hiv aids determinants english

8/18/2019 HIV AIDS Determinants English

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Determinants of the effectiveness of HIV prevention through sport

Wim Delva, Marleen Temmerman

A societal framework of effectiveness

Having the potential to effectively curb the HIV epidemic does not however guarantee

success. Whether significant numbers of new HIV infections will be averted through sport

programmes depends on the sociocultural and political conte!t of the intervention, the socio

economic conte!t of the targeted se!ual behaviour and the epidemiological conte!t in which

individuals ac"uire and transmit HIV infection. #$% &igure ' illustrates how these conte!tual

factors potentially attenuate the effectiveness of HIV prevention through sport at different

stages of the interventionimpact cascade.

1. Determinants at the intervention level:

Is there breathing space for youth and sport in the community

The sociocultural and political conte!ts in which the youth and sport culture are embedded

are li(ely to affect the effectiveness and sustainability of HIV prevention through sport. )

myriad of framewor(s rooted in social science theory have been proposed to identify

structural facilitators and barriers of HIV prevention interventions and to understand how

these factors interfere with the implementation of interventions. #*''% )lthough social

framewor(s provide insights into the comple! nature of se!ual ris( behaviour and health

see(ing behaviour, they typically do not allow for an ob+ective, "uantitative evaluation of

prevention programmes. #'% -evertheless, social science is imperative to determine the

&inances

Volunteers

oordinators

/port fields

/port programmes 0ehavioural change )verted HIV infections

1erceptions and attitudes

in the community

&inancial threshold for

participation

2pta(e

3utreach 4fficacy

1eer pressure, selfefficacy

5ender 4"uity

/ocial norms

4conomic Independency

HIV prevalence

/TI prevalence

Mi!ing patterns

/e!ual behaviour of

untargeted groups

Impact


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sociocultural and political appropriateness of a given intervention. 6uestions related to

feasibility, accessibility and affordability of sport programmes include7 Is sport being

encouraged by parents, schools and governments8 Do (ids have the opportunities, ample

leisure time and space to play and practice sports in the community8 )re local, regional and

national authorities ma(ing an effort to lower the #financial% threshold to participate in sport

and play8 )re human capacity, infrastructure and financial resources in place to train and

guide the trainers and coaches, to supervise the programmes and to monitor and assess their

effectiveness8 )dditionally, it is essential to investigate potential sportrelated sources for

stigmatisation, discrimination or formation of unfavourable stereotypes before promoting a

particular sport activity as the vehicle for life s(ills building and behavioural change. /ocial

science should however not be limited to 1olicy )dvisory 9esearch. When impeding and

+eopardi:ing factors related to the intervention and;or the target population are (nown,

informed actions can be underta(en and the intervention can be adapted;modified to

ma!imi:e its accessibility. In spite of the importance of establishing an acceptable, feasible

and affordable intervention, the current evidence base regarding the sociocultural and

political appropriateness of sport programmes for HIV prevention is sparse and social science

research in this regard is urgently needed.

>?@ #a schoolbased approach to HIV prevention% because

teachers and;or parents believed that e!plicit information on se!uality and safe se! would

increase se!ual e!ploration in learners. #'A% )nother issue demanding attention is the plight of

hildren )ffected by )ID/ #)0)%, who are particularly vulnerable to lose the opportunities

to sport and play as their wor( burden in the household and during income generating

activities is often e!tremely high. #'B% 9eaching these children will prove to be a growing

challenge in the light of a continuously e!panding population of orphans and vulnerable

children.


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through trainers and coaches and their umbrella organisations are (ey to ensure the lasting

legacy of current development efforts. #A%

!. Determinants at the level of se"ual behaviour:

Does the intervention result in sustained behavioural change

-o oneCs perceptions and attitudes are developed independently of oneCs cultural bac(ground

and social networ(s. /ubse"uently, #se!ual% behaviour is never +ust a matter of ma(ing

personal choices. It always involves issues such as peer pressure and role models, self

efficacy and perceived benefits versus ris(s. 5reat lessons can be learnt from the evaluations

of schoolbased programmes aimed at behavioural change. ) recent systematic literature

review from /outh )frica points out that although schoolbased programmes are usually

associated with improved awareness, (nowledge and attitudes, very few result in actual

changes in ris( behaviour. #'?% 3nly programmes dedicating ample time to communication

s(ills, gender e"uality, selfesteem and selfefficacy training and roleplays showed to impact

on se!ual behaviour. #','$% In contrast, programmes based upon the belief that behaviour

was the result of an informed choice failed to act beyond raising awareness and more positive

attitudes and intentions. #'*>% )dditionally, peopleEs behaviour is very often rooted in

economic and developmental realities7 unemployment, poverty, migrant wor( and gender

ine"uality have been identified as the most important driving forces of the HIV epidemic in

/ub/aharan )frica. #'?%

In conclusion, planning of HIV prevention programmes through sport should include a

comprehensive situational analysis of barriers that could hamper sustained behavioural

changes. In addition, e!perience and study findings from past operations research can help

develop best practice guidelines in addressing and overcoming anticipated sources of

disempowerment.

