HIV crisis in developing countries: the need for greater understanding and innovative health promotion approaches.

AIDS/HIV CRISIS IN DEVELOPING COUNTRIES: THE NEED FOR GREATER UNDERSTANDING AND INNOVATIVE HEALTH PROMOTION APPROACHES Ivor Lensworth Livingston, PhD, MPH Washington, DC

Epidemiologic data on morbidity and mortality have shown that the acquired immunodeficiency syndrome/human immunodeficiency virus (AIDS/HIV) epidemic is relatively widespread in the developing countries of the world, especially in the already economically deprived regions of Sub-Saharan Africa. Africa is estimated to have approximately 5 million seropositive individuals, and by the year 2000, this number is expected to include 10 million HIV-infected children. Improved control over this epidemic can only come through a greater understanding of the specifics of the disease and, eventually, the introduction of more effective and innovative health promotion campaigns targeted at medical personnel, traditional healers, families, and persons with AIDS. Comprehensive health promotion campaigns, carefully using mass media strategies in addition to more community-based programs, all operating under "decentralized" AIDS control programs, are reasoned to be the most efficacious approach that African and other developing countries can use to successfully contain the AIDS/HIV epidemic. Given the reality of the following factors: Pattern 11 (ie, transmission of AIDS via heterosexual sexual From the Department of Sociology/Anthropology, Howard University, Washington, DC. Requests for reprints should be addressed to Dr Ivor Lensworth Livingston, Dept of Sociology/ Anthropology, PO Box 987, Howard University, Washington, DC 20059. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 9

activity) is the main mode of HIV transmission in Africa, the traditional dominant roles males have in sexual relations, and the positive relationship between sexually transmitted diseases and AIDS, health promotion campaigns must focus specifically on addressing at-risk culturally related sexual values and behaviors in African communities. Failure to address these and other related factors will certainly lead to an escalation of the AIDS/HIV epidemic in Africa and, therefore, concomitant devastation in the human and societal realms of the region. (J Nati Med Assoc. 1992;84:755-770.) Key words * acquired immunodeficiency syndrome (AIDS) * human immunodeficiency virus (HIV)developing countries * Africa - health promotion AIDS-Acquired immunodeficiency syndrome-is the term used to refer to the physical condition resulting from infection by HIV, the human immunodeficiency virus. Human immunodeficinecy virus, the generic term used for two viruses known as HIV- 1 and HIV-2, gradually disables an important part of the body's immune system by invading T-helper lymphocytes and macrophages-cells in the bloodstream that normally help protect the body from attack from infection. Acquired immunodeficiency syndrome has reached global epidemic proportions and continues to be perhaps the most serious public health challenge of the 20th century. It is estimated that approximately 8 to 10 million adults and 400 000 children have been infected with HIV worldwide.' Recent reports by the World 755

AIDS/HIV & HEALTH PROMOTION

Health Organization (WHO) predict that there will be 30 million new HIV infections and more than 6 million new AIDS cases by the year 2000, a tenfold increase over the past decade's figures.2 Although AIDS is a worldwide problem affecting both developed and developing countries, it is the developing countries,3 especially the relatively poorer ones in Africa, that experience a disproportionate share of the economic, structural, and human losses associated with AIDS. An example of a worst case scenario is Uganda, where more than 5% of the entire population is already infected with HIV.2 This article discusses AIDS in developing countries, especially African countries, and addresses why there is a need to better understand and subsequently implement new innovative and culturally sensitive "preventive" approaches aimed at changing the at-risk behaviors for AIDS in these countries. It will be pointed out, however, that success in changing at-risk behavior is directly related to an understanding of the specifics of the cultural context in which the behavior change is to be conducted as well as having a relatively sound understanding of the dynamics involved in changing at-risk human behavior itself4 There is no "magic bullet" to be used in the cure of AIDS. Current management of HIV infection includes at least three components: therapy against HIV infection, treatment or prophylaxis of associated infections (ie, tuberculosis, pneumonia, and diarrhea), and counseling and psychosocial support.5 All three of these elements are essential to promote survival of HIV-infected patients and provide them with a better quality of life. In terms of anti-HIV therapy, zidovudine or azidothymidine (AZT), which was launched in 1986, is still the standard treatment for HIV infection in countries that can afford it. Whereas the life expectancy of AIDS patients is increased by 2 or more years with AZT, which delays the development of opportunistic infections in asymptomatically individuals, it has serious toxic side effects. These side effects are more noted in AIDS patients whose bone marrow can be severely affected, resulting in severe anemia, which may require blood transfusions.5'6 Prophylactic treatment is increasingly being used in individuals with HIV infection. It consists of taking a drug against an endogenous infection before disease develops (eg, tuberculosis and Pneumocystis carinii pneumonia) or to prevent relapse of disease (ie, cryptococcal meningitis). While this form of treatment has contributed to the longer survival of AIDS patients, again, its cost is usually prohibitive in developing countries. Because of the complexities associated with the nature of HIV infection and AIDS, 756

it is important that patients be given appropriate counseling and support. Also, community support and assistance are essential for these patients, especially in developing countries, where resources are severely lacking. In developing countries, most families prefer caring for their family members at home when the option is presented to them, rather than abandon them to the health-care system.5 As there is no effective treatment for AIDS and no vaccine available to prevent the acquisition of HIV, the only pragmatic course of action to controlling the spread of the disease is to encourage individuals at risk to change their risky behaviors. There is growing consensus, therefore, that health promotion/education and social marketing efforts are the most effective means through which at-risk behavior can be changed.7'8 Also, given the increasing dominant mode in which AIDS is being transmitted, ie, by sexual means, especially anal and vaginal intercourse without the use of a condom and via the sharing of contaminated needles and syringes by intravenous drug users,9 these behaviors, then, constitute the main designated at-risk ones to change. It has been widely hoped that the provision of health education material will encourage individuals to change their behavior. For purposes of this article, however, it will be noted that for health education to be effective in changing at-risk AIDS behaviors, especially in the developing countries of Africa, both the contents of the message and the medium through which it is disseminated must be innovative, sensitive, and culturally specific to the "needs" of the target group in question. Additionally, given the specific focus on Africa and the knowledge that AIDS is eminently vaginally transmissible and it is the predominant manner in which it is spread in Africa,'0"' there is a strong argument for directing health education information at anyone who is sexually active. This latter fact compounds the problem given that human sexuality is a relatively difficult subject to address.'2

CLINICAL MANIFESTATIONS OF AIDS Shulman and Mantell'3 have reported that over

a

period of years following infection with HIV, the body's immune system gradually breaks down and becomes increasingly vulnerable to attack from diseasecausing organisms (eg, viruses, bacteria, fungi, and protozoa). While many of these microorganisms are normally harmless to people, when the body's immunesystem is damaged or suppressed, these organisms have the opportunity to thrive, thereby giving rise to a variety of opportunistic infections and malignant diseases. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 9


