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Monday, January 21, 2013

Uganda Unity for HIV Messages


By Esther Nakkazi

In manifestation of a need for unity in the HIV response, Uganda is to revamp its national information campaign, with new HIV messages, aimed at a change in behavior to reduce new infections.  

All HIV messages in Uganda will soon be standardized, with basic HIV facts, suggesting evidence based interventions, emphasizing prevention and vetted through a clearing-house at the Uganda Aids Commission (UAC), which coordinates HIV/Aids issues in the country.

“It is critical for the public good that a quality assurance mechanism is put in place to protect the public from any wrong doing messages on HIV and AIDS disseminated through the mass media,” said Professor Vinand Nantulya, the chairman of UAC.

With the rising infections, it is indeed, now understandable that maybe the level of knowledge about basic facts on HIV information is quite limited among the public. This is partly blamed on HIV messages and campaigns that do not seem effect behavior change, as was the case previously, to prevent new infections.

The need to avoid mixed HIV messages comes at a time when Uganda’s new infection rates, which are partly fueled by behavioral change are on the rise to 130,000 in 2011 from an average 100,000 five years ago according to the AIDS Indicator Survey (UAIS) results released in June this year. The prevalence rate is also higher at 7.3 from 6.4 percent in 2005.

Yet HIV information and education was most significant in the early preventive national response. The-abstain, be faithful and condom use (ABC) strategy and approach was successfully used to achieve appropriate effective communication. 

HIV messages were prepacked, customized, flexible, targeted- like ‘Love Faithfully’ for the religious. ‘Love carefully’ and ‘Zero grazing’ for the public and condom use as an alternative fall back position.
They were also visually fearful and emotionally appealing prompting behavior change- a strong warning that AIDS kills with the sound of loud drums did it, said Dr. Paul Kaggwa the assistant commissioner Health education and promotion at the Ministry of Health. 

These fear appeal HIV messages led to behaviour change that managed to bring the prevalence of HIV from 30 percent in the 1980’s to 6 percent to-date.

But overtime, behavior change the mainstay of reducing new infections has deteriorated: extramarital relations are high, so are concurrent sexual partners.  Casual sex, which had declined by 60 percent in the 1990s, is back to previous levels.  Scientists have observed complacency and a less committed attitude both in rural and urban areas.

HIV Messages are now are not pre tested or standardized for quality.  Most of them are merely information sharing with no elements of effective communication to elicit feedback, the principle element of good communication, said Dr. Kaggwa.

These messages are also confusing, misleading, medicalised, and only slowing but not stopping new HIV infections. Unfortunately, they have turned out to be generic making the campaigns that are designed unsuccessful and their messages misinterpreted.

“Current campaigns are so stuck in the medical model of marketing where we are only selling the direct attributes of the product with no attachment or appeal to the emotional needs,” said Julius Lukwago, the director marketing and communications at PACE- Program for Accessible health, Communication and Education.  

“We say “go and test, to avoid HIV” or “get off the sexual network to avoid HIV” but what emotional appeal does getting off the sexual network give? ”asks Lukwago contrasting it to Coke, which sells happiness- not some black sugar solution that quenches thirst.

For instance the ‘stop cross-generational sex’ campaign, which stopped young people from having sex with the older generation- but suggested that it was okay for them to indulge in sex with fellow youngsters and only wrong if the partners were older.

This message and others that were not well thought out, ended up causing more damage than good because they lay themselves open to misinterpretation, commented Mrs. Janet Museveni, the first lady.

It was designed on the basis of the prevailing situation, when young people were having sex with older people for material gains. Research showed that new infections were highest among long-term, multiple and concurrent sexual partnerships- which included these cross-generational affairs.

Then came the two-year ‘one love campaign’ that urged people to leave the sexual network and was aimed at increasing monogamous married couples. It was a behavior change campaign for married and cohabiting couples, and adopted a new term ‘side dish’.

It started after research, the 2004/05 Uganda HIV Sero Behavioural Survey, showed that married persons accounted for about 65 percent of new HIV infections and HIV transmission was highest within marital sex at 42 percent, prevalence rate, twice as high as commercial sex workers.

One love, started with an awareness campaign about the risks involved in multiple partnerships and the implications of the sexual network. It then sought to increase the understanding on how being part of the sexual network impacts on the family especially the children. But was only considered to have got the ‘public talking’ mostly about side dishes but not ditching them. 

Behavior change experts argue that the campaign would be more successful if it gave people reasons to dump the ‘side dishes’. For instance, if it portrayed a couple in old age, happy with their grown up children who are married, it would be a more realistic picture for a reason to have a single partner.

But it addressed the usual issue -risk perception- in the usual fashion- increase knowledge- although most people were already aware of the risks in having multiple partnerships or not using condoms, said Lukwago. “Drumming that in further may not cause any behavioral impact.”

In its last run, the ‘one love’ campaign painted a disgusting side dish like a garbage attendant as part of the sexual network.  “This was arrived at after talking to the target audience and quite a number expressed tolerance to side dishes. When we added a ‘Maskini’ the reaction changed instantly from tolerance to disgust,” said Daudi Ochieng head of communications Uganda health Marketing Group (UHMG) 

Messaging for medical interventions like Safe Male Medical Circumcision is also faulted. Messages for circumcision have indicated that there is protection for everybody, although research clearly indicated that chances of acquiring HIV for a circumcised man are 60 percent but transmitting HIV is at the same level as any man who is HIV positive.

Cathy Watson from Straight Talk Foundation during a presentation in an HIV conference said that single-issue campaigns over simplify communication. “Concentrating on one new evidence based intervention ignores the underlying reality of how people live their sexual, emotional and economic lives so Uganda needs more holistic campaigns,” said Watson.

There have been suggestions to revert to fear appeal messages that led to behavior change because this would give the public the liability to act.

David Bakyayita a communications expert with the ministry of Health says fear appeal messages can be used but should be better packaged to suit the audience at this point in time. When they worked the HIV epidemic was at an outbreak stage and people were hopeless.

“The fear of HIV/AIDS has diminished given that it doesn’t show immediate danger with anti-retroviral therapy and care. We need to understand our customers better-gain enough audience insight to determine what they are looking for in choosing to take these risks which they know have dire consequences,” said Lukwago.

“We need to go back to the original message of prevention but that has implications on how we are going to change behavior. The kinds of messages that change behavior are not on billboards. The way you change behavior is through informal communication, by word of mouth,” said Professor Nantulya.
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