HIV/AIDS continues to be one of the world’s greatest challenges because of the associated wide scale loss of life, declining life expectancy, increasing infant mortality, disability adjusted life years (the number of years lost due to ill-health) and the consequent number of orphans and vulnerable children. HIV/AIDS has placed a huge burden on governments as the number of people in need of medical treatment and care continues to rise. State hospitals are struggling to cope with the increasing number of patients, while economies suffer the loss of labour and families become impoverished due to lose of income.⁽²⁾

The global distribution of HIV/AIDS is uneven due to a plethora of social, political and economic factors, with Africa bearing the greatest burden of the disease. The hardest hit areas are those south of the Sahara, with Southern Africa being the epicentre of the disease. Over two thirds (63%) of all adults and children in the world who are HIV positive live in Sub-Saharan Africa. Of these, 32% are in Southern Africa.⁽³⁾ Current statistics confirm a disproportionate infection rate between males and females, with the prevalence of infection higher in females. This disproportionate prevalence is most noticeable in places where heterosexual contact is the dominant mode of transmission. In Sub-Saharan Africa, for every 10 adult men living with HIV, there are about 14 adult women who are infected and women make up 59% of the HIV-infected sub-population in Sub-Saharan Africa.⁽⁴⁾

The impact of HIV/AIDS has become far worse than ever imagined. However, a number of promising developments in the fight against HIV/AIDS can be identified, some of which are attributed to the success of behaviour change strategies. This CAI paper discusses the limitations of a behaviour change approach in the management of HIV/AIDS. The paper recognises that HIV/AIDS is more than just a bio-medical issue, and that its spread and effects can be linked with various socio-political and economic factors that discourage behaviour change and increase the impact of the disease on both infected and affected persons.

A behaviour change approach

A dominant prevention response to HIV/AIDS has been the behaviour change approach. Behaviour change strategies are used to modify behaviours that lead to chronic illness as well as to change or maintain behaviours in wellness promotion and disease management.⁽⁵⁾ This involves applying a wide range of strategic interventions and conducting actions that modify negative behaviours and encourage positive behaviours through educational or motivational techniques. These may be targeted towards an individual or a social group.⁽⁶⁾ Many factors influence behaviour change and these include increased knowledge, awareness and contextual factors. Generally, behaviour change strategies place emphasis on a person’s self-efficacy in achieving change. Self-efficacy is defined as a person’s judgement of their own capabilities to organise and execute a course of action that is required to realise a change in their behaviour.⁽⁷⁾

In HIV prevention, behaviour change strategies have been applauded for the decline in incidences of HIV. The most common behaviour change strategy in HIV prevention is the ‘ABC’ approach, advocating abstinence (‘A’), being faithful (‘B’) and correct and consistent condom use (‘C’).⁽⁸⁾ According to the UNAIDS 2012 report, rates of new HIV infections have been cut dramatically in 25 countries in Africa; by 73% in Malawi, 71% in Botswana, 68% in Namibia, 58% in Zambia, 50% in Zimbabwe and 41% in South Africa.⁽⁹⁾ This reduction is attributed to behaviour change strategies that include the delay of the onset of sexual intercourse, a reduction in the number of partners, and increased condom use.⁽¹⁰⁾

Limitations of behaviour change strategies

Despite the successes, behaviour change approaches are limited, as they are based on the premise that people will always make rational decisions, especially when engaging in an emotive and symbolic activity such as sex. They fail to consider the temporal dimensions that characterise human action; for example, the use of here-and-now reasoning. With sexually transmitted diseases such as HIV/AIDS, people may not, for example, consider the impact of their sexual encounter on their life expectancy, but rather focus on immediate needs such as satisfying a sexual need or ensuring emotional, social and economic security. In fact, behaviour change gives an illusion of choice and agency, when in reality, choice is constrained or absent. Consequently, people may fail to change even if they know that they should.⁽¹¹⁾ The desire for sexual gratification, the risk of rejection, mistrust, loss of income or emotional support can be more important than the abstract risk of death in the future. Behaviour change models underplay the fact that people do not always make rational choices but may act out of habit, emotion or impulse. Individuals may even make here-and-now decisions choosing short-term gain over long-term gain.⁽¹²⁾

