In this article, three AIDS prevention programmes are studied. the MEDIA campaign in Seattle, USA, the 100% condom programme in Thailand, and the Hindelbank prison needle exchange project in Switzerland. Even though these programmes were successful, they also demonstrate the difficulties encountered in AIDS prevention, such as a lack of uniform and continuous national strategies, which hamper locally achieved successes; a lack of openness towards new ideas and approaches; a large political influence on AIDS prevention; a lack of continuity and valorisation of pilot projects; and the absence of a supportive social and structural environment. To improve the success in prevention, three points must be observed: first, the impact on public health must be made visible; second, the continuation of the actions at all levels should be guaranteed; third, a regular accompanying assessment as well as valorisation should be the standard rule for all prevention projects. Finally AIDS prevention should not be treated as an isolated programme but should be integrated into general health promotion activities.
INTRODUCTION
After more than 10 years of AIDS prevention activities, widely varying from one country to
another, it is practically impossible to give a complete overview of whathas been
achieved. It is, however, certainly possible to learnfromseveral examples, to see what has
been successfull and what has not and to understand the difficulties encountered by AIDS
prevention efforts.
In this article, three AIDS prevention programmes are examined in detail. These programmes have beenselected as they are a good example of both the successes and difficulties encountered in the field of AIDS prevention. After a short presentation of the three programmes and their main results, the difficulties encountered in each of these programmes are discussed. Finally the lessons learned from these experiences are presented in the form of theses.
THE AIDS PREVENTION STRATEGY IN SEATTLE: THE MEDIA CAMPAIGN'
The AIDS prevention strategy in Seattle is best described by its openess. The strategy
includes a daring and original media campaign, which addresses subjects like sexually
transmitted
'. . . 4 out of 4 ... people prefer condoms over herpes!!'
'. . . condoms improved dramatically! Since your parents used them ... if they had sex, that is.'
'. . . condoms. 250 000 cheaper!! ... than the average child'
The primary target group of this campaign was the sexually active young adults aged 15-17 years. The campaign used several information channels and have had three successive waves. The campaign has been ry successful and 73. 1 % of the targeted audience ported exposure to this campaign (see Table 1).
The open nature of the AIDS prevention strategy in Seattle goes beyond the media campaign. Seattle is one of the few cities in the United States where legal needle exchange projects exist: there are six sites in Seattle and between 80 000-85 000 syringes are exchanged every month. Furthermore, the AIDS prevention strategy in Seattle includes HIV education in the prison, even though it is not implemented in a consistent manner.
THE AIDS PREVENTION STRATEGY IN THAILAND: THE 100% CONDOM PROGRAMME'
It is well known that Thailand is a country where HIV prevalence is very high: the estimated infections in Thailand have risen tenfold since early 1990 (Metson, 1994) The main way of HIV transmission in Thailand is heterosexual relationships with commercial sex workers. In order to hinder this way of transmission, the government launched an ambitious condom promotion programme, specifically aimed at commercial sex workers and their clients. The programme combines an authoritarian attitude towards brothel holders with a large information campaign. The brothel owners are forced to have all their employees use condoms in a systematic and consistent manner. This rule is controlled by an active contact tracing programme for those found with sexually transmitted diseases, which allows to identify the'guilty'brothel. The campaign used mass media to reach potential clients of commercial sex workers and to promote a general awareness towards the AIDS epidemic.
The results of this
programme are impressive:
· More than 150 million condoms were distributed by the government in the last couple of
years (see Table 2);
· The number of sexually transmitted diseases reported has decreased significantly
(see Table 3);
· The protective behaviour reported has increased significantly: 92% of all commercial
sex acts occurred with a condom (see Table 4).
THE AIDS PREVENTION STRATEGY IN SWITZERLAND: THE HINDELBANK EXPERIENCE
The Swiss AIDS prevention strategy is based on a three-level intervention method.' First,
interventions for the general population. The most famous intervention at this level is
the Stop AIDS campaign, which started as early as 1987.' The main themes of this campaign
are condom use, fidelity and solidarity. At the same time, the campaign also includes
themes for specific minority groups, such as needle distribution for injecting drug users.
Second, interventions for specific population groups, such as: commercial sex workers, iajecting drug users, men having sex with men and prisoners.
