prevention.
Downloaded by [University of Leeds] at 05:47 05 February 2015
Behavioural research There were several KABP surveys (Bomboko et al., FC709; Gerst et al., 4055; Jinadu et al., FD845; Hapigi et al., SC45; Konings et al., 3020; Louis et al., FC732; Matondo et al., FC749; Messou et al., 4124; Moore et al., ThClOS; Musgrave et al., FC607; Ogunyankin et al., FD843; Ojofeitmi et al., FC752; Payanzo et al., ThD782; Payanzo et al., ThD783; Van Dyk et al., SC784), which generally observed that despite reasonable awareness, risk behaviours persist. Several Euro- American researchers reported experimental comparisons of different interventions, which is laudable and deserving of emulation in Africa, but if we are to avoid the pitfalls of decades of psychotherapy re-
375
search, it is vital to specify e x a c t b what each intervention comprises. Ethnographic, qualitative, work, based on participant observation and action research, is imperative and it’s paucity here is lamented. Quantitative approaches cannot provide the answer when we scarcely know what questions to ask to understand the fundamental cultural, interpersonal and psychological forces that shape our approaches to two sexuality and disease.
Conclusions The low ratio of interventions to research, apparent above, is infinitely disturbing. While the boycott, which affected community groups heavily, the 6 month lead time for abstract submission, the emphasis on original reports, with hard data to hand in the calls for abstracts and the natural affinity of research paper and conference medium are doubtless contributory, it is hoped that post San-Francisco activities and the Florence VZZth Znternational AIDS Conference, will emphasize interventions, action research and research linked to interventions.
AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
HIV/AIDS in Africa a
D. Wilson & S. Lavelle
a
a
Department of Psychology , University of Zimbabwe , PO Box MP 167, Harare, Zimbabwe Published online: 25 Sep 2007.
To cite this article: D. Wilson & S. Lavelle (1990) HIV/AIDS in Africa, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 2:4, 371-375, DOI: 10.1080/09540129008257756 To link to this article: http://dx.doi.org/10.1080/09540129008257756
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
371
AIDS CARE, VOL. 2, NO.4,1990
HIWAIDS in Africa D. WILSON& S. LAVELLE
Downloaded by [University of Leeds] at 05:47 05 February 2015
Department of Psychology, University of Zimbabwe, PO Box MP 167, Harare, Zimbabwe
Introduction The VIth International AIDS Conference presented starkly different prospects for rich and poor countries. In the former, those with access to health services may receive an increasing array of effective treatments (Delaney, F.plenary presentation; Fischl, Th.plenary presentation), increased length and quahty of life (Hessol et al., ThC33; ThC621; Volberding et al., ThB17) and the possibility of a vaccine t h ~ sdecade (Berzofsky, F-plenary presentation; Clerici et ul., ThA332; Koff et al., ThA330). The latter, whether in Africa (De Cock et al., FC103; Kamenga et ul., ThD127; Katabira. F.plenary presentation; Kiereini, W.plenary presentation; Ntaba, S.plenary presentation), Asia (Bhargava et al., SD50; Bhimani et d., ThDll7; Thanprasertsuk, FC99) or Latin America (Chequer et al., ThC40; OmelasHall, Th.plenary presentation), face uncertain access to limited care, destitution and the apparently inexorable march of HIV through their communities. As Jonathan Mann reiterated inside (Splenary presentation) and outside the conference halls, the greatest challenge facing AIDS workers is to ensure that the scientific advances reported or in sight reach all who need them. Promoting this objective is as necessary a task for AIDS workers as promoting behavioural risk reduction. The following review s w e y s work either from, or germane to, AIDS prevention
in Africa. Campbell covers counselling and care elsewhere in this volume.