Kaposi's sarcoma is the most common neoplasm, and P carinii pneumonia is the most prevalent opportunistic infection found in persons with AIDS. Pneumocystis carinii pneumonia has accounted for more than half of the reported AIDS-related deaths. Acquired immunodeficiency syndrome has three major routes of transmission: through the semen and blood'3 during intimate sexual contact, through the sharing of contaminated needles and other drug paraphernalia, and through vertical transmission of AIDS (congenital or perinatal) from HIV-infected women to the fetus during pregnancy, labor, and possibly birth, as well as during breast feeding.'4 The clinical spectrum of HIV infection is broad and variable, ranging from asymptomatic to rapidly progressive disease.'5 The symptoms of AIDS and AIDSrelated complex are complex, systemic, and ravaging to the body. Acquired immunodeficiency syndrome has a very high case fatality rate, with an average time from diagnosis to death of 18 to 24 months.'6 The disease is episodic and progressive in severity, and AIDS patients typically require several hospitalizations over the course of their illness. Care protocols may necessitate treatment in an intensive care unit and use of extensive life-support measures, for example, ventilators/ intubation and cardiopulmonary resuscitation. Additionally, expensive and extensive drugs and nursing and respiratory therapy services may be required to stabilize the person with AIDS during acute illness episodes.'3 However, it will be pointed out later that these AIDS-related activities, while relatively available in developed countries are, for the most part, few or nonexistent in developing countries simply because they cannot be afforded. 17

TRANSMISSION OF AIDS WORLDWIDE AND THE IMPORTANCE OF POVERTY With the picture changing somewhat, it has been reported that there are three emergent distinct patterns of AIDS epidemiology. According to Carballo and Carael,'8 in Pattern I, which occurs in North America, Western Europe, and Australia, HIV infection has tended to focus around homosexual acts and drug injecting with shared needles and syringes. Pattern II, which is more specific to East, South, and Central Africa as well as parts of the Caribbean and Latin America, involves heterosexual transmission and affects equal numbers of men and women. In Pattern III, which is specifically associated with the Pacific and Asian regions, the prevalence of AIDS is primarily linked to sexual contact with infected individuals from JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 9

countries in North America, Northern Europe, and Africa. It is in the Pattern II countries, eg, Africa, where AIDS is heterosexually transmitted and where the ratio of infected men to women is 1:1 that the implications of the epidemic could have the greatest impact on population and reproduction. Recent estimates of the higher than average incidence of AIDS in Africa have been put at up to 5 million.19 Heterosexual transmission of HIV infection is increasing in the developing as well as the developed world. This is more true in urban areas with high rates of other sexually transmitted diseases and drug injectors. It has been speculated' that by the year 2000, 75% to 80% of HIV infection will result from heterosexual transmission. This has very serious consequences for women of childbearing ages as well as for children, both of which groups are expected to show an increase in the incidence of HIV infection. Although the means of transmission may vary, it is the poorer sections of society and the poorer countries of the world that are the most vulnerable to HIV/AIDS. For some individuals, AIDS can be described as "the disease of poverty."20 Of the 35 poorest nations in the world, 26 are located in Africa.21 For some individuals,22 a paradox exists because while Africa is the richest, most naturally endowed region in the world, its people are the poorest. This fact has severe implications for the disproportionate incidence of AIDS/HIV infection and accompanying economic and human hardships afflicting African countries today. In a related manner, additional evidence indicates that the consequences of underdevelopment, underfunded health systems, and rural/urban migration may have a profound influence on the transmission and distribution of AIDS. For example, shortages of money, hospitals, and doctors have led in many places to high rates of untreated sexually transmitted diseases (STDs), which are now known to facilitate the transmission of HIV.23 A WHO meeting concluded that "the AIDS pandemic further emphasizes the urgent need for increased support of broad programs of STD prevention, control and research."24 Furthermore, a study conducted in Kinshasa, Zaire indicates that the deprivations caused by poverty itself lead to the faster development of AIDS among women and an increasing likelihood that their newborn children will be HIV-positive.25

THE GLOBAL AIDS CRISIS, ESPECIALLY IN DEVELOPING COUNTRIES The World Health Organization estimates that between 8 and 10 million adults are now infected with 757


HIV worldwide. Also, pediatric data reveal an estimated 400 000 cases of AIDS among infants and children under 5 years of age since the pandemic began. The frightening picture is that by the year 2000, there may be a cumulative total of 25 to 30 million HIV-infected men, women, and children in the world. Also, if HIV infections increase rapidly in Asia and Latin America, this projection will need to be revised significantly upward.' It is reportedl that the rate of increase in HIV infections is rapidly increasing in the developing countries. While about 50% of the world total of infections was estimated to be from developing countries in 1985, it is currently estimated to be approximately two thirds, and the figure is expected to increase to 75% to 80% by the year 2000 and reach 80% to 90% by the year 2010. The potential demographic consequences of these outbreaks is striking when a high percentage (up to 20%) of young adults are infected as is the situation in many cities in Central and East Africa. In such cities, current HIV infection could cause a doubling or a tripling of the total adult mortality rate during the 1990s. According to WHO,26 at least half of those infected worldwide with HIV are under the age of 25, and about 20% of all people with AIDS are in their 20s. A large proportion of them were infected in their teens, probably between 15 and 19 years of age. There are various reasons why the actual AIDS/HIV statistics are not fully known as well as why the incidence of disease/infection is escalating. For example, in the case of Pakistan, which has only a 26% literacy and, therefore, the reading of relevant AIDS education materials is difficult for most, the government has not moved aggressively enough in informing the public about the disease.27 At the Fifth International Conference on AIDS in Africa, it was said'9 that in the countries of North America, Western Europe, Australia, and New Zealand, the estimates of HIV seroprevalence have been revised downward in view of more recent epidemiological and serological data. In the case of Southeast Asia, Eastern Europe, the Middle East, the Pacific, and some countries in North Africa (all together with approximately 70% of the world's population), which initially had 5% of the estimated global HIV infections, the picture is changing upwardly. Some of the main contributing factors to the increased incidence of AIDS/HIV infection include: increased HIV transmission in infants and young children in the Soviet Union and Romania, epidemiological studies in Thailand 758

indicating dramatic increases in HIV infections since 1988, and recent surveys in India showing HIV infection rates as high as 70% in groups of female prostitutes. In the case of the Caribbean and Latin America, relatively high increases in AIDS/HIV infections have been noted. It was reported that some of the world's highest AIDS case rates are found in the Caribbean (ie, Bermuda, Bahamas, and Haiti). And while the estimates in the region are difficult to make (primarily because of limited data), the total as of 1990 is thought to be between 500 000 and 1 million.19 The economic costs and implications of AIDS for several developing countries (eg, in Africa and Latin America) are menacing; AIDS is the latest in a series of diseases that have hit the already disadvantaged countries of the developing world, minorities, and races disproportionately.3 For example, faced with the third highest number of AIDS cases in 1988, the major problem confronting the government of Brazil was to secure funds for enforcing its regulations and to purchase diagnostic tests.28 Approximately half of all people infected with HIV will develop AIDS within 10 years of being infected, and the vast majority are expected to develop the disease eventually unless more effective drugs are developed. This fact poses a particular problem for developing countries whose economies do not allow them to purchase what drugs are currently available. One drug, AZT, improves the clinical picture and prolongs the lives of persons with AIDS. A year's supply of AZT, based on a daily dosage of 800 mg, costs about $3750, far beyond the health budgets of developing countries, some of which are already battling many other endemic diseases on total health budgets of less than US $10 per person per year.29 In terms of other drugs, scientists have developed new ways to prevent or treat some of the most common complications of HIV infection, such as P carinii pneumonia, Kaposi's sarcoma, and blindness caused by cytomegalovirus retinitis. However, while none of these drugs constitute a cure for AIDS or HIV infection, these and other advances are still beyond the economic and technical resources of many developing countries where the epidemic is most severe.1

AIDS in the Caribbean Given its proximity, trade relationships, and travel (vacationing and migrant work) with North America, all important reasons contributing to the increasing incidence of AIDS/HIV infection, the Caribbean is singled out for more attention as a developing region. As is the JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 9


case with other developing countries of the world, the Caribbean countries are experiencing an increase in AIDS cases and HIV infection. The Caribbean Epidemiology Center (CAREC) has been the surveillance center for communicable disease in the Caribbean since 1975. It has 19 member countries that vary in population from 7500 to 2.4 million, with a total population of 6.4 million. The Caribbean Epidemiology Center also receives regular reports on the occurrence of communicable disease from most other countries in the region. It has been reported30 that outside of North America, the Caribbean has generated more than 10% of the cases in AIDS in the Americas. Indeed, some Caribbean countries (eg, Bermuda, Bahamas, Barbados, Trinidad, and Tobago) have some of the highest per capita rates of reported cases in the world. This, perhaps, together with the high rate of occurrence in Haiti, has led to the description of the Caribbean as an area of "high risk" in some of the early reports. The male:female ratio of adults infected has moved rapidly from 5.8:1 at the end of 1985 to 2.8:1 at the end of 1989. Pediatric AIDS cases account for 9% of all cases, and 98% of these are the result of perinatal infection.31 Certain common patterns exist with respect to risk factors. In most countries, the early cases tended to be among homosexual/bisexual men, but as the epidemic progressed, the pattern of transmission became increasingly heterosexual (Pattern II). This is also true of Haiti, the Dominican Republic, and the French Countries (eg, Martinique, Guadeloupe, and French Guana). One possible exception, it has been said,30 is Bermuda, where the majority of cases are associated with intravenous drug use. In terms of cumulative cases, the distribution of adult cases by transmission category in rank order was heterosexual contact, 52.9%; homosexual and bisexual contact, 38.1%; intravenous drug use, 6.6%; and blood transfusion, 1.2%. Of importance for prevention and health education strategies is the fact that more than 90% of cases were a result of sexual transmission. According to Hospedales,32 besides Bermuda, the only other Caribbean territory with an intravenous drug use problem is Puerto Rico. Also, in Guyana, which started reporting AIDS cases in 1987, homosexual/bisexual contact is still the chief mode of transmission. In 1988, all the countries in the English-speaking Caribbean developed 3-year medium term plans (MTPs) with the assistance of CAREC, the Pan American Health Organization (PAHO), and the World Health Organization's Global Programme on AIDS (WHO/GPA). In general, the MTPs listed five major strategies: epidemiological surveillance, preJOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 9

vention of sexual transmission, prevention of transmission through blood and blood products, prevention of perinatal transmission, and reduction of the impact of HIV infection in individuals, groups, and societies.31

AIDS in Africa Acquired immunodeficiency was described for the first time in Africans not long after its description in the United States in 1981.10 Since then, the disease has been described in Central Africa, East Africa,33 and other African countries.34'35 The World Health Organization reports that the AIDS epidemic is one of the worst problems to hit Africa, which has had its share of them. Also, the AIDS epidemic will remain there for a long period of time because even if by some miracle contamination stopped now, the long incubation period is such that millions of Africans would still go on developing it. The World Health Organization also estimates that 5 million Africans are already HIVpositive and that death could well claim hundreds of thousands of them-mainly in the 15 to 44 age bracket, which is economically the most active-by the year 2000.36 The disease is at its worst in sub-Saharan

Africa.26 For Dr Michael Merson, Director of the WHO Global Program on AIDS, there are two basic reasons why the projections for the African AIDS epidemic are gloomy. First, given that it takes approximately 7 to 10 years for 50% of the AIDS cases to occur, the cases that are now showing up are in people who were already infected, therefore there is not much that can be done, especially in terms of primary prevention (ie, prevention of the disease). Second, with regard to infection, although there has been some success, it is evident that there is a spread from urban to rural areas and from Central and Eastern Africa into Western Africa, and that there is continuing high rates of infection in some countries, but not in all.37 Another complicating issue that has been reported has to do with accurately detecting the clinical spectrum of AIDS in Africa. In essence, this difficulty has to do, in part, with the complex relationship between the existing endemic infectious diseases in Africa and the newly recognized HIV infection. Many endemic diseases in Africa are known to activate HIV replication and/or to immunosuppress infected individuals.38 Therefore, as an indirect outcome, there may be an increased susceptibility to HIV infection in exposed individuals. In summary, it can be said that before the advent of AIDS, African countries had a relatively high incidence of certain epidemic and endemic conditions, 759


all of which, either directly or indirectly, have contributed to the exasperation of the health problem in Africa, more so the AIDS problem. Given that the 15 to 44 age group is the most sexually active in Africa36 and that STDs are associated with HIV infection39 and constitute a major medical and social problem in African countries,38 the 15 to 44 age group should definitely be the primary target group of interest for innovative health promotion approaches. This age group also constitutes the literal backbone, ie, in relation to work, productivity, family stability, and education, in most societies, including those of Africa. Therefore, any dysfunction, AIDS or otherwise, associated with this group will have serious effects on the economic, social, and productive capacity of society. With this fact in mind, it has been projected that in some African countries, approximately 10% of the middle class-the industrial workers, teachers, army personnel, and political leaders-will die of AIDS-related conditions in the 1990s.37 In a related manner, it is reported that more than 100 million people between the ages of 15 and 24 live in Africa. They have a very high age-specific fertility rate and also make a significant contribution to total fertility.38 The additional reason for adolescents and young adults being a focused target group for health promotion is underscored by an example in Kenya. In Kenya, more than 50% of the urban teenage population is infected with STDs, and the number of adolescents carrying the AIDS virus is not

and in the Kagera Region in Tanzania, it is projected that approximately 5000 children will be orphaned by the early part of this decade.42 The sheer economic costs and implications of AIDS are menacing for several African (and other developing) countries.43 For example, by 1988, one out of every four hospital beds in some Central African countries were needed for AIDS patients.44 It was also reported44'45 that Zaire will need US $2 million just to equip three laboratories to carry out blood screening in the next 3 years. The financial support per case of AIDS in Zambia, Rwanda, and Uganda (and Haiti) is already 15 to 50 times higher than that of the United States.45 Where a country's health resources are already inadequate, patients are also at risk of HIV infection through blood transfusions,28 and the lack of sterilized needles and gloves for different patients.46 In addition, the poorer infected persons are in rural areas or urban slums. Such individuals have less access to the few hospitals with facilities capable of diagnosing and treating AIDS.43 With Zambia as an example, it was reported42 that the country was attempting to run an AIDS information and prevention program in the face of a contracting economy. At the same time that it must deal with AIDS, its per capita government spending on education decreased by 62% in a decade, and the expenditure on essential drugs dropped by 75%.

known.38

AIDS CONTROL THROUGH HEALTH PROMOTION

After a recent visit to seven (ie, Nigeria, Cote d'Ivorie, Uganda, Malawi, South Africa, Zimbabwe, and Senegal) sub-Saharan nations in January 1991 to review progress in child health and child survival, Dr Louis Sullivan,40 Secretary of the US Department of Health and Human Services, presented a very gloomy picture. He said that during the last 10 years, some 500 000 infants in Africa were born with HIV infection. By the year 2000, it is estimated that there will be an additional 10 million HIV-infected children in Africa. He went on to add that AIDS will set back the advances made in other child health areas, with child mortality rates in some African countries increasing 50% as the result of HIV infection. In terms of the family as a very important institution in society, the projection was just as gloomy. Beyond those infected with HIV, as many as 10 million children may become orphans due to the death of parents from AIDS and, in a related manner, economies will be subverted by the loss of productive adults. For example, in the Rakai District in Uganda, more than 24 000 orphans were enumerated in 1989,41

According to Erben,'2 the global epidemic of AIDS continues to gain momentum, and the gap is widening between the growth and the epidemic and what is being done-or can be done-for prevention and control. As alluded to before, many societies, especially the poorer countries in Africa and the rest of the developing world, are already facing major difficulties in meeting critical needs for health and social services. It has been said47 that the HIV epidemic will only be controlled by developing a national strategy that combines health education, health care, legal, educational, public health, and financial wisdom. Health promotion, if defined comprehensively, whereby encompassing all these and other areas, has the potential to be very effective in controlling AIDS/HIV infection in general and in the developing countries of Africa in particular. It should be said, however, that these successes will, to a large degree, be contingent on the cooperation of international health (eg, WHO), development, and economic (eg, World Bank) institutions. These institutions need to infuse massive economic, technical, and structural aid

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in these countries for these health promotion (and other related) programs to be effective. While there is no effective treatment for AIDS and no vaccine to prevent the acquisition of HIV, the only way of controlling the disease is through strong preventive programs aimed at changing at-risk behavior. Given that the developing countries mainly fall under Pattern II, where transmission is primarily through "sexual activity," prevention efforts through health promotion and health education must, then, of necessity, be geared to changing sexual behavior and making it less risky. As will be pointed out, fowever, this objective is much more difficult to achieve than it is to state. The importance of the sex-AIDS relation has been extolled in the past. Acquired immunodeficiency is not a medical problem but a sexual problem was the conclusion reached by one medical specialist who documented the presence of AIDS in Uganda.48 His remarks draw attention to the fact that it is not a virus alone that is the issue, but human beings and human life. The devastating progression of AIDS and its accompanying human, economic, structural, and societal consequences indicate that all available expertise should, then, be directed to the complexities of human behavior change in general and AIDS at-risk behavior (eg, sexual and drug related) in particular. In attempting to reach a global consensus and strategy in the war against AIDS, the World Health Assembly called on its member countries "to develop strategies for health promotion and health education as an essential element of primary health care and to strengthen the required infrastructure and resources at all levels."49

What Is Health Promotion? Health promotion is very much an "in" term at present. Tannahill50 said that health promotion is one of those terms that people tend to throw around glibly, without spelling out their interpretations. He was of the opinion, and so is this author, that health promotion is an "umbrella" term covering health education as well as environmental, legal, and fiscal measures designed to advance health.5' It is useful to reserve health promotion to define clearly a realm of health-enhancing activities that differ in focus from currently dominant "curative," "high technology," or "acute" health services.50 Given the bold and innovative health promotion approaches called for in this article to prevent and control AIDS/HIV infection, moreso in the developing countries, the arguments put forward from here on relate to the comprehensive model of health promotion suggested by Tannahill.50 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 9

Tannahill proposed a model of health promotion comprising three overlapping spheres of activityhealth education, prevention, and health protection.50 Each of these three components is described below. Health Education. "Communication activity aimed at enhancing well-being and preventing or diminishing ill-health in individuals and groups, through favorably influencing the knowledge, beliefs, attitudes and behavior of those with power and of the community at large."50 Prevention. Four foci of preventive action are as follows 52: * prevention of the first occurrence of a given illness or other unwanted phenomenon, * prevention of avoidable consequences of an illness or other unwanted state through early detection when this favorably affects the outcome (early detection is the essential preventive step), * prevention of avoidable complications of an established irreversible disease or other unwanted state, and * prevention of recurrence of an illness or other unwanted phenomenon. Health Protection. This may be seen as descending from traditional public health activities5l and it can be defined as follows: "Legal or fiscal controls, other regulations or policies, or voluntary codes of practice aimed at the prevention of ill-health or the positive enhancement of well-being."50 According to Tannahill,50 this three-sector model takes into consideration both the positive and negative aspects of health, acknowledges a political dimension, and takes into account the importance of public participation and empowerment, of making healthful choices, easier choices, and of influencing people other than the general public. It is reasoned that all three of these inter-related dimensions are necessary for successfully controlling the AIDS/HIV epidemic, especially in developing countries. Erben's12 view of health promotion complements the position of Tannahill.50 For Erben, health promotion puts health on the agenda of policy makers at all levels; it demands that health aspects be taken into account in shaping public policy and reminds those who shape it that they are responsible for the health consequences of their decisions. Health promotion calls for efforts to create supportive environments; it urges a redelegation of responsibilities in health through the strengthening of community action; it emphasizes the importance of developing personal skills and enabling people to exercise more control over their health and their 761


environment; and last but not least, it calls for a reorientation of health services which need to be sensitive to the total needs of the individual and the whole person. According to Erben,12 with the advent of AIDS, health promotion has taken on a sense of urgency. It is the increasing view that controlling AIDS is not only a matter of controlling a virus; AIDS is now increasingly seen as being inextricably associated with behavior. And, at present, the only practical tool for influencing its epidemiology is to influence behavior. In order to make the Tannahill50 model functional, for purposes of this article, health promotion is viewed as being directed at all people in African societies, including those at-risk, medical care personnel, indigenous healers, immediate and extended family members, workers, students, and clergy-essentially the entire community. Given the economic problems of developing countries, the "protective-oriented" message geared at influencing the knowledge, beliefs, attitudes, and behaviors of the community can reach more people if AIDS educators operate in conjunction with primary health-care personnel, who have had immense experience and resources (eg, transportation, networks in the community) battling other diseases in developing countries.4 Last but not least, health promotion via health education messages should be systematic and conveniently categorized into three levels of prevention: primary prevention, secondary prevention, and tertiary prevention. Primary prevention means preventing the disease or infection altogether, secondary prevention is the attempt to prevent the disease from spreading through early diagnosis, and tertiary prevention means attempting to prevent complications and to stop the disease from getting worse.53 In the case of AIDS, tertiary preventive medication has so far not fully succeeded in preventing patients from dying. As for secondary prevention, the treatment of seropositive individuals is still further away. However, warning contacts of seropositives can have some preventive effect on the spread of the epidemic, but difficult ethical questions would have to be answered. Therefore, the most powerful tool in the control of AIDS at this moment is primary prevention.54 It remains without saying that diseases such as AIDS are generally better prevented than cured; however, given the complicated picture of AIDS presented so far, especially in the developing countries of Africa, all three types of prevention complement each other and are badly needed in any successful health promotion campaign. 762

Factors Related to Changing At-Risk Behavior Through Health Promotion There are usually two main objectives for health education campaigns directed at controlling the AIDS epidemic by changing at-risk behaviors.7 The first is to encourage people at risk, not just homosexuals and intravenous drug users, but also sexually active heterosexuals, to make any necessary changes in sexual behavior to reduce their risk of acquiring the virus or, if they are already infected, from passing it on to others. The second is to convey information about how the virus cannot be transmitted so that public anxiety can be allayed. Political interests of governments as well as their particular public health foci will, to a great degree, allow for successful AIDS control efforts in Africa. In Uganda, for example, the AIDS Control Program in 1989 embarked on a strategy of decentralization of AIDS prevention and control activities to the district level. This was aimed at increasing the coverage and effectiveness of the national effort. District medical officers were given the responsibility and resources to plan and implement day-to-day activities. They had the additional task of involving health staff, nongovernmental organizations, religious groups, local government structures, and other local bodies through local AIDS committees in community mobilizations for health education. This delegation of responsibility from the national to the local levels and health officials is a strategy used in West Africa as well.55 Also, some countries have decided to integrate AIDS prevention and control activities into primary health-care pro-

grams.2' While primary health care may have been relatively effective in addressing other past and current epidemics and health problems, great care has to be taken that primary health care is not sufficiently restrictive to preclude or inhibit comprehensive and innovative health promotion efforts that are needed to control the AIDS/HIV epidemic, moreso in Africa. In underscoring this point, it was suggested56 that the traditional primary health-care approach may have failed to control the conditions that produce (good) health and that facilitate the emergence of diseases.57 It was further pointed out that planners and health providers have "pre-empted comprehensive education and mobilization" for an array of narrowly defined health campaigns (eg, with a focus on maternal and child health, "traditional midwifery," family planning, and oral rehydration).57 The decentralization of AIDS control activity in Africa down to the village level is a move toward a community-based approach to health care. Basically, a JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 9


community-based approach is a grassroots movement that attempts to involve a coalition of agencies and interested parties in the provision of services needed by persons with AIDS and their families.58 Depending on the African country in question and the nature (ie, it being restrictive) of its public health-care program and infrastructure, a community-based approach to health promotion may be a more viable approach to use in attempting to control the AIDS/HIV epidemic. At the very least, it should be used to complement existing health promotion programs. Additionally, frontline services for maternal and child health, family planning, and STDs need to reexamine their policies and ensure that HIV and AIDS activities are integrated in their programs. 12 Several other factors have the potential to influence how successful health promotion strategies are in changing at-risk AIDS-related behavior. Greater understanding and innovation need to be directed around five essential factors: * How will the message be delivered (eg, using mass media, billboard signs, or English/tribal dialects)? * Who will get the health education and related message? Who is the target group-sexually active children, adolescents, young adults, or prostitutes? * Where will the message be delivered (eg, over loud speakers on public transportation and areas of public congregation, at schools, at work, at church, or on the streets)? * What will the specific contents of the message/ information be? Will it concern knowledge, values, beliefs, attitudes, or cultural experiences? * When will the message be delivered (eg, on the weekend, after most people have come home from work, or during government mandated set-aside time periods called "health periods" during the day)? It becomes readily evident that it is very difficult to speak about each of these five factors separately because they are all interrelated. As such, although mention may be made of each of these five factors separately, for the most part, the discussion that follows will generally refer to them in a collective or integrated manner. There are several ways through which health education information can reach the target group of interest. However, over the last decade, the mass media have become increasingly popular as a strategy for delivering preventive health messages.59 The noted advantages of the mass media59 should be given serious consideration in implementing innovative health education programs in developing countries in general and in Africa in

particular. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 9

Nutbeam and Blakey60 reason that knowledge is a necessary but not sufficient condition for behavior change. Therefore, the target group's knowledge (base) about the phenomenon of interest (eg, AIDS/HIV) is an important inclusion in any health promotion strategy. In terms of sexual behavior and treatment, families have faced problems of lingering misconceptions that hinder change in attitudes and behavior.61 For example, an upsurge of pregnancies in Kampala in 1989 to 1990 were explained locally as the result of the belief that where a newborn child survived for 1 year, the mother was free of HIV pregnancy, rather than blood screening being used as a means of testing the mother to reassure her that she was free of the virus and that perinatal transmission had not occurred.2' In a study of 20 traditional healers who were selected from different sites in Uganda,61 all 20 had received patients who believed that the traditional healer could cure them of the disease. Of further importance was the fact that these healers were found to have very low levels of knowledge about AIDS. Also, only three of them had any direct AIDS education from health educators. Such indigenous healers, then, must be a target group as well for any comprehensive health education concerning AIDS/HIV. Because sexual contact is the principal mode of transmission of HIV throughout the world,62 Dr Jonathan Mann, Director of the WHO Global Program on AIDS, has emphasized that educational programs should be aimed at children and teenagers before they engage in sexual experimentation.63 In recognizing this need, WHO and the United Nations Educational, Scientific, and Cultural Organization (UNESCO) have been instrumental in establishing guidelines, both for policy makers and teachers, and seven school projects were started in Jamaica, Fiji, Mauritius, Ethiopia, Sierra Leone, Tanzania and Venezuela.'2 This emphasis on at-risk sexual activity of children, adolescents, and young adults is extremely relevant to the Africa scenario, where STDs are relatively high among the young,37'38 and because, as a consequence of genital lesions or inflammation, many sexually transmitted infections may increase the risk of sexual transmission of HIV by more than 300%.1 Some African countries have started to fight back aggressively in this area. For example, educational operations aimed at venereal disease sufferers are being run in Mozambique and Senegal, both of which have expanded the venereal disease control sections of the national AIDS campaigns. Consistent and motivated behavior change is very 763


difficult to achieve. Oftentimes the failure to be successful in changing human behavior is a result of the target group being entwined into an array of cultural norms, values, and beliefs, all of which guide and sustain past, present, and future behavioral practices. According to Ankrah,43 in the analysis of cultural factors, two things are of immediate importance. The first is the conceptualization held by the local people of the variables (eg, sex or prostitution) under study. The second is their belief systems about disease, sickness, and death as these relate to AIDS. It is not unusual for researchers, for example, to assign meanings to these phenomena-some derived from other contexts-that do not correspond to local reality. Misconceptions and the use of certain terminologies in cross-cultural research on AIDS can also be problematic in preventing researchers and health educators from achieving the desired goals, ie, changing at-risk behavior. Brokensha64 noted, for example, that the term "prostitute" is often imbued with Western ethical values and moral issues that tend to ignore economic realities in much of Africa. As a result of this, biases are introduced in the study of sex workers, eg, in the definitions and strategies followed. There is increasing evidence that having multiple sex partners is a significant factor in increased HIV infection rates.65 Given this fact, it is understandable that many Africans have protested at being labeled "promiscuous" on the basis of their rates of HIV incidence, and most social analysts would avoid the term because it implies a moral quagmire.64 In sum, therefore, the term "riskgroup" should be used carefully based on the assumptions the target group (ie, the group at which the health education message is directed) may have of itself relative to this label. A fundamental issue that health promotion efforts must address involves the socialization experiences surrounding the sexuality of the African male. Given the importance of heterosexual transmission of HIV or Pattern II in Africa alluded to before,'8 failure to address this critical issue will lead to massive failure in controlling AIDS/HIV epidemic. The Society for Women and AIDS in Africa,66 for example, also focuses attention on the African man, urging that in seeking a solution to the problem of AIDS prevention and control with respect to the African woman, the approach of "cooperation" rather than "confrontation" be taken. Innovative health promotion efforts directed at the African male as a specific target group should be geared to providing him with greater empowerment over his 764

sexuality. Similar empowerment must be given to the African female as well. Significantly altering the male/female relationship in Africa through feelings of self-empowerment will only result from new and culturally ingrained health education messages, in short, a resocialization of the targeted individuals. Many factors are already facilitating this process, for example, the feminist and liberation movements as well as informal discussions in the household and at school about new perspectives on sex roles. The end product is that the African man has to be resocialized about the African woman and vice versa. They need to learn to communicate with each other about feelings and about sex, where new and emergent accommodations will seek to enhance rather than to overpower the other.21

Health Promotion and Theory Although the specific content and mode of the health promotion strategies used in Africa (and the developing world) should reflect the cultural context of the region, these strategies should be directed by proven theory and research in the area. For example, health promotion involving health education messages, especially when directed to at-risk adolescents (in Africa), should have a built-in component associated with the target group's perceived control67 and self-efficacy68 regarding AIDS prevention. Prior research suggests that knowledge alone is insufficient to convince teens they are vulnerable for contracting AIDS from a sexual partner. Adolescents' perceptions of invincibility may inflate their risk of HIV transmission, especially when combined with their misconceptions and misinformation about AIDS.68 Existing theories on behavioral change should be used as a guide for including specific information (eg, regarding controllability and selfefficacy) in health education messages to these and other select target groups. Flay and his colleagues69 suggested that behavior change does not automatically follow from information provided (eg, knowledge about AIDS). These authors contend that several intervening variables need to be addressed before behavior change is likely to occur. Such variables include, for example, values, decisionmaking, skills training, and behavior reinforcement. These authors believe that intentions to perform behaviors will only be actualized if subjects perceive they have the abilities (ie, self-efficacy) and available behavioral alternatives. Basically, then, the selfefficacy construct measures a person's self-perceived capability of performing a specific behavior (eg, engaging in unprotected sex). A frequently used theory JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 9


of self-efficacy is Bandura's theory. This theory demonstrates that perceived self-efficacy is an important mediating factor between knowledge and behavior (change).70

PROGRAM CHANGES AND INNOVATIVE APPROACHES ASSOCIATED WITH HEALTH PROMOTION It is reasoned that the comprehensive and functional view of health promotion can be very effective in controlling AIDS/HIV infection if supportive environments are created, not only for the AIDS patient or the at-risk person, but for medical workers and the community at large. A target group of importance in any health promotion activities concerning AIDS/HIV has to be the caregiver given his or her pivotal role in the delivery of health care in the community. Although there are several affecting factors that can be discussed, a salient one has to do with the stresses placed on health-care workers.71 In terms of AIDS itself there are a wide array of neurologic and psychiatric problem behaviors72 that add a severe patient management burden to medical and support staff. As a result of the limited resources that already exist in Africa and other developing countries, this issue must be given priority in the type of comprehensive and innovative health promotion activities called for in this article. When serologic assays for HIV became available, the hope was that knowledge of infection would cause subjects to initiate changes in behaviors that transmit the virus. However, this has not been realized,73 and various explanations can be offered. First, the potential public health and personal medical benefits of early detection oftentimes are weighed against the possible detrimental psychosocial consequences of a seropositive test result.74 If health promotion cannot halt these types of behaviors from occurring, either through direct information or via supportive groups and organizations, other destructive behaviors (eg, excessive alcohol consumption and suicide) are likely to occur.75 Second, an additional undesirable outgrowth that can have an impact on the etiology of the disease include reports76 that distress may increase susceptibility to HIV infection, or in those already infected, increase immunosuppression and disease progression. This distress can come in many forms. Although there are now many organizations in Africa that have been introduced as a result of the AIDS epidemic, one that stands out in terms of its philosophy and intervention strategies of care-giving directed to support families that are not medically based is The AIDS Support JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 9

Organization or TASO in Uganda. The AIDS Support Organization basically provides care, counseling, and support for individuals with AIDS or HIV infection and their families. As with a growing number of other organizations, some of TASO's volunteers and staff members are themselves individuals with AIDS or HIV infection. The home-based care program, developed by the Salvation Army at the Chikankta Hospital in Muzabuka, Zambia,77 is a good example of innovative approaches that can be taken given the limited resources and varied cultural context of the region. Another innovative organization, the Zimbabwe Women's AIDS Support Network, is an example of women getting together to overcome the prejudice and blame associated with AIDS, gain confidence to fight the disease, and suggest some possible means to do so in a social and cultural context where women have traditionally little control over the sexual behavior of their men. 12 Innovative health education messages, perhaps via film, folklore, or popular music, should go beyond the avoidance of risky sexual behaviors and include additional messages regarding HIV transmission to the entire family and community. For example, according to Ankrah,2' such additional messages should provide information relating to more recent revelations on not-too-known ways of transmission. More specifically, messages should tell of and provide ways to discourage social practices that may also weaken the immune system or increase risk of infection, such as drug abuse, excessive alcohol consumption, untreated STDs, and unsanitary home environments.21 The theater is also proving to be an important ally in fighting AIDS/HIV discrimination and stigmatization,78 and it has the potential to be one of several effective media to disseminate health education messages to those at risk as well as the community at large in Africa. One innovative approach to promote safe sex practices with a social marketing approach is used in Zaire. After instituting a donor-subsidized program using private sector techniques to sell contraceptives via commercial channels, the per-month sales of condoms were boosted in less than a year from 7600 units to 300 000. Pharmacies were the main channel used by the program, which was aimed at reaching

men.79 Another potentially viable approach to health promotion is to structure intervention through a wider social network than members of the traditional extended family. District-level AIDS committees have been used by the governments in Uganda80 and Tanzania.81 These 765


organizational structures are especially important where major demographic changes have occurred,82 eg, where men and women in their most productive years between the ages of 15 and 40 have died or have left the community, leaving behind their old parents and young children. According to Wallace,83 these wider social networks with families serve as a relatively permanent base and channel for AIDS information and health services. Elders act as agents in getting sexual norms and traditions reinterpreted in view of AIDS.66 In Ethiopia, the Ministry of Health has joined forces with the Ethiopian Orthodox Church in getting the AIDS message to remote parts of the country. The Church, one of the oldest in Christendom, is estimated to have 200 000 individual churches and a following of no less than 28 million. Given the "belief in the parish priest" and the church's capacity to reach every part of society (eg, through preachers and confessors) and deep into the villages, the Ministry of Health recognizes its importance in providing and disseminating AIDS

information.84 Another innovative approach to health education occurred in Kenya.85 A special AIDS issue of the popular children's magazine, Pied Crow, was so successful that it led to CARE Kenya being asked to prepare additional materials for World AIDS Day. The request came from the Kenyan National Committee on AIDS. Some 60 000 copies of a new booklet using illustrations from Pied Crow were distributed on the day at gathering places such as discos, cinemas, and railway stations. In addition, 2000 posters and 5000 caps bearing the Kenyan "Crush AIDS" logo were produced. The issue also was sent to institutions catering to young people such as the National Youth Service. This effort was a great success, and it sparked instant and overwhelming responses from thousands of readers both inside and outside of Kenya. It is important for health promotion activities concerned with AIDS/HIV infection to address the reorientation of existing health services in Africa. According to Erben,12 apart from the frontline services associated with maternal and child health, STDs, and family planning, efforts should be directed at guaranteeing the safety of the blood supplies to Africa (and the developing world). In addition, health-care workers and support staff, all of whom may be expected at some time to deal with complex issues of sexuality and to provide counseling on the misconceptions surrounding AIDS/HIV infection, should receive adequate preparation and training. In reorienting to the needs of clientele, one innovative strategy that may have some value in 766

Africa, albeit with a modified approach, is the Sidney's AIDS bus. This program was designed to make health services readily accessible to male and female prostitutes and intravenous drug users. Basically, the bus service offers AIDS education; direct street support in the form of condoms, needles, and syringes; medical care; counseling; and confidential HIV antibody testing if requested.

PERSONS WITH AIDS AND HEALTH PROMOTION Another effective mode of disseminating information on AIDS is through individual and personal testimonials of persons with AIDS. This fact was made evident in a special report entitled "Who Would Like to Be Seen as a Virus?" For example, Robert Mugemana, a Kenyan journalist with AIDS, mentioned that the turning point in his life as an HIV-positive person was when he met other people with HIV in Kinshasa, Zaire. "For the first time since testing positive, I met people who understood me and I understood them," he said. "We shared our own experiences, our worries and fears and we laughed together. They gave me the will to live on and ever since I have the belief that a positive attitude is as good a medicine as there is for AIDS." In Zimbabwe, Ronnie Mutimusekwa, a 34-year-old man with AIDS, became the first person in his country to come out openly and volunteer his services in the AIDS education campaign. He said he had "come out of hiding" in the hope that it would inspire others like him, as well as help in the prevention efforts. University of Zimbabwe sociologist, Dr Marvellous Mhloyi, welcomed Mutimusekwa's action, saying that it was only when Zimbabweans "get to know people dying of AIDS" that the message will truly sink in.86 Of all the testimonials of AIDS patients, however, perhaps the one that stands out is that of Philly Bongoley Lutaya,87 a native-son of Uganda and the composer of the catchy and popular song "Born in Africa." He surprised fans and admirers by declaring at a press conference in Kampala in 1988 that he had been diagnosed with AIDS. "From now on till my death I'm going to give AIDS a human face, be involved actively in programs aimed at the prevention of further spread of the deadly disease, and appeal to the public to treat people with AIDS with compassion, love, and understanding," he said. Before dying in Uganda on December 2, 1989, he achieved most if not all of his objectives. At live concerts, he drew thousands of Ugandans to listen to his message. He launched an album, "Alone," about his experiences, and, during a JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 9


4-week working visit to Uganda, shot a documentary film entitled "The Life and Times of Philly Bongoley Lutaya." He also addressed the young in schools and colleges and put on shows against AIDS. Although the picture is somewhat changing, AIDS/ HIV has been seen as "a disease of others." This has led both to discrimination against people with HIVand to individuals and entire communities failing to recognize that they too are at risk for HIV and that AIDS concerns them.29 Again, testimonials and public appearances of persons with AIDS will certainly help health promotion activities in the overall control of the AIDS-related epidemics, especially in Africa. More specifically, HIV-infected persons who are well-supported and informed are likely to live longer, be productive longer, require less hospitalization, be more responsible in adopting safer sexual practices, and become involved in health education activities in the community. On the other hand, spouses, families, friends, and other support people who are wellinformed are more likely to: be freer of myths and stereotypes about AIDS, which cause unnecessary fear of contagion, have accurate information on how to protect themselves against infection, continue to care for the infected individual in the home and the community versus isolating that individual in a hospital, become more involved in mutual support groups with others affected by the epidemic, and become involved in health education activities in the community as a way of channeling grief into feeling useful and contributing to the public well-being.'2 As a result of the relatively small, dwindling, or nonexistent economic17 resources in African countries, in addition to the wide cultural diversity in their societies, persons with AIDS can contribute greatly to health promotion efforts controlling the AIDS/HIV epidemic. Perhaps one of the main modes through which their contribution can be assessed is personalizing, validating, destigmatizing, and providing a "face" to this disease.

CONCLUSION The AIDS/HIV epidemic poses a serious public health problem, especially for Africa and other developing regions of the world. This fact underscores the urgent need for a greater understanding, by medical and related personnel (both inside and outside of these countries), of geographic, organizational, and cultural factors related to the incidence and prevalence of the AIDS/HIV epidemic. Only with this increased understanding can more innovative and effective health promotion approaches be successful in controlling this JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 9

dreadful disease. The consequences for failing to control AIDS/HIV in the already economically impoverished countries of the developing world, especially Africa, will lead to catastrophic destruction of people, societies, and cultures, the like of which has never been witnessed in the 20th century. Innovative and effective health promotion efforts, through the various strategies discussed, should help to change the view people have of AIDS and its victims, and provide a willingness to help, within the context of available resources. For example, the emphasis needs to be more on "the life that remains" than the "death that is to come." In addition, the issues of "shame" or "blame," which are apt to occur in some African communities and which are perpetuated by traditional and religious leaders who label AIDS as a "curse from God" and sufferers as "deserving of punishment," need to be openly addressed.2' Without the benefit of a clear and contrary message conveyed through health promotion, this distorted view will prevent some families from seeing their obligation to persons with AIDS, thereby withholding valuable spiritual, emotional, and economic resources. The individual and collective lack of such resources could, indeed, expedite deleterious outcomes associated with AIDS.67'76 Two main points were discussed in the article, and their importance should be emphasized. The first is that the success of any health promotion campaign in Africa (or for that matter, any other developing country) relates to how much consideration is given to the specific and unique cultural (eg, the need for increased sexual empowerment of African females) and other factors of the region when the campaign is designed. Second, these campaigns must, of necessity, also pay close attention to and build on relevant theories/constructs (eg, behavioral change, self-efficacy, and controllability) and research that have been established in the area. For example, caution should be exercised against the indiscriminate use of the mass media as a means of educating people. Instead, the benefits of using interpersonal channels of communication (eg, the testimonials of persons with AIDS) for reaching select groups and influencing sensitive behaviors within the community must be explored.84 This latter point is important, especially in the African context. It has been said that despite the cost and effort behind many of the AIDS print media efforts, research into popular understanding about AIDS demonstrates clearly that although levels of consciousness about the epidemic have been raised, misunderstanding still persists.84 Shifts of attitudes in some countries have 767


been slight after initial campaigns,85 and in many have been opposite to that desired. It has been speculated that, paradoxically, target groups have been disabled by the media message. Because of this possibility, a point emphasized in the article is that new, innovative, and complementary strategies must be adopted in health promotion campaigns involving AIDS/HIV. Decentralization of AIDS control activity in Africa down to a more community-based health-care approach was emphasized as being more efficacious in controlling the AIDS/HIV epidemic. A more community-based focus, which in essence would be more participatory, would in part shift away from the prescriptive traditions of information giving, which seem to characterize most AIDS campaigns, and move to more information sharing, equality, and mutual respect between all parties concerned. Medical personnel, families, traditional healers, and persons with AIDS should all be brought together and have meaningful dialogue about ways of controlling the disease. Awareness workshops in villages, schools, workplaces, and churches should be convened in an atmosphere of confidentiality, openness, and respect for each participant present. Examples of such activities that are already being conducted and can serve as guiding models include Awareness Workshops for Traditional Healers and Donor Promoter Courses for Blood Donors.84 If these and other similar participatory programs are carefully guided, it is reasoned that in the 'long run, they will contribute significantly to increased feelings of empowerment and self-efficacy of the target group-all Africans, thereby providing them with the motivational wisdom to protect themselves from at-risk AIDS/HIV behavior and activities. The birth of the next generation of Africans as well as the quality and quantity of life experiences of those currently living with and around the disease, depend on the success of this gargantuan but surmountable task. Literature Cited 1. The global AIDS situation. WHO Notes and News. 1990;1 1:341-342. 2. Sottak KJ. A Mann for the times. Harvard Public Health

Rev. 1991;2(3):30-35. 3. Tinker J. Breadwinners and the poor are most vulnerable. People. 1987;14:17-19. 4. Livingston IL. Hypertension and health education intervention in the Caribbean: a public health appraisal. J Natl Med Assoc. 1985;77:273-280. 5. Piot P. In search of the magic bullet. The Courier 1991;126:70-72. 6. Weller IVD. Antiviral therapy in HIV infection past, present and future. In: Fleming AF, Carballo M, FitzSimons DW, 768

Bailey MD, eds. The Global Impact of AIDS. New York, NY: Alan R. Liss Inc; 1988:385-395. 7. Sherr L. An evaluation of the United Kingdom government health education campaign on AIDS. Psychology and Health. 1987;1 :61-72. 8. Solomon MZ, DeJong W. Recent sexually transmitted disease prevention efforts and their implications for AIDS health education. Health Educ Q. 1986;13:301-316. 9. Green J, Miller D. AIDS. The Story of a Disease. London, England: Grafton Books; 1986. 10. Clumeck N, Sonnet J, Taelman H, et al. Acquired immunodeficiency syndrome in African patients. N Engl J Med. 1 984;31 0:492-497. 11. Van de Perre P, Munyambuga D, Zississ G, et al. Antibody testing to HTLV-III in blood donors in central Africa. Lancet. 1985;1:336-337. 12. Erben R. Health challenges for the year 2000: health promotion and AIDS. Health Educ Q. 1991;18:29-37. 13. Shulman LC, Mantell JE. The AIDS crisis: a United States health care perspective. Soc Sci Med. 1988;26:979-988. 14. Ziegler JB, Cooper DA, Johnson RO, et al. Postnatal transmission of AIDS-associated retrovirus from mother to infant. Lancet. 1985;1:896-898. 15. Volberding PA. The clinical spectrum of the acquired immunodeficiency syndrome: implications for comprehensive patient care. Ann Intern Med. 1985;1 03:729-733. 16. Moss AR, McCallum G, Volberding PA, et al. Mortality associated with mode of presentation in the immune deficiency syndrome. J Natl Cancer Inst. 1984;73:1281-1284. 17. Over M, Bertozzi S, Chin J, et al. The direct and indirect cost of HIV infection in developing countries: the case of Zaire and Tanzania. In: Fleming AF, Carballo M, FitzSimons DW, Bailey MD, eds. The Global Impact of AIDS. New York, NY: Alan R. Liss Inc; 1988:123-135. 18. Carballo M, Carael M. Impact of AIDS on social organization. In: Fleming AF, Carballo M, FitzSimons DW, Bailey MD, eds. The Global Impact of AIDS. New York, NY: Alan R. Liss Inc; 1988:81-93. 19. Nkowane BM. The current situation. The Courier

1991;126:43-46. 20. Struchiner C. Intervention. Presented at the AIDS and Reproductive Health Network Meeting; February 1990; Bangkok, Thailand. 21. Ankrah EM. AIDS and the social side of health. Soc Sci Med. 1991;32:967-980. 22. Mazrui AA. The African Condition: A Political Diagnosis. London, England: Heinemann; 1990. 23. Darrow WW, Gorman EM, Glick BP. The social origins of AIDS: social change, sexual behavior and disease trends. In: Feldmen DA, Johnson TM, eds. The Social Dimensions of AIDS: Methods and Theory. New York, NY: Praeger Publishers; 1986:95-107. 24. Consensus Statement From Consultation on Sexually Transmitted Diseases as a Risk Factor for HIV Transmission. Geneva, Switzerland: World Health Organization; 1989. WHO/

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27. Sadeque N. Pakistan: we're not immune. World AIDS. 1990;7:2. 28. General L. Brazil steps up AIDS campaign. AIDS Watch. 1988;2:6-7. 29. Panos Dossier. The Third Epidemic-Repercussions of the Fear of AIDS. London, England: The Panos Institute; 1990. 30. Hospedales CJ, Mahabir S. The epidemiology of AIDS in the Caribbean and action to date. In: Fleming AF, Carballo M, FitzSimons DW, Bailey MD, eds. The Global Impact of AIDS. New York, NY: Alan R. Liss Inc; 1988:27-33. 31. White E. AIDS in the Caribbean. The Courier

1991;126:58-60. 32. Hospedales CJ. An update on AIDS in the Caribbean (1982-1989). West J Med. 1990;39:128-130. 33. Piot P, Quinn TC, Taelman H. Acquired immunodeficiency syndrome in a heterosexual population in Zaire. Lancet. 1 984;ii:65-69. 34. Neequaye AR, Ankra-Badu GA, Affram RK. Clinical features of HIV infection in Accra Ghana. Ghana Medical JournaL 1987;23:3-6. 35. Denis F, Barlin F, Gershy-Damet T, et al. Human T-lymphphotrophic virus type III (HIV) and type IV in Ivory Coast. Lancet. 1987;1:408-411. 36. Traore A. The cost of AIDS: food for thought. The Courier 1991;126:47-49. 37. Traore A. An interview with Dr Michael H. Merson, Director of WHO Global Program on AIDS. The Courier

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JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 9

Innovative business approaches for incenting health promotion in sub-Saharan Africa: progress and persisting challenges.

The immunization and vaccine crisis in developing countries.

Health crisis in African countries.

National health guidelines in I.R of iran, an innovative approach for developing countries.

Innovative approaches to understanding and addressing health disparities in diabetes care and research.

Drug promotion and labeling in developing countries: an update.

Community health workers in Canada: innovative approaches to health promotion outreach and community development among immigrant and refugee populations.

Health care in developing countries.

Innovative platform and incentive mechanism are the keys for electronic waste collection in developing countries.

Health care in developing countries.

Health research in developing countries.

Mental health in developing countries.

Issues in HIV testing in developing countries.

Noncommunicable diseases among urban refugees and asylum-seekers in developing countries: a neglected health care need.

The need for heuristics in ecosystem approaches to health.

Continuing education for the health team in developing countries.

Health and education in developing countries.

Rethinking HIV prevalence determination in developing countries.

Schoolteachers and health in developing countries.

Understanding parental participation in health promotion services for their children.

Developing countries: health round-trip.

Health promotion--the importance of demedicalized and active approaches.

Sexual health, alcohol and the university environment: is there a need for sexual health promotion intervention?

Brucellosis in livestock and wildlife: zoonotic diseases without pandemic potential in need of innovative one health approaches.