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Research findings are catalyst to nationwide rollout of HIV prevention program in Botswana

April 27, 2016

Remarkable new research into HIV prevention among the "choice disabled" — vulnerable groups less able to make the right choices to protect themselves — has led to a nationwide rollout of three intervention programs in Botswana. 

Three years of research in southern Africa has revealed important new findings for preventing AIDS among those who are unable to make choices to protect themselves, even when they have the knowledge to do so. One of the key demographics among the so-called "choice disabled" are victims of sexual violence. 

Tackling the spread of HIV/AIDS

With HIV rates as high as 33%, prevention is critical in tackling the HIV/AIDS epidemic in sub-Saharan Africa. But prevention strategies have generally been designed for and are more accessible to those in a position to make preventive decisions and who have access to services when they need them.

Those who struggle with poverty, low levels of education, income disparity between partners, and intimate partner violence are all at higher risk of HIV infection, according to an earlier 2008 survey by the Community, Information Empowerment and Transparency (CIET) Trust of 15-to-29-year-olds in Botswana, Namibia, and Swaziland. These are all considered to be factors that adversely affect choice, and thus boost the likelihood of infection.

The new research was also conducted by CIET Trust in Botswana, Namibia, and Swaziland, with support from Canada's International Development Research Centre. 

Researchers adapted existing prevention efforts to increase their effectiveness among the choice disabled. Through audio dramas and focused workshops targeting young women, researchers carried outprimary prevention education that empowered participants  and at the same time, educated local services about the needs of the choice disabled.Randomized control trials aimed to multiply the impact of HIV prevention strategies already in place by increasing the number of people able to choose existing prevention options, including abstinence, condoms, or fewer partners.

The research project also supported training to boost the capacity of emerging African researchers and policymakers in the socio-cultural aspects of HIV/AIDS, epidemiological methods, and putting policy into practice.

Photo: Service providers singing about HIV during a community meeting / Anne Cockcroft

Reduced cases among young women

The research showed that the interventions were adopted by more young women in Botswana than in Namibia and Swaziland. At the end of the three-year project, 22.3% of young women in control communities in Botswana were HIV-positive, compared with only 10.6% of the young women in communities who received all of the intervention efforts. 

The research found that gender violence, regressive views of gender hierarchy, economic dependence, and substance or alcohol abuse all lead to choice disability when it comes to HIV/AIDS prevention.

The evidence also pointed to the structural factors that contribute to HIV infection, with lack of education, food insecurity, and income disparity between partners playing key roles. The risk increases in line with the number of structural factors present. 

Dangerous misconception leads to high-risk behaviours

The study also looked at common-held beliefs around male circumcision and the prevention of HIV. The research concluded that male circumcision did not affect the likelihood of contracting HIV. But the research uncovered examples of the misconceptions that surround it, for example, that circumcision can prevent the spread of HIV. This is a dangerous belief, as it can lead to high-risk behaviour. The research found that stronger efforts are needed to educate people that male circumcision does not protect women.

This research was a key area of interest for IDRC, in light of a concerted push by donors for male circumcision as the prevention intervention of choice. The results showed that male circumcision may not be as effective as many donors believe.

National rollout

Much of the work done on HIV/AIDS to date has focused on it as a medical problem requiring a clinical fix. Evidence of the links to structural issues and how to address them are important to ensure long-term solutions to addressing the AIDS epidemic. 

In Botswana, the results led to the government making a substantial contribution of US$3.1 million to scaling up the interventions as part of their poverty alleviation program. And following the 2013 visit by the Governor General of Canada, His Excellency the Right Honourable David Johnston, and Jean Lebel, IDRC President, to Botswana, IDRC provided further support to Botswana's scaling-up efforts.

And in Swaziland, audio dramas produced though the project have been integrated into the school curriculum. The CIET Trust trained teachers in holding discussions around the dramas, Beyond Victims and Villains, with students. 

The Botswana government is integrating this approach into their poverty alleviation program, putting those at the heart of the AIDS epidemic at the centre of its program. 

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