Epidemiological research with implications for intervention This conference was spared the numbing sero-epidemiologies of urban, convenience, samples presented at the Marseilles IVth AIDS in Afnca Confmence. However, the HIV epidemic is poorly understood in many rural areas in Africa and the San Francisco meeting shed little further light here. There were numerous transmission dynamics studies, which, in general, confirmed the association of non-circumcision and ulcerative STDs with HIV transmission, but, more decisively than before, implicated non-ulcerative STDs as co-factors (Bassett et al., ThC581; Bulterys et al., ThC576; C h pangwi ef al., ThC98; Duerr ef al., ThC575; Laga et al., ThC97; Moss et al., ThC750; Nzila et al., ThC579; O’Farrell et al., FC604; Plourde, ThC571; Serwadda et al., FC100; Zeking et al., FC598). These data have clear implications for interventions. Attempts to interfere with HIV transmissibility by controlling STDs should focus on several STDs, not just ulcerative ones. Similarly, efforts to select those STD patients who most need intensive HIV prevention counselling should not focus exclusively on ulcers. An intact foreskm was implicated as an
Downloaded by [University of Leeds] at 05:47 05 February 2015
372
S A N FRANCISCO SUMMARIES: D.WILSON & S. LAVELLE
based activities was underscored by a French survey (FD847), which found that the massmedia can impart factual information, but interpersonal communication has greater impact on behaviour. Sherr (SC688) also reported that health advertising, a pillar of mass media campaigns, increased awareness, but had little effect on behaviour, among British drug users and members of the general population. Zambia’s Chikankata hospital remains a model for community-based activity and their presentations focused on home-based, paediatric care (Chela et al., FB479), the use of volunteer educators and care-givers (Mwilu et al., FD780), the role of the church in AIDS work (Campbell et al., ThD818) and overcoming impediments to the implementation of community-based projects (sexual Rader er al., FD783). A singular feature of this groups’ work was a willingness to draw on their rich, programmatic experience and cogent qualitative insights, without KABP props. Several other community programmes are discussed in Mass media and complementary various categories below. community programma Television and video may seem massAfrican AIDS prevention activities, initiated media approaches. However, because of their by governments in a region where few in- rarity in Africa, they are keenly anticipated, digenous PVOs exist, lean heavily on mass viewed communally, often with vociferous media approaches (Rukarangira et al., audience involvement, and animatedly disFD844). A Zimbabwean study of adolescent cussed afterwards-which makes them an condom use argued that the predictors of ideal focal point for community-based intended condom use identified in their re- group, activities. A Zairean study (Kyungu search (belief in the efficacy of condoms, et d., FD846) reported widespread viewing having talked about AIDS with a partner, and retention of televised AIDS information friend or teacher, lack of anxiety about up- among Kinshasa adults. In Kigali, Rwanda, setting one’s partner by suggesting condoms AIDS knowledge and intention to adapt and perceived normative support for con- HIV-preventive practices increased markdom use) could best be modified using com- edly after exposure to an AIDS education munity-based, small-group, face-to-face, video (ThD781). However, the value of this participative, approaches. The presenters medium is vitiated by the exiguity of suitnoted that, while lip-service is unswervingly able material. Thus, Stone et d ’ s (ThD906) paid to community work, few funds ever description of a meticulously developed, reach communities lrectly and it remains dramatic film on AIDS for Ugandan workeasier to secure funding for outside, ‘expert’, places, by Riber, the producer of the repersonnel or IEC materials than for tran- spected teenage pregnancy film, Consesport or part-time salaries for community quences, was welcome. One quibble: a focus educators (Wilson et al., ThD53). The ur- beyond the workplace might have been pregent need for complementary, community- ferable for a trailblazing production in a
HIV risk factor at the Washington IIIsd Intnnational AIDS Conference 3 years ago, with many odds-ratios reported then or since far exceeding those associated with behavioural interventions, yet there have apparently been no anthropological studies of cultural attitudes or obstacles to infant circumcision, nor attempts to introduce it as a long-term preventive measure. While circumcision arouses fierce e h c feeling in Kenya, It seems to be regarded largely with indifference in central and southern Africa, where its promotion is arguably warranted. This raises larger questions about the practical utilization of research. Dallabetta (ThC574) reported that 9% of primiparous and 15% of multiparous women had used vaginal tightening agents in the last 3 years and that one agent, stones, increase susceptibility to HIV. This practice must be urgently addressed by researchers and interventionists.