Third, interventions at an individual level. This level includes counselling, therapies, etc.
The successful pilot project of AIDS prevention including needle distribution in the female prison of Hindelbank falls under the second level of intervention. As this project has already been discussed elsewhere, only the main results are shortly listed here:
· no increase in drug use was observed;
· the health of prisoners improved;
· a significant decline in needle sharing could be observed;
· no new cases of HIV or hepatitis infection were seen; and
· syringes were not used as weapons.
DIFFICULTIES ENCOUNTERED BY AIDS PREVENTION STRATEGIES
At first sight, the examples presented above seem very successful and seem to suggest that
our fight against AIDS is nearly over. This, however, is too optimistic and really naive.
Looking at these examples again, this time in more detail, taking into account the
environment, there are several difficulties and insufficiencies to be noted.
If the AIDS prevention strategy in Seattle is so successful, why was it not implemented on a national level? Why didn't it at least influence the national AIDS policy in the United States? This aspect of local effectiveness of AIDS prevention strategies in the United States can be explained by two factors:
1. there has been no national leadership in the United States
concerning AIDS; and
2. there has been no openess at a national level in the United States.
There have been several efforts in the United States to set up a national strategy of AIDS
prevention. However, as Francis (1994) describes: 'There has been an absence of solid
national leadership, and respected panels continually use phrases like "woefully
inadequate" or "absence of leadership" to describe America's response to
AIDS.'
At the same time, the national level, especially the Congress and its politicians, have shown no openess at all. This can be illustrated with two examples, which show the large influence of politicians and thereby the limits of the influence of public health experts.
The first and one of the best examples of this political influence is the question of sexual education in schools, which has been subject to a large debate on moral acceptability of such programmes. The famous federal'Helms'amendment forbids funding AIDS prevention programmes that'promote, or encourage, directly, homosexual or heterosexual activity or drug abuse'(Gostin, 1989). At a State level, AIDS prevention in schools ranges from restrictive programmes, stressing abstinence, to facilitating programmes. This mainly conservative approach to sexual education in schools is all the more worrying as several projects and studies have shown that'providing explicit HIV prevention programs prior to the time that adolescents are sexually active can have greater impact than programs initiated after the initiation of sexual activity' (Choi, and Coates, 1994).
The second example concerns the question of needle exchange programmes. Bayer (1995) clearly states that: 'The Congress, which easily gets caught up in crusades involving drug use, has since 1988 passed seven laws prohibiting the use of federal funds for needle exchange.'
The 100% condom programme in Thailand also seems a successful programme. However, the success of this programme is rather fragile, as the cultural and social environment which pushes girls into prostitution is not addressed. If a programme onlyfocusses on prevention of HIV transmission, the success of such a programme will be limited. In order to reach a situation where HIV transmission is prevented in the long term, programmes should also address the problem of women's dependance and the changing of social and structural changes should be included (e.g. reach a better level of education for women in general). Without these social and structural changes, the incidence of HIV may rise again dramatically, if, for instance, the coercive measures accompanying the 100% condom programme are not rigorously implemented.
The Hindelbank pilot project in Switzerland is the third example used to describe
successful AIDS prevention programmes. Even though the Hindelbank project had a positive
outcome, a more detailed look provides some difficulties with AIDS preven
tion in prisons. First, AIDS prevention in this field is hampered by its political nature
as well as by the different levels of competence: the federal government is responsible
for prevention of epidemics, the cantonal authorities are responsible for the prison
management. This means that openness in one prison (in this case Hindelbank), does not
automatically mean that a successful prevention programme is implemented in all prisons.
