Preventing and Mitigating AIDS in Sub-Saharan Africa Research and Data Priorities for the Social and Behavioral Sciences (1996) / Chapter Skim
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SUMMARY
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estimates that approximately 11 million adults and as many as 1 million children have been infected with HIV, and where basic infrastructure, financial, and managerial resources, as well as health-care personnel to deal with the catastrophe, are all extremely scarce. Sub-Saharan Africa is geographically, demographically, socially, and culturally heterogeneous, and the extent and spread of HIV infection and AIDS have accordingly been heterogeneous as well.
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Thus, changing human behavior to slow the speed or limit the extent of transmission will remain for the foreseeable future the first and probably the most important line of defense against HIV/AIDS in sub-Saharan Africa. More and better social and behavioral research is needed to develop more effective and acceptable preventive strategies and to find more effective ways of mitigating the negative effects of the epidemic.
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Our recommendations cover five areas: the monitoring of the epidemic, information on sexual behavior and HIV/AIDS, primary HIV-prevention strategies, mitigation of the impacts of the epidemic, and the building of an indigenous capacity for AIDS-related research. Both our five key recommendations and our other recommendations are offered with full acknowledgment of the importance of the economic, political, and societal context of the HIV/AIDS epidemic in Africa.
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EPIDEMIOLOGY OF THE HIV/AIDS EPIDEMIC The global HIV/AIDS epidemic consists of many separate, individual epidemics, each with its own distinct characteristics that depend on geography, the specific population affected, the frequencies of risk behaviors and practices, and the timing of the introduction of the virus. No single factor, biological or behavioral, determines the epidemiologic pattern of HIV infection.
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Good social science research is as dependent as public health and medical research on reliable and valid HIV/AIDS surveillance data. With the implementation of various interventions aimed at controlling HIV transmission, periodic monitoring of STD and HIV prevalence and incidence among selected populations is essential both for assessment of the impact of these programs and for decision making on program design and implementation.
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SEXUAL BEHAVIOR AND HIV/AIDS Patterns of sexual behavior- both partner selection and particular practices are clearly the primary determinant of the spread of the HIV/AIDS epidemic in sub-Saharan Africa. Information on sexual behavior is needed to help project the future course of the epidemic, to develop more effective prevention strategies, and to provide baseline data for evaluating the effectiveness of alternative preventive strategies.
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Population-based research is needed to collect and analyze data on both the variables that describe individual sexual behavior and the possible socioeconomic determinants of the decision to have sex with a new partner or forgo protection. Since the details of interconnected sexual networks are difficult to deduce from the answers to individual questionnaires, there is also an important role for social network research.
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Recommendation 4-7. Research on attitudes and beliefs about and behavioral responses to sexually transmitted diseases is required.
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For example, broad-based education campaigns have persuaded large numbers of people to have their children immunized against various childhood diseases and have educated mothers to give their children oral rehydration formula during episodes of diarrhea. Of course, attempting to modify more personal behavior, such as sexual practices, is more challenging.
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_ KEY RECOMMENDATION 3. More evaluation research is needed to correlate process and outcome indicators such as reported condom sales and behavior change with reductions in HIV incidence or prevalence.
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Nevertheless, it is a priority to begin now a few large-scale behavioral interventions, including adequate baseline surveys, multiround surveys, and longitudinal studies with comparison cohorts, even if these interventions are relatively expensive. It is only with these types of studies that more definitive information on the effectiveness of various interventions, which is so desperately lacking for most studies in sub-Saharan Africa, can be obtained.
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Research is needed to determine the extent to which STDs help cause HIV infection, to examine the importance of the behavioral synergy of STD and HIV transmission, and to design more effective intervention programs. There is a need for assessment of the relative efficacy and feasibility of various interventions for STD treatment and sexual behavior change in reducing HIV transmission.
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The growth of the HIV/AIDS pandemic in the past 20 years in sub-Saharan Africa has led to the development of institutional and community-based responses and a corresponding need for operations research to improve the effectiveness, cost-effectiveness, and quality of these responses. Primary research needs include scaling up successful experimental interventions, improving the effectiveness and reducing the cost of existing programs, examining the cost-effectiveness of linking HIV prevention with HIV/AIDS care, and improving the sensitivity .
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, hyperimmune gammaglobulin, vitamin A, vaginal washes, and other means of intervention should be undertaken to determine their overall effectiveness and cost-effectiveness in decreasing HIV perinatal transmission. MITIGATING THE IMPACT OF THE EPIDEMIC AIDS will have a large social, psychological, demographic, and economic impact on both individuals and societies.
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Research is needed to ascertain whether decreased life expectancy reduces willingness to save or invest in financial and real assets, in human capital, and in the relationships necessary to maintain social interactions. In the long term, the impact of HIV/AIDS on sub-Saharan Africa will depend on the strength and malleability of social and economic networks in accommodating the changes that are occurring.
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Thus, beyond the immediate challenge of identifying the critical research questions, there remain enormous practical challenges of actually obtaining the answers. Key aspects of a basic infrastructure for conducting effective research include access to adequate funding, skilled labor, and appropriate technology, as well as sufficient managerial and administrative capacity to plan, execute, monitor, and evaluate studies.
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Linkages with international organizations, especially if built on an evolving and well-defined research agenda, can help local institutions develop and assist local researchers by providing relatively secure long-term funding, offering support for the preparation of data and manuscripts for publication and dissemination, and providing in-country technical assistance and research training. Experience in a number of settings has demonstrated that such long-term collaboration, in addition to contributing significantly to understanding of the HIV/AIDS epidemic, is mutually beneficial to all institutions involved; it could be very
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They should also have AIDS databases on CD-ROM (CD-ROM-equipped computers are available in most national AIDS control program offices.) In addition, national and regional conferences should be held to provide forums at which researchers can discuss their research plans and present their results to a larger group of local researchers than those that attend international conferences.
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If more effective strategies for AIDS prevention and mitigation are to be developed in the future, better coordination among donors is needed, particularly sharing of information about which prevention and control efforts work and which do not. The role of the new cosponsored United Nations Programme on AIDS (UNAIDS)
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Efforts to model the demographic effects of the HIV/AIDS epidemic are hindered by a paucity of data sets that combine fertility, mortality, migration, and other sociodemographic information with HIV serology. Conversely, serological studies that fail to collect adequate behavioral data miss an important opportunity to assess the effects of key factors in the spread of HIV, such as sexual practices and sexual networks within given populations.
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