USING SURVEYS TO DESIGN EFFECTIVE RESPONSES TO HIV/AIDS
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The messages given are often threatening and stigmatizing. People are encouraged to get tested for HIV but not told where to go for a test. Churches and civic organizations sponsor lectures on AIDS by doctors who talk about "the virus" and modes of transmission. Condoms may or may not be mentioned as a preventive device. Unfortunately, such strategies often reinforce stigma and discrimination against seropositive persons. This "one-size-fits-all" approach is not effective. Changing risky behaviors and encouraging uptake of VCT services requires overcoming ignorance, denial and fear. By creating an enabling environment, with access to confidential counseling, testing and care, more people will avail themselves of HIV/AIDS services, particularly when there are "positive living" support groups of seropositive persons.
Information about attitudes and behaviors is needed in order to develop appropriate messages.
In Botswana, for example, the Botswana Network of People Living with HIV and AIDS has succeeded in encouraging people to be public about their HIV status through special events like the 2006 "Mr. Positive Living Pageant". How can an organization develop a strategy on HIV prevention, access to VCT and support for positive living? The development of an effective and sustainable response to the epidemic requires information on the target population and how it is stratified in terms of knowledge, attitudes, practices and behaviors related to HIV/AIDS.The focus of the article is on two KAPB(1) studies conducted to assess how the populations served by two African organizations react to HIV/AIDS issues in order to obtain base-line measurements to inform the design of effective intervention of HIV prevention, counseling, testing and treatment. The KAPB studies will also serve to provide indicators for the evaluation of the impact of the programs. (1)Knowledge, Attitudes, Perceptions and Behavior. Two different organizations The two examples presented are the KAPB studies of the Ivorian National Agency for Support to Rural Development, or ANADER(2) and the Ibani-se HIV/AIDS Initiative of Nigeria. ANADER is a quasi-governmental agency established in 1993 with the mission of contributing to the development of agriculture and improvement of the living conditions in rural areas. ANADER is, in many ways, the main contact point between the rural population and the Ivorian government. (2)Agence Nationale d’Appui au Développement Rural. On the other hand, the Ibani-se HIV/AIDS Initiative is a community-based NGO established on Bonny Island, Nigeria in early 2006. MSD worked closely with the Nigeria Liquefied Natural Gas Company (NLNG) in creating Ibani-se and provides it with ongoing technical assistance. It is the only AIDS NGO on Bonny Island and is currently the only entity supporting PLWA groups there. Two different locations ANADER and Ibani-se operate in very different environments: one rural and agricultural, the other urban and industrial-commercial. Despite certain differences in the HIV risk factors, the two organizations face similar challenges in developing effective programs on prevention, mitigation and care. With a population of over 16 million, the Ivory Coast has a generalized HIV epidemic and the highest HIV prevalence in West Africa. The national HIV prevalence rate among adults in the Ivory Coast was officially estimated to be 4.7 per cent in 2006. However, there is wide variation in prevalence among the regions, ranging from 1.7 to 5.8 per cent. The figures may be higher, however, as the recent civil war disrupted HIV/AIDS prevention and monitoring work. Overall, the epidemic in the Ivory Coast contributed to the loss an estimated 5.6 per cent of its workers by 2000 and the cumulative loss is projected to be in the range of 11.4% in 2020.(3) The fact that 60 percent of the population lives in rural areas and that agriculture represents 33 per cent of the Gross National Product underscores the seriousness of the HIV/AIDS threat to the economy. Commercial agricultural production (particularly cacao, coffee, palm oil and coconuts) is labor-intensive and concentrated in the south of the country. (3)Population Division, DESA, United Nations Secretariat, "The Impact of AIDS" Nigeria, with about 140 million people, has the largest population of any African country. The national adult HIV prevalence was 4.4% as reported in the latest sero-prevalence survey (2005)(4). However, it ranges between 1.6 - 10 per cent in different parts of the country, with the highest rates in the cities in southern Nigeria. For instance, the 2006 KAPB study on Bonny Island revealed an adult prevalence of 8.3%, which is almost twice the national average. (4)Journalists Against AIDS Nigeria http://www.nigeria-aids.org/news/content.cfm/346 Nigeria's economy is highly dependent on capital-intensive oil industry which contributes around 95% of export earnings and about 75% of government revenue. One of the major production and export centers of petroleum and natural gas is Bonny Island, a long-established kingdom as well as a Local Government Area situated at the southern edge of Rivers State in the Niger Delta. Although only about 180 square kilometers in area, with an estimated population of 100,000, it is the home to over 30 billion dollars in oil terminals and the world’s second-largest liquid natural gas production facility. Ferries are the main form of transport to and from the island. The approximately 30,000 indigenous Ibani have become a minority on their island as Nigerians of all walks of life from other ethnic groups as well as foreign technicians employed by the construction, gas and oil companies have settled on the island, either on a permanent or transient basis. The presence of these migrants, who are mainly men, has attracted other service industries, including large numbers of sex workers, who operate in shanty town bars and brothels and periodically infiltrate the company compounds. The ANADER and Ibani-se KAPB studies The two organizations have different concerns in the area of HIV/AIDS. In the case of ANADER, HIV/AIDS initiatives were initially concentrated on the farming communities that are serviced by the ANADER extension agents. It became evident, however, that ANADER staff and their families were also at risk of HIV infection, particularly since most of the 2,138 employees are men whose agricultural extension work takes them away from home for extended periods of time. For ANADER, the new concern is HIV/AIDS in its own work place. In the case of Ibani-se, however, the primary focus of its work is the Bonny Kingdom at large. This means devising a diversified strategy of prevention, VCT and treatment that addresses the needs of women, school children, transportation workers, industrial workers, the uniformed services and commercial sex workers. ANADER 