Behaviour change strategies also fail to take into account the importance of certain religious and cultural factors that influence identity construction and social acceptance. In some cultures, marriage and parenthood form the basis of people’s self-identity and social status. These, to a certain extent, shape what it means to be a ‘man’ or a ‘woman’ and influence one’s self esteem. Some people will therefore behave in ways that safe-guard these values, even when it is at the expense of their well-being. For example, people engage in unprotected sex to have a baby or practice polygamy in order to prove fertility.⁽¹³⁾ Studies in Sub-Saharan Africa have shown that infertile couples are socially stigmatised and excluded from leadership roles in their communities. Consequently, both males and females engage in sex with multiple partners to prove their fertility, despite the known risks for their reproductive health.⁽¹⁴⁾

Another important limitation of the behaviour change approach is that it fails to recognise that someone else’s behaviour can cause illness in another. This is particularly important for sexually transmitted diseases where one party may be able to change their own behaviour but cannot change or control that of their intimate partner.⁽¹⁵⁾ The faithfulness of one partner is insignificant if the other is engaging in unprotected sex. For example, a faithful wife is as much at the risk of infection as anyone who is promiscuous, if her husband is unfaithful. To quote Graça Machel:

The existing methods to prevent infection are failing many women. Asking women to simply abstain, be faithful or use condoms is not practical. Nor is it enough, especially [considering] UNAIDS reports that 75% of new infections are acquired from a spouse or a regular partner … Marriage or being in what a woman thinks is a monogamous, faithful relationship is sadly one of the biggest HIV risk factors for many young African women.⁽¹⁶⁾

Furthermore, arguing that HIV/AIDS is best prevented using a behaviour change strategy is to imply, to a certain extent, that those infected behaved in an unbecoming manner that resulted in infection. This moralistic perspective can also be extended to mean that the risk of infection lies in the ability, or lack thereof, of people to behave in a certain way. This of course is a simplistic understanding of the politics of infection and prevention and fails to explain why, for example, there is a disproportionate infection rate between various sectors of society. It also encourages moral censor, stigmatization and discrimination of people living with HIV/AIDS (PLWHA). Currently, trends in the epidemic show that HIV/AIDS infection is highest among the poor and marginalised groups such as women, men who have sex with other men, prisoners, sex workers and vulnerable children.⁽¹⁷⁾ This disproportionate infection points clearly to more than just a behavioural cause and therefore requires more than just a behaviour change prevention strategy.

As mentioned earlier, behaviour change strategies tend to emphasise individuals’ self-efficacy in achieving change. Despite the behavioural change approach’s emphasis on individuals’ self-efficacy, self-efficacy is affected by various factors, including environmental ones, some of which are outside the individual’s control.⁽¹⁸⁾ Examples are poverty, lack of knowledge and even cultural constraints.  Therefore, improving the environment that people are living in so that they have more power to change their behaviour is important. The focus on self-efficacy or the power of an individual to act places the burden of change and blame for failure to change on the individual. Such individualistic theories blame AIDS on sexual lifestyles and leave out the role of environmental factors in facilitating or discouraging change. This not only reinforces the assumption that behaviour is the only important variable in HIV infection, but also shifts attention from the fact that, for some people, it is extremely difficult to navigate social and economic contexts that predispose them to infection. Such contexts include, among others, unequal power relations, poverty and a lack of information.

Moving beyond behaviour change

It is difficult for people to change already established behaviours. Behaviour change is rarely a discrete, linear process that happens easily and immediately – “[m]ost people find themselves ‘recycling’ through the stages of change several times, relapsing before the change becomes truly established.”⁽¹⁹⁾ However, for a disease such as HIV/AIDS, relapse may mean infection. This is why strategies for mitigating HIV/AIDS should not focus only on behaviour change, but must be expanded to include strategies aimed at addressing the social problems that prevent people from undergoing behaviour change.