AIDSINAFRICA
country and region with so few adults in formal employment. Nonetheless, this drama will admirably complement Born in Africa, the superb documentary on the late Ugandan musician, PWA and hero, Philly Lutaya. A generic African AIDS video has also been commissioned by AIDSTECH.
Downloaded by [University of Leeds] at 05:47 05 February 2015
Condoms
373
Prevention forwomen The female condom and anti-viral spermicides are the only preventive measures directly controlled by women. Evidence showing the female condom to be an effective and acceptable barrier to the exchange of sexual fluids was presented (Leeper, SC758). Field trials are urgently required in Africa, where female subordination and male resistance to condoms underpin desperate need for a female condom. However, given it’s likely cost, its utility in Africa is likely to hinge on whether it is safely re-usable-which it apparently was not intended to be. Discouraging data were presented for nonoxynol-9. A Rwandan study found it to be ineffective against HIV (Allen et al., SC35) and a sample of Canadian prostitutes reported vaginal irritation and inflammation during intercourse and oral side effects including burning and stomach cramps during oral sex when nOnO~ynOl-9lubricated condoms were used (Rekart et al., SC36).
Remarkable strides have been made in the distribution of subsidized, (with partial cost recovery) condoms among several groups in Kinshasa and other regions of Zaire (Ferroros et al., SC697; Payanzo et al., ThD782; Payanzo et al., ThD783; Spilsbury, SC696), where condom sales rose from 935,515 in 1988 to 4,140,000 in 1989, an increase of 443%. A similar cost recovery programme is underway in Tanzania (Strand et d.,FD60). However, notwithstanding increased sales in Zaire, condom use remains low. It would also be helpful to know the estimated number of condoms used by different groups each month, the cost of a condom in relation to the minimum wage, Focused interventions the cost of a loaf of bread, or a prostitute’s fee, the time period for which price stability RoninCtes is assured and whether withdrawal of subsidies is envisaged. Cost recovery cannot en- Little work on prostitute interventions was sure a self-sustained programme, since costs presented presumably because these are are recovered in local currency and condoms established, long-term, programmes, which must be procured in foreign exchange, which have been described before. Interventions most African countries desperately lack. for prostitutes were published from Kenya (Similar problems beset free services, such (Ngugi et al., 3033) and presented from as Zimbabwe’s, which face burgeoning de- Nigeria (Williams et al., SC717). The latter mands for condoms to prevent STDs.) The drew upon fertile programmatic experiences quality of condoms supplied to Africa (both and insights-a focus Wrely to be developed ex-factory and after storage), a subject of further at the forthcoming Kinshasa Vth frequent complaint, was not addressed. Since AIDS in Aj%a meeting. Moses et al., latex condoms may degrade in tropical Afri- (FD837) estimated that an intervention for can temperatures, great hopes rest on plastic 1,OOO prostitutes in Pumwani, Nairobi, precondoms, which are presently being tested vents 12,OOO HIV infections annually, at a cost of U S 6 per infection prevented, which by Family Health International. Unexpectedly high and sustained rates is highly cost-effective. Eke ((SC718) reof condom use were reported among discor- ported that role plays were useful in promotdant couples in Rwanda (Tice et al., SC694) ing behaviour change in a small sample of .Kinshasa prostitutes. Corby et al. (SC714) and Zaire (Jingu et al., SC695).
374
SAN FRANCISCO SUMMARIES: D.WILSON & S. UVELLE
presented quasi-experimental evidence of the effectiveness of including condom use and skills training in HIV-prevention counselling among Californian prostitutes. Those working with prostitutes should note disturbing reports of police in Brazil and the U.S.A. identifying street-kids and prostitutes from possession of condoms or bleach and harassing them (Clay et al., ThD780; Luna et al., SC573).
Downloaded by [University of Leeds] at 05:47 05 February 2015
STD patients There is consensus that HIV-prevention counselling for STD patients is (a) essential and (b) difficult to do effectively, as the recidivism rate attests. In Africa, the problem is compounded by the lack of proper clinics in many areas and by the insupportable ratio of health staff to patients where affordable treatment exists. Regrettably, no detailed approaches to this vexed issue were presented, but Cohen et al. (SC678) reported that STD patients exposed to two group-based interventions recorded 50% and 65% fewer reinfections than controls who received individual counselling. Groupbased, sUs-orientated, participative, approaches, which have proved effective in many different contexts, should be examined in African STD clinics. If they show promises, the challenge will be to train health staff to lead such groups.