In 2004, also with the support of MSD, ANADER developed its HIV/AIDS Strategic Plan for 2005-2007 with two main thrusts. The first is to strengthen the programme for employees and their dependants (an approximate total of 15,000 persons, including 2,138 staff, 1,200 of whom are mobile extension workers). The second thrust is to expand prevention, VCT, care and treatment for rural communities, with a target population of 3.8 million rural inhabitants. In terms of its own staff, ANADER’s goals on HIV/AIDS prevention, mitigation and treatment are that:
Table 1: Key findings of the ANADER KAPB study
The Ibani-se HIV/AIDS Initiative Because of its recent creation (2006), the Ibani-se HIV/AIDS Initiative is in the initial phases of its work on prevention, mitigation and care and has a small permanent staff. For those reasons, it decided to contract the Society for Family Health, a well-known Nigerian NGO specialized in HIV/AIDS research and program development. The KAPB study, conducted in September and October, 2006, was designed to give an overview of the HIV/AIDS situation in the Bonny Kingdom. The research was the first of its kind to be conducted on the island. The planned sample was stratified to comprise 4,500 total respondents plus 1,650 persons volunteering for HIV testing, the latter in order to establish an adult HIV prevalence rate. There were three groups of respondents: members of the general population of Bonny Island, aged 15 to 49; NLNG staff and employees of its subcontractors and female sex workers, a large occupational group on Bonny Island. In reality, only 2,603 people finally agreed to participate in the KABP survey (from all three categories of respondents) and 714 volunteered for HIV testing. In addition to the quantitative survey, there was a qualitative assessment. The qualitative researchers conducted a total of 20 focus group discussions and two individual in-depth interviews among specific target groups. The key target groups included the industrial workers, boat drivers, motor cycle (okada) taxi drivers, youth, adult men and women. There was also a health facility survey that covered 14 public and private health facilities located within Bonny Town and in the rural creek areas. The assessment evaluated VCT and PMTC services in these facilities. Highlights of the findings of the KAPB study conducted among the general public are as follows. The respondents were nearly equally divided between young men and women. Seventy-five per cent were aged 15 to 34 and 48 per cent were single. Table 2: Key findings of the Ibani-se KAPB study
Discussion Both ANADER and Ibani-se face significant challenges in using the results of their respective KAPB studies to devise strategies of HIV/AIDS prevention, mitigation and treatment. In the case of Ibani-se, its "target audience" is extremely heterogeneous, comprising many different professional groups, ranging from commercial sex workers to expatriate technicians in the gas and oil industry. Some stakeholders are well-educated while others have very limited literacy. The advantage is that they are all concentrated in a compact area but the disadvantage is that reaching vulnerable groups like sex workers means overcoming considerable stigma, silence and denial. As an NGO, Ibani-se needs to establish a relationship of confidence with NLNG, the oil and companies as well as various stakeholder groups in the community in order to design and launch its program. ANADER, on the other hand, has a more unified group (its own staff and their families) but they are scattered over a wide area. Fortunately, there has been some preparatory work going on for a few years and an HIV/AIDS strategy for the rural communities was launched with PEPFAR funding. ANADER management is also committed to supporting the new program for staff and their families. In conclusion, the two KAPB studies indicate certain priorities for program development by each organization: Table 3: Elements of programs being developed based on the two KAPB studies
Conclusions Given the scope and complexity of the tasks in developing prevention, mitigation and treatment programs in rural Ivorian communities and the densely-settled but very diverse Bonny Kingdom populations, the two KAPB studies are proving to be valuable sources of guidance. It is expected that the studies will also serve to monitor and evaluate the effectiveness of the programs through follow-up studies. In conclusion, the cost and effort needed to conduct KAPB studies is a worthwhile investment in successful AIDS programming. Article by Eric Allemano, HIV, AIDS and education specialist Photos by Eric Allemano, Donald de Korte, Sophie d'Aurelle de Paladines Bibliography Avert. 2006. "HIV/AIDS in Nigeria." Available at http://www.avert.org/aids-nigeria.htm Journalists Against AIDS Nigeria (2007). Available at http://www.nigeria-aids.org/news/content.cfm/346 Ministère de la Lutte contre le Sida and Institut National de la Statistique. (2005). Résultats de l’Enquête sur les Indicateurs du Sida en Côte d’Ivoire 2005 (EIS-CI). Abidjan, Ministère de la Lutte contre le Sida et l’Institut National de la Statistique. Available at : http://www.measuredhs.com/pubs/pdf/ HF14/CotedIvoire_HIV_factsheet_french.pdf Office of the United States Global AIDS Coordinator (2005). Country Profile - Côte d’Ivoire. Washington, D.C., U.S. President’s Emergency Plan for AIDS Relief. Available at: http://www.cdc.gov/nchstp/od/gap/c.../FY04OGACCotedIvoire.pdf Population Division, UN Department of Economic and Social Affairs (2003) The Impact of AIDS. New York. United Nations Secretariat. Available at: http://hivaidsclearinghouse.unesco.org/ev_fr.php?ID=3356_201&ID2=DO_TOPIC |
Initially seen as a medical issue concerning so-called "high-risk" groups, the HIV/AIDS epidemic has become a much broader threat to communities and the economy. Indeed, the epidemic affects persons from all walks of life. These include women, children, agricultural and industrial workers, technicians and civil servants at all levels. Hoping to stop risky behaviors among the public or their employees, governments and private organizations try to prevent the spread of HIV through information or "education" campaigns. Typically, the information campaign includes of billboards warning against risky behavior or brochures describing the medical and epidemiological aspects of AIDS.
