HIV/AIDS communications such as campaigns and public messaging are important aspects of successful prevention and treatment agendas, but are fraught with complex challenges that must be recognized and overcome – UCLA MD candidate and Global Health enthusiast Abraar M. Karan explains…
Many countries, in the last decade, have started HIV-related campaigns to help mobilise their populations to get tested, undergo treatment, reduce stigmatisation, and limit risky behaviours. However, finding a way to safely communicate these messages, as we’ve been trying to do while constructing Mozambique’s campaign, has taught our team important lessons in the profound complexity that the HIV epidemic demands.
A starting point for any HIV communications agenda would surely include some of the following questions:
How does one start a voluntary counselling and testing (VCT) campaign? Or a sero-status disclosure campaign? How does this differ from an anti-retroviral therapy adherence campaign? Or a behaviour change campaign? What benefits instead, would a stigma reduction campaign bring?
These are all important questions, each of which we considered and worked through. Let’s explore some of our findings…
A campaign for universal Voluntary Counselling and Testing (VCT) in Mozambique, and many other countries in the region, wouldn’t be advisable given that the public health systems currently lack the capacity to test the vast numbers who would be likely to come forward. Thus, there would have to be a focus on high-risk groups. Unfortunately, there is mixed data on how best to target communication to these groups, and for some, such as female/male sex-workers, the strategy is completely different than for others, like, long-distance truck drivers. Thus, a campaign advising everyone to get tested is problematic, particularly if the people who actually do get tested aren’t the people who are sick, further burdening an already struggling healthcare system.
HIV Sero-status Disclosure campaign
An HIV sero-status disclosure campaign would seem like a good choice with an easy enough message. However, disclosing one’s HIV status is more difficult than even finding the immense courage to tell your loved ones or friends that you are infected. In Mozambique, where the legal system is inadequate to protect those who have disclosed, revealing your HIV status could mean, at best, discrimination in the workplace, in the healthcare system, in your community, and in your house. At worst, especially for women, it could mean abandonment or even death. And so for obvious reasons, Mozambique and many countries around the world just aren’t ready for major disclosure campaigns.
ART Adherence Campaign
For an antiretroviral therapy (ART) adherence campaign, one would think there are are only so many ways to encourage and empower someone to take their medication. However, aside from the fact that the guidelines have now changed (the new Option B+ regimen recommends all HIV+ mothers are treated for life, regardless of CD4 count), the further confounding consideration is that many people who find out they are HIV+ don’t have low enough CD4 counts to even qualify for treatment. Thus, they are sent home newly informed that they are HIV+, but with no medications because they are essentially not sick enough.
A behavioural campaign doesn’t seem easy, but it’s actually really difficult - because we keep finding that we know less about behavioural drivers than we thought. The leading view for the propagation of HIV/AIDS in Sub-Saharan Africa has been the existence of multiple concurrent sexual partnerships—having sex with more than one person regularly in the same general time-frame. So, some campaigns, such as OneLove by the Uganda Health Marketing Group, have focused specifically on pushing people out of these “sexual networks.” However, a recent paper in the Lancet suggests that total life-time partners rather than concurrent ones could be the real driver and the models up to date may have been focusing on the wrong aspect of the epidemic. It’s an immensely difficult and complicated question as to what type of behaviour change is most needed, but it would be wise to try and figure that out before trying to change people’s behaviours (which in itself is unbelievably hard to do).
Lastly, we considered an HIV stigma reduction campaign given that stigma affects everything previously discussed. But alas, even here there is a major catch. On the one hand, we want to create a campaign that would reduce the vilifying attitudes currently pervasive against HIV+ individuals. However, at the same time, we wouldn’t want to completely de-vilify the disease and unintentionally create laxity around precautionary measures to avoid HIV transmission. Separating people living with HIV/AIDS from HIV/AIDS itself is an important distinction that any stigma reduction campaign needs to make.
Ultimately, we found that there are a number of ways how not to start an HIV communication campaign, and identifying those is just as important, if not more so, than figuring out how to start one. Communication is a public good and continued action on HIV is essential. But once a successful or poor campaign starts, it affects all programs, regardless of which organization put the messages out. Thus, it is critical that all groups currently involved in campaign creation appreciate the challenges and complexities outlined above – and develop appropriate, effective and considered responses.
Abraar Karan is an MD candidate at UCLA and worked as an external consultant at the CDC in Mozambique where he advised on creating a national HIV communication strategy for the country. He has experience abroad in India, Latin America and Africa and he blogs about his global health experiences at Swasthya Mundial (@swasthyamundial).