Adolescents
Despite the early onset of sexual activity re’ported (Dupree et al., ThD858; Kapiga et al., SC45; Matondo, FC749; Ouedruoga et al., FC595; Wilson et al., ThD53), few comprehensive school programmes were described. An exception was Malwi (Dupree et al., ThD858), where, with government support, multisectoral support was secured, focus groups were held with pupils, parents and teachers and materials, including teacher’s guides and student handbooks, were developed and pre-tested. Teachers will be
trained to teach others, so that all 3,000 Malawian public sector teachers will be able to teach, answer pupils’ questions or refer the pupils appropriately. Kambamba et al. (FD910) inserted AIDS education messages-derived from attitudinal research-in notebooks that Zairean pupils buy at subsidized prices. In South Africa, where the numbers with HIV are doubling in 6 to 8 months, teachers have been trained to educate ‘mixed race’ pupils about AIDS (Englebrecht et al., 4049) and community educators are used to reach youths outside schools (Greathead et al., 4097; Ramakhula et al., SD62). Despite these efforts, it seems that a minority of African countries have comprehensive national programmes for adolescents.
Workplace programmes Rwakagiri et al. (ThD212) outlined a programme, conducted through the Federation of Ugandan Employers, in which trained peer educators distribute condoms and literature in worksites. Long-distance transportation workers were again identified as a vulnerable occupational group, with 23% of a sample of 237 drivers tested near Nairobi, Kenya, seropositive (Omari et al., FC729), but none of the several interventions underway for this group were described in any detail. No prevention activities were presented for another vulnerable occupational category, the uniformed services, for whom the most intensive interventions are direly needed.
Involvement of PWAs Cranston et al. (SC724) reported that interventions involving PWAs had greater impact on attitudes than knowledge or skills-based approaches, but the value of PWA participation was most vividly depicted by Staley of ACT-UP’S stirring address, McKusikick’s moving personal perspectives on AIDS (both W.plenary presentations), and above all, activists outside the convention centres.
AIDSINAFRICA
AIDS is, in so many ways, the affliction of the voiceless and we all-AIDS administrators, doctors, educators, researchers-need PWA activism and participation to keep us accountable. In Africa, following Philly Lutaya’s lead and notwithstanding cultural obstacles, we must recognize the pivotal role of PWAs in AIDS prevention.
Downloaded by [University of Leeds] at 05:47 05 February 2015
Behavioural research There were several KABP surveys (Bomboko et al., FC709; Gerst et al., 4055; Jinadu et al., FD845; Hapigi et al., SC45; Konings et al., 3020; Louis et al., FC732; Matondo et al., FC749; Messou et al., 4124; Moore et al., ThClOS; Musgrave et al., FC607; Ogunyankin et al., FD843; Ojofeitmi et al., FC752; Payanzo et al., ThD782; Payanzo et al., ThD783; Van Dyk et al., SC784), which generally observed that despite reasonable awareness, risk behaviours persist. Several Euro- American researchers reported experimental comparisons of different interventions, which is laudable and deserving of emulation in Africa, but if we are to avoid the pitfalls of decades of psychotherapy re-
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search, it is vital to specify e x a c t b what each intervention comprises. Ethnographic, qualitative, work, based on participant observation and action research, is imperative and it’s paucity here is lamented. Quantitative approaches cannot provide the answer when we scarcely know what questions to ask to understand the fundamental cultural, interpersonal and psychological forces that shape our approaches to two sexuality and disease.
Conclusions The low ratio of interventions to research, apparent above, is infinitely disturbing. While the boycott, which affected community groups heavily, the 6 month lead time for abstract submission, the emphasis on original reports, with hard data to hand in the calls for abstracts and the natural affinity of research paper and conference medium are doubtless contributory, it is hoped that post San-Francisco activities and the Florence VZZth Znternational AIDS Conference, will emphasize interventions, action research and research linked to interventions.