Furthermore, as stated by Mertens
Summarising the difficulties encountered in these three examples of successful AIDS prevention strategies, we can see the following:
· a lack of a uniform and national strategy, including unclear competences for all actors, will hamper the locally achieved successes;
· a lack of opening towards new ideas, new ways of reaching and ~rming specific population groups will hamper ~kIDS prevention strategies;
· a large political influence will hamper AIDS prevention as public health experts have a
smaller influence on the setting up of AIDS prevention strategies;
- the continuity and valorisation of pilot and local projects should be ensured in order to have a successful overall AIDS prevention strategy; and AIDS prevention programmes should not only focus on the individual, but should combine the behavioural interventions with enabling approaches, that is creating a supportive social and structural environment for the individuals (Tawil et al., 1995)
LESSONS LEARNED FOR THE FUTURE
The situation we face today is really challenging as two new developments will influence the future of AIDS prevention strategies. The first is the fact that AIDS is slowly losing its special status and will be integrated more and more in general public health strategies. This integration should mean that we integrate what we have learned from AIDS prevention in a newly to be focused public health strategy. The integration of the AIDS experience in general public health should improve the latter and should also improve the general enabling approaches. The second development is the decreasing funds available for AIDS prevention. This means that new priorities on activities and targeted population need to be discussed. The setting of new priorities should be made carefully, as it is not advisable to favourjust target groups and to forget to maintain solidarity by and interest of the general population, as this could very easily lead to discrimination and isolation ofseropositive people and patients with AIDS.
The challenge of today and tomorrow can only be faced if we learn from experiences made in the past. Based on the examples presented in this paper, several theses can be formulated:
1. We have seen that AIDS prevention programmes can be successful and can dramatically reduce unsafe behaviour. However, resistance to
AIDS prevention can be stronger than the results. It is thus the task of public health experts to overcome political controversy and to convince policy makers that the benefits of such programmes are greater than the assumed harms.2. AIDS prevention does not stand by itself. Various factors, including the social and cultural environment, are playing a role in the success or failure of AIDS prevention, and should, therefore, be taken into account. Enabling approaches shou ld be the logical complement of AIDS prevention programmes.
3. Successful pilot projects, aimed at a specific population group in a specific part of the country, are not enough to ensure AIDS prevention for the future. The valorisation, the reproduction and adaptation of such projects on a wider scale are decisive for the future of AIDS prevention.
4. AIDS prevention should be a continuous effort: having one project for two years or one media campaign is not enough to sensibilise yeople to change their behaviour. Information and education need to be a continuous effort in order to achieve behaviour modification.
5. AIDS prevention should not focus on one level of intervention (e.g. aimed at the general population), but should simultaneously intervene on all levels (general, target-groups, individual) in order to ensure effectiveness.
6. There should be a certain coherence in AIDS prevention, that is, there should be one clear message, one clear strategy and no contradictory strategies. If it is decided that needle distribution is possible in a country, this should also mean that the possibility of needle distribution in the prison should not be excluded.
7. AIDS prevention should not be seen as isolated from other health-related problems, but should be integrated in general health promotion. Young adults, for instance, are more concerned by unwanted pregnancies and sexually transmitted diseases, than by AIDS alone.
8. Finally, feed-back on experiences made is essential and should be given at all levels. This included a certain openess about the successes or failures of experiences made, so that lessons can be learned. This paper can be seen as a sort of feedback, and we hope that it will help others in their AIDS prevention efforts.
Dr Pierre G. Bauer, Swiss Federal Office of Public Health Main Unit Addiction and AIDS,
Section of AIDS, Hess-Strasse 27E, CH-3097 Liebefeld, Switzerland. e-mail:
pierre-georges.bauer@bag.admin.ch
REFERENCES
Bayer R (1995). Politics, social science and HIV prevention in the United States: looking backward, looking forward. In: Friedrich D, Heckmann W (eds). AIDS in Europe - The Behavioural Aspect. Berlin: Sigma.
Choi KH, Coates TJ (1994). Prevention of HIV infection. AIDS 8(10):1371-1389.
Francis DP (1992). Towards a comprehensive HIV prevention program for the CDC and the Nation. JAMA 2680 1): 1444-1447.
Gostin LO (1989). Public health strategies for confronting AIDS: legislative and regulatory policy in the United States. JAMA 261(11):1621-1630.
Merson MH (1994). Global status of the HIV/AIDS epidemic and the response. Presentation given at the Xth International Conference on AIDS in Yokohama on the 8th of August 1994.
Mertens T. et al (1994). Prevention indicators for evaluating the progress of national AIDS programmes. AIDS 8(10): 1359-1369.
Tawil o, VersterA, O'Reilly KR (1995). Enabling approaches for HIV/ AIDS prevention: can we modify the environment and minimize the risk? AIDS 9(12): 1299-1306