Although people need to be continually educated about HIV/AIDS, interventions must go beyond this. The underlying assumption for educating people about HIV is that if they are informed, then they would change their behaviour, stop taking risks and prevent new infections.⁽²⁰⁾ This is what informs campaigns that encourage safer sex behaviour through abstaining, being faithful and wearing condoms. However, these interventions are limited, as they tend to be “conceptually committed to a linear and cognitive model of human action where knowledge and belief determine choice and agency.”⁽²¹⁾ However, some studies have shown that some people are well aware of the risk related to unsafe sex, that some even outwardly preach safe sex but do not practice it. This highlights the fact that, despite public awareness regarding the epidemic, knowledge is not sufficiently influencing behaviour in people’s private lives. On the contrary, this can result in cognitive dissonance, with individuals knowing how they should be behaving, yet acting hypocritically because they are unable to effect the purported change.⁽²²⁾

Strategies for mitigating HIV/AIDS must also address the social problems that pose a constraint on behaviour change. These kinds of approaches should ideally aim at empowering individuals and eliminating social injustices that render them powerless or hopeless regarding their ability to change their lifestyles and situations. This further incapacitates them from taking steps that ensure their protection from infection. Among the most vulnerable groups to HIV infection are women, the poor and children. These groups lack the necessary resources and the political power to live as they wish most of the time. Poverty, for example, makes it difficult for people to worry about safe sex, when providing for their families is their number one priority. In developing countries, a large number of people are living in poverty and everyday decisions centre on immediate survival.⁽²³⁾ To these individuals, AIDS may not be categorised as an immediate problem when compared to hunger and starvation. Social inequality could also be in the form of religious and cultural norms that strip people of authority over their own lives, for example, some cultures practice widow inheritance, which forces people into a new sexual relationship despite the HIV status of the parties involved.⁽²⁴⁾

The UNAIDS report of 2005 posits that empowerment entails providing people with the knowledge, skills and resources that help them protect themselves from infection or improve their standard of living while living with the disease. However, it also recognises that there is a need to shift from programmes that focus only on education, as education does not indiscriminately foster empowerment. Education must be accompanied by practical assistance to in the application of knowledge to effect behaviour change. The availability of necessary and appropriate information and services does not necessarily mean that people will use them. Thus, there is a need to address the obstacles to behaviour change.⁽²⁵⁾ Unless socio-economic factors are addressed, HIV/AIDS will continue to rage on and, possibly, reverse the hard-won development gains achieved so far.⁽²⁶⁾

Concluding remarks

HIV/AIDS prevention should encourage behaviour change that, in turn, reduces the chances of sexual transmission and mother to child transmission. However, such a focus is limited if it just becomes an awareness raising venture and fails to change the norms of how people respond to specific situations, and foster an empowering and enabling environment that supports individuals and communities in sustaining behaviour change.⁽²⁷⁾ Effective HIV prevention strategies should recognise that HIV/AIDS has “to do with the risks that each one of us take, our personal ability to make choices about those risks – and [that] some of us have far more choices than others.”⁽²⁸⁾ Emphasising behaviour change in situations where people feel powerless to change encourages despair and helplessness; but when individuals are empowered to tackle socio-economic problems, they are better placed to make informed decisions about their lives. Even if awareness is raised about HIV, without redress of the complexities of gender, other social inequalities and power imbalances, behaviour change is neither possible nor sustainable.⁽²⁹⁾ Effective management of HIV/AIDS cannot over-emphasise the benefits of an approach that combines behavioural prevention programmes with strategies that focus on empowerment and social change.

Written by Patience Mungwari-Mpani ⁽¹⁾

NOTES:

(1) Patience Mungwari-Mpani is a Research Associate with CAI and has a particular interest in sexual and reproductive health, human rights and gender equity. Contact Patience through Consultancy Africa Intelligence's Public Health Unit ( public.health@consultancyafrica.com). Edited by Liezl Stretton.
(2) Abdool-Karim, S.S. and Abdool-Karim, Q. (eds.), 2005. HIV/AIDS in South Africa. Cambridge University Press: Cambridge.
(3) ‘HIV/AIDS and human rights’, UNAIDS, 2008, http://www.unaids.org.
(4) ‘AIDS epidemic update’, UNAIDS, 2006, https://www.unaids.org.
(5) Coleman, M.T. and Pasternak, R.H., 2012. Effective strategies for behaviour change primary care: Clinics in office practice. Primary Care, 39(2), pp. 281-305.
(6) Coates, J.T., Richter, L. and Caceres, C., 2008. Behavioural strategies to reduce HIV transmission: How to make them work better. The Lancet, 372(9639), pp. 669-684.
(7) Bandura, A., 1996. Social foundation of thought and actions: A social cognitive theory. Prentice Hall: Englewood Cliffs, NJ.
(8) Shelton, J.D., et al., 2004. Partner reduction is crucial for balanced “ABC” approach to HIV prevention. British Medical Journal, 328(891), pp. 891-893.
(9) ‘Report on the global AIDS pandemic’, UNAIDS, 2012, http://www.unaids.org.
(10) ‘Eastern and Southern Africa HIV and AIDS Issues’, UNICEF, 2012, http://www.unicef.org.
(11) Welbourn, A., 2002. “Gender, sex and HIV: How to address issues that no one wants to hear about”, in Cornwall, A. and Welbourn, A. (eds.). Realising rights: Transforming approaches to sexual and reproductive well-being. Zed Books: London.
(12) Ibid.
(13) Vambe, T.M., 2003. HIV/AIDS, African sexuality and the problem of representation in Zimbabwean literature. Journal of Contemporary African Studies, 21, pp. 470-482.
(14) Tabong, P.T. and Adongo, P.B., 2013. Infertility and childlessness: A qualitative study of the experiences of infertile couples in Northern Ghana. BMC Pregnancy and Childbirth, 13(72), pp. 1-10.
(15) Welbourn, A., 2002. “Gender, sex and HIV: How to address issues that no one wants to hear about”, in Cornwall, A. and Welbourn, A. (eds.). Realising rights: Transforming approaches to sexual and reproductive well-being. Zed Books: London.
(16) Achmat, Z., ‘Make truth powerful: Leadership in science, prevention and treatment of HIV/AIDS’, 2006, http://www.tig.org.za.
(17) ‘Report on the global AIDS pandemic’, UNAIDS, 2012, http://www.unaids.org.
(18) Bandura, A., 1996. Social foundation of thought and actions: A social cognitive theory. Prentice Hall: Englewood Cliffs, NJ.
(19) Zimmerman, G.L., Olsen, C.G. and Bosworth, M.F., ‘A 'stages of change' approach to helping patients change behaviour’, 2000, http://www.aafp.org.
(20) Welbourn, A., 2002. “Gender, sex and HIV: How to address issues that no one wants to hear about”, in Cornwall, A. and Welbourn, A. (eds.). Realising rights: Transforming approaches to sexual and reproductive well-being. Zed Books: London.
(21) Edstrom, J., et al., 2002. “Ain’t ‘misbehavin’: Beyond awareness and individual behaviour change”, in Cornwall, A. and Welbourn, A. (eds.). Realising rights: Transforming approaches to sexual and reproductive well-being. Zed Books: London.
(22) Cundari, A., ‘The AIDS pandemic: Cognitive dissonance theory and HIV/AIDS prevention’, 2007, http://the-aids-pandemic.blogspot.com.
(23) An-Na’im, A., (ed.), 2002. Cultural transformation and human rights in Africa. Zed Books: London.
(24) Ibid.
(25) ‘Operational guide on gender and HIV/AIDS: A right based approach’, UNAIDS, 2005, http://www.unfpa.org.
(26) ‘Survival is the first freedom: Applying democracy and governance approaches to HIV/AIDS work’, PACT, 1999, http://www.comminit.com.
(27) Edstrom, J., et al., 2002. “Ain’t ‘misbehavin’: Beyond awareness and individual behaviour change”, in Cornwall, A. and Welbourn, A. (eds.). Realising rights: Transforming approaches to sexual and reproductive well-being. Zed Books: London.
(28) Welbourn, A., 2002. “Gender, sex and HIV: How to address issues that no one wants to hear about”, in Cornwall, A. and Welbourn, A. (eds.). Realising rights: Transforming approaches to sexual and reproductive well-being. Zed Books: London.
(29) Ibid.