#. Determinants at the level of the epidemic:

$ill behavioural change result in a lower HIV incidence and prevalence

)ccording to the epidemiological framewor( outlined by 5rassly et al., the impact of

programmes altering se!ual behaviour and promoting condom usage on HIV incidence

depends on the epidemiological conte!t, indicated by the HIV prevalence in the target

population, the prevalence of cofactors of HIV transmission #e.g. /TI prevalence%, mi!ing

patterns between the target population and untargeted populations, and the se!ual behaviour


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of the untargeted populations. In other words, merely proving that sport can reduce unsafe

se!ual practices would not be enough to ensure significant conse"uences in terms of averted

HIV infections. Indeed, besides the effects of sport on se!ual behaviour #delayed se!ual

initiation, secondary abstinence, increased condom use, reduced number of partners, reduced

number of casual and transactional se!ual contacts%, the indicators for the epidemiological

conte!t as mentioned above need to be measured as well. 3bviously, the effectiveness of a

programme merely targeting secondary school boys may be seriously curtailed if most of the

learnersC partners have dropped out of school already and are therefore not reached. 4ven

worse results may be e!pected if these female partners tend to have concurrent se!ual

partnerships with older men because women in such relationships often lac( the power to

negotiate safe se! and older men are more li(ely than younger men to be HIV positive.

onversely, a programmeCs effectiveness may be enhanced when the epidemiological conte!t

is (nown. &or instance, adding promotion of /TI screening and treatment through sportbased

peer education may be re"uired when /TIs are rife and disappointingly little changes in HIV

incidence are observed even after significant increases in condom usage. 5arnett and

)nderson showed that dramatic increases in condom distribution may have very little impact

on HIV spread until use during se!ual intercourse is close to '>>F in highris( partnerships.

#%

%he epidemiological conte"t in &outh African youth

HIV prevalence and incidence in the target population

The HIV prevalence in /outh )frican youth is worrisome and, in girls, has continued to rise

since the >> national household survey. #$% &igure shows how the HIV prevalence pea(s

at a higher level and in younger age groups for women than for men. 0ased on weighted data

to correct for stratified, disproportionate sampling and account for nonresponse to HIV

testing, the HIV prevalence in the '> to 'B year old age group is estimated to be '.BF for

boys and '.$?F for girls. In '? to 'G year olds a differential infection rate becomes apparent

as A.AF of these male adolescents is infected compared to G.B>F of female adolescents. This

trend is reinforced in the > to B year olds with .>AF of men being infected in contrast to

A.*?F of women. #*% When applying these prevalence rates to the >>? midyear

population estimates for /outh )frica, more than one million young /outh )fricans between

'> and ? years old are estimated to be HIV positive, representing nearly one "uarter of all

people living with HIV in /outh )frica. #G%


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0

5

10

15

20

25

30

35

40

45

2 – 4 5 – 9 10 – 14 15 – 19 20 – 24 25 – 29 30 – 34 35 – 39 40 – 44 45 – 49 50 – 54 55 – 59 60 and

above

Age grp (years) Males FemalesSoure! Sou"# A$r%an &a"%onal ' *revalene+ ' n%dene+

,e#av%our and -ommun%a"%on Survey+ 2005

&igure . HIV prevalence in /outh )frica for >>?, by age and gender.

The relatively lower prevalence rates in youth compared to the adult population may generate

a false sense of comfort and control. In fact, they hide;disguise shoc(ingly high HIV

incidence rates7 using advanced testing essays, the HIV incidence among youth aged '?B

years was estimated at A.AF in >>?. Highly alarming is the fact that females in this age

group have an eighttimes higher HIV incidence than males #.?F compared to >.*F%. These

findings are consistent with data on se!ual behaviour indicating that youth have a high turn

over of se!ual partners and that a si:able proportion becomes se!ually active early in

adolescence. 9easons for the increased susceptibility of girls include biological factors

#cervical ectopy, incomplete vaginal lining, larger surface of mucosal membrane% and

difference in mi!ing patterns7 a high proportion of girls tend to sustain se!ual relationships

with men who are older #and therefore more li(ely to be HIV positive%. )dditionally, forced

se! and se!ual violence may also contribute to their vulnerability to HIV infection.

The prevalence of cofactors of HIV transmission

)dditionally, /TI prevalence rates are high in /outh )frican youth especially in females

+ustifying intensified efforts to improve /TI screening and treatment in these groups. In a

/outh )frican communitybased study, the prevalence of hlamydia trachomatis was A.?F


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for males aged '?'G and G.'F for females of the same age. -eisseria gonorrhoeae was

prevalent in '.'F of '? to 'G year old males and in A.?F of their female counterparts. #A>%

Mixing patterns between the target population and untargeted populations

While boys and young men tend to have se!ual partners of their own age groups, this is not

true for many of their female counterparts. Through highris( and often transactional se!,

these women are at high ris( for HIV ac"uisition, thus introducing the virus into the se!ual

networ(s of younger age groups. These mi!ing patterns have important implications for the

design and implementation of HIV prevention interventions7 )n isolated intervention only

focussing on youth is unli(ely to have a significant impact on HIV incidence and HIV

prevalence rates.

Sexual behaviour of the untargeