Community-based intervention for AIDS prevention.
According to the WHO, about 40 million people are living with
HIV/AIDS globally. AIDS is the leading cause of death worldwide for
adults aged 15-49. In 2006, 4.3 million people were newly infected with
HIV and 2.9 million people died of HIV/AIDS-related illnesses.
Antiretroviral treatment (ART) has prolonged the survival of patients
infected with HIV-1. Morbidity and mortality related to HIV-1 have
dramatically declined in developed countries, converting HIV infection
into a treatable chronic disease. However, current antiviral drugs do
not eradicate the virus, and prolonged treatment can have serious side
effects and select for drug-resistant viral strains. However, just one
in five people at risk for HIV in sub-Saharan Africa has access to the
information and tools they need to prevent infection, and millions are
in urgent need of antiretroviral medicines. The WHO set the goal to stop
the spread of HIV/AIDS by 2015. The goal is feasible as HIV/AIDS is
preventable. Simply using condoms can make a big difference. Providing a
safe blood supply is another major step. Most important of all is
raising awareness about HIV/AIDS through community mobilization,
education program for AIDS prevention, and behavior change in special
groups. This review focuses on community-based interventions for
Keywords: Community-based Intervention; HIV/AIDS awareness; Behavioral change; Prevention
(Development and progression)
HIV (Viruses) (Care and treatment)
AIDS (Disease) (Development and progression)
AIDS (Disease) (Care and treatment)
Chronic diseases (Development and progression)
Chronic diseases (Care and treatment)
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Current antiviral drugs do not eradicate HIV, and prolonged treatment can have serious side effects and select for drug-resistant viral strains. (1,2) Most important of all is raising awareness about HIV/AIDS through community mobilization, education program for AIDS prevention, and behavior change in special groups. This review focuses on community-based interventions for HIV/AIDS prevention.
Behavior Change Programs in Special Groups
Injecting drug users (IDUs)
A quasi-experimental study was conducted among IDUs in communities located in urban areas in Sichuan Province, China. (3) A pair of sites was selected; one site was the "intervention city" in which various intervention measures were implemented, and the other was the "control city" in which no intervention was implemented. A Behavior Surveillance Survey was used to evaluate intervention exposure and the effect of behavior change. In the intervention city, services received by IDUs increased over time; awareness of HIV increased from 34.2% in 2003 to 58.3% in 2004, and to 67.4% in 2005. Overall needle sharing decreased from 17.1% in 2003 to 7.0% in 2005, and needle sharing in the past month decreased from 42.4% in 2003 to 18.4% in 2005. The intervention was effective in changing this risk behavior. A Pakistani group (4) reported a study conducted among 608 IDUs, of which 607 were male, only one was female, the median age was 32 years old, and 45% had no formal education. Half were married, of whom 25% were living with their wives. With regard to sexual behavior, 14% had sex with other males, 28% reported sex with both males and females, 49% had paid money to have sex, and only 10% had ever used condoms. One-fifth reported having had a sexually transmitted disease (STD) and about 40% reported having suffered from either one or more STD-related symptoms. Only 41% had heard about HIV/AIDS, of whom 17% knew that HIV/AIDS could be transmitted through sexual contact. The authors concluded that high-risk sexual behaviors are prevalent among male IDUs in Pakistan (5-6), and awareness of transmission risks is low. Effective and specific interventions in Pakistan are urgently needed to prevent the transmission of HIV and STDs among IDUs and their sex partners. The prevalence of HIV infection among IDUs in Saudi Arabia was reported for the first time in a study of 2,628 men admitted to a rehabilitation facility from January 1995 to May 1996 and who were screened for HIV-1 and/or HIV-2. (7) The study found that 81.2% of participants were aware of HIV/AIDS and two-thirds knew that the virus can be transmitted by sharing needles and syringes. Five samples were found to be positive by enzyme immunoassay, but only four were confirmed by Western blot, for an HIV prevalence of 0.15%. The low HIV prevalence detected in this study among a high-risk group suggests that Saudi Arabia is in a pre-epidemic stage. However, community-based data are necessary to establish the true situation in the country. Continued public awareness campaigns on the modes of HIV infection were recommended by the authors. IDUs in London have made positive reductions in risk behavior. (8) Levels of syringe sharing were substantially lower than those reported up to 1987 before generalized AIDS awareness and the introduction of HIV prevention measures. The majority did not share syringes or confined their sharing to close friends and sexual partners, and when sharing, cleaned their syringes. The continuation of indirect sharing indicates the need for more detailed prevention messages. While the initial decline in syringe sharing rates may be attributed to the wide availability of sterile injecting equipment and other preventive measures, it may now be necessary to look beyond current intervention initiatives to develop interventions that seek to change the social etiquette of sharing and move towards the long-term maintenance of low levels of injecting risk behavior.
A participatory community project in the US-Mexico border town of Ciudad Juarez aimed at helping women who are sex partners of male IDUs to reduce behaviors that increase their risk of HIV infection. (9) The design and implementation of the project were influenced by Paulo Freire's pedagogy in the Latin American tradition of 'popular' education, by Bandura's self-efficacy concepts, and by David Warner's 'barefoot doctor' community health care methodology. Using these approaches, the participants were directly involved in the development of teaching materials and curriculum content, and implementation of the project. The program was evaluated quantitatively using National Institute on Drug Abuse (NIDA's) AIDS Intake and Follow-up Assessment (AIA/AFA) questionnaires and qualitative open-ended interviews. While the AIA/AFA questionnaires detected small changes in the frequency of condom use among the participants, ethnographic interviews detected significant changes in the nature of the behaviors that were placing the women at risk. The changes seemed to stem from an increase in the degree of self-esteem, self-efficacy, and awareness of the social, economic, and political constraints of their lives. This study demonstrated the need for qualitative measures to be incorporated in the evaluation of community-based health education programs.
Female Sex Workers in the Entertainment Industry
Female sex workers at different sites in five different provinces of China were targeted to evaluate STDs/HIV intervention program. (10) A Women's Health Clinic was set up near participants' working place at each site. Clinic-based outreach activities, including awareness-raising, condom promotion, and sexual health care, were developed and delivered to sex workers. Cross-sectional surveys at baseline and post-intervention were used to evaluate changes in condom use with the last three clients, and the prevalence of chlamydia and gonorrhea. A total of 907 sex workers were examined at baseline; 12 months post-intervention, 782 were examined to measure the effect of the intervention. Outreach teams made a total of 2552 visits to 13,785 female sex workers and distributed 33,575 copies of educational material and 5,102 packets of condoms. The condom use rate increased from 55.2% to 67.5%. The prevalence of gonorrhea fell from 26% to 4%; and that of chlamydia fell from about 41% to 26%. The intervention was effective in increasing condom use and reducing STDs among sex workers. The results were used to develop national guidelines on sex worker interventions for nationwide scale up.
Males In Rural Communities
In Goa, India, a sample of 300 males aged 15-49 years was selected by stratified random sampling. (11) A cross-sectional community-based survey was conducted following the "UNAIDS protocol for measurement of HIV/STD prevention indicators." Of the men surveyed, 198 reported having sexual intercourse (66%) and 17% were single. Fifty-three (17.7%) males reported intercourse with a non-regular partner in the past 12 months; of these men, 90.6% had intercourse with strangers, 92.5% had paid for sex, and only 43.4% had used a condom for the last sexual encounter with a non-regular partner. Less educated males (<10th grade), those who were single, and those who were employed were more likely to have sex with non-regular sexual partners. The level of knowledge about HIV/ AIDS was very high in all areas of causation and prevention. Despite that, condom use was very low, resulting in high-risk behavior related to HIV/AIDS and STDs among males. The authors recommended more effective behavior change communication (BCC) strategies in the community as well as innovative methods like village level peer education. Behavioral change has also been reported in a South African gold mining community (12) and among fishermen in a coastal area of Balochistan. (13)
Educational Programs for AIDS Prevention
Peer Education Model for Low-Literacy Rural Communities
Low HIV awareness and high stigma, fueled by low literacy, seasonal migration, gender inequity, spatial dispersion, and cultural taboos, pose extra challenges to implementing much-needed HIV education programs in rural areas. A peer education model was developed to educate and empower low-literacy communities in the rural district of Perambalur (Tamil Nadu, India). (14) From January to December 2005, six non-governmental organizations (NGOs) with good community rapport collaborated to build and pilot-test an HIV peer education model for rural communities. The program used participatory methods to train 20 NGO field staff (outreach workers), 102 women's self-help group (SHG) leaders, and 52 barbers to become peer educators. Cartoon-based educational materials were developed for low-literacy populations to convey simple, comprehensive messages on HIV transmission, prevention, support, and care. In addition, street theater cultural programs highlighted issues related to HIV and stigma in the community. The program is estimated to have reached over 30,000 villagers in the district through 2,051 interactive HIV awareness programs and one-on-one communication. Outreach workers (OWs) and peer educators distributed approximately 62,000 copies of educational material and 69,000 condoms, and also referred approximately 2,844 people for services including voluntary counseling and testing (VCT), care and support for HIV, and diagnosis and treatment of sexually-transmitted infections (STIs). At least 118 individuals were newly diagnosed as persons living with HIV (PLHIV); 129 PLHIV were referred to the Government Hospital for Thoracic Medicine (in Tambaram) for extra medical support. Focus group discussions indicate that the program was well received in the communities, led to improved health awareness, and also provided the peer educators with increased social status. Using established networks (such as community-based organizations already working on empowerment of women) and training women's SHG leaders and barbers as peer educators is an effective and culturally appropriate way to disseminate comprehensive information on HIV/AIDS to low-literacy communities. Similar models for reaching and empowering vulnerable populations should be expanded to other rural areas, like Papua New Guinea. (15)
Community-Based Education Program
One approach to alleviating the stress on national health provision is to expand the knowledge base at the community level with contributions by lay health workers (LHWs). (16,17) In order to accurately assess the impact of interventions, we should pay attention to socioeconomic and behavioral aspects and to disease surveillance at the local level. We need to marshal volunteers from within communities, taking account of their problems and motivations to ensure interventions incorporating two-way dialogue with the general populace to package expertise in the medical/research community for lay consumption. Community "gatekeepers," heads of households, and religious and community-based leaders should also be included in the education program to increase their level of awareness. It is especially important to implement services for the prevention of mother-to-child HIV transmission. (18,19) When facing limited awareness and accessibility to high-risk groups, a strategy was developed to encourage members of the high-risk population to assume a leadership role in the development and implementation of the community-based program. (20,21) When designing an education program, attention is focused on the segmentation of the audience (urban, rural, urban slum) and messages, and on how appropriate communication and educational strategies can be adopted to raise awareness of AIDS. (22) Community participation, program activities, and outreach strategies, including the development of educational materials and media contacts, are key for the success of a community educational program. (23-25) A family health awareness campaign (FHAC) has been implemented and scaled up in India. (26,27)
Secondary School Peer Education Program
A peer education program was conducted among adolescents in a rural area of Nigeria, to evaluate whether such programs promote HIV/AIDS awareness in terms of knowledge, misconceptions, and behavior. (28) A comparative case series (n = 250), cross-sectional structured survey (n = 135), and focus group discussions (n = 80) were undertaken among adolescents. In both the case series and structured survey, a questionnaire was used to address socio-demographic factors, knowledge on the transmission and prevention of HIV/AIDS, accessibility to different sources of HIV/AIDS information, stigmatization, and sexual behavior. Binary logistic regression was applied to compare responses from the peer-educated and not peer-educated populations. The model was adjusted for confounders. It was demonstrated that, among adolescents receiving peer education, HIV/AIDS knowledge increased and misconceptions and risky sexual behavior decreased when compared to adolescents not receiving peer education. These differences were apparent both over time (2005-2007) and cross-sectionally (2007). Peer education in rural areas can be effective in HIV/AIDS prevention, by positively influencing knowledge and behavior.
AIDS Awareness through Community Mobilization
Community Mobilization to Prevent HIV Transmission
The PRECEDE-PROCEED model for community planning and health promotion to eliminate local disparities in HIV disease was adopted by a coalition led by public health professionals. During the first year of the project, discussion groups and other formative evaluation activities maximized input from community members and community-based organizations. Twelve of 53 ZIP code areas, which accounted for 73% of reported AIDS cases among Black and Hispanic young adults (18 to 39 years) from 1994 through 1999, were selected as the primary sites for intervention. (29) Horizontal outreach to residents, vertical outreach to stakeholders and gatekeepers, strategic communication, and capacity building and infrastructure development were chosen as the most promising activities to promote behavioral and social change. Results from baseline computer-assisted telephone-interview (CATI) surveys completed with 2,011 community residents in 2001 and first-year follow-up interviews with 2,381 residents in 2002 indicated that: awareness of program efforts had increased from 5.4% in 2001 to 6.7% in 2002; recognition of the extent of the HIV/AIDS problem had increased from 27.5% in 2001 to 35.3% in 2002; and participation in HIV prevention efforts had increased significantly. Interventions were reaching the target audience, informing young adults of the risks of HIV infection and encouraging them to take ownership and action. Community KAP (knowledge, attributed, practice) of AIDS prevention is critical. (30-34)
Networking Communities in Fighting against AIDS
When combined with major social inequities, the AIDS epidemic in Brazil becomes much more complex and requires effective and participatory community-based interventions. (35) A civil society organization, the Center for Health Promotion (CEDAPS), in the slum communities (favelas) of Rio de Janeiro, Brazil, used a community-based participatory approach in which 55 community organizations were mobilized to develop local actions to address the increasing social vulnerability to HIV/AIDS of people living in squatter communities. This was achieved through on-going prevention initiatives based on the local culture and developed by a Network of Communities. The community movement has created a sense of "ownership" of social actions. The fight against AIDS has been a mobilizing factor in engaging and organizing communities and has contributed to raising awareness of health rights. Local actions included targeting the determinants of local vulnerability, as suggested by health promotion workers.
Serial Theme Education Programs
There have been successful experiences from the US. (36) During the 1987-90 period, five phases of new AIDS information materials were released to the general public in the ARTA (America responds to AIDS) campaign, including a national mailer. The five phases consisted of "General Awareness: Humanizing AIDS" in October 1987, "Understanding AIDS," the national mailout, in April 1988, "Women at Risk/Multiple Partners, Sexually Active Adults" in October 1988, "Parents and Youth" in May 1989, and "Preventing HIV Infection and AIDS: Taking The Next Steps" in July 1990. From planning to implementation to evaluation, ARTA is based on well-established theory and practice. Initially, the campaign was a response to an immediate crisis. It has evolved into the deliberate and systematic development of objectives to combat a chronic problem. ARTA represents one of the most comprehensive formative research processes in the history of public service campaigns. The dynamic process of carefully developing each new phase to include such important entities as state and local health agencies and community-based organizations is at least as important as the quality of the end materials. The objectives of each new phase are based on the needs of the public and of specific audiences. Maximum input from all relevant constituencies is obtained to ensure that they support the campaign's objectives and implementation strategy. Other special theme educational programs, such as the "Focus on Kids" HIV Risk Reduction Program (37), and the use of qualitative methodology in a remote Uganda community (38) have had success.
Community-Based HIV Mobilization for VCT
Forty-eight communities in Tanzania, Zimbabwe, South Africa, and Thailand (39), and in Ouagadougou, Burkina Faso (40) were randomized to receive the intervention or receive clinic-based standard voluntary counseling and testing (VCT) for comparison. The intervention included changing community norms to increase awareness of HIV status and reduce HIV-related stigma. Utilization of community-based HIV mobile VCT and clinic-based standard VCT by the community at 3 sites was monitored to assess differential uptake. Quality assurance procedures to evaluate staff fidelity to the intervention were also developed. The provision of mobile services, combined with appropriate support activities, may have significant effects on the utilization of VCT. These findings also provide early support for community mobilization as a strategy for increasing testing rates.
Community-based interventions to promote HIV/AIDS awareness and change risky behavior in special groups help to prevent the spread of HIV/AIDS.
Conflict of interest: None declared.
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Yanmei Li, Hongrong Cai, Qihan Li
Institute of Medical Biology, Chinese Academy of Medical Sciences, Peking Union Medical College, Kunming, Yunnan Province, China
Corresponding author: Yanmei Li, Associate Professor, Institute of Medical Biology, CAMS 379 Jiao Ling Rd, Kunming, 650118 Yunnan Province, China Email: email@example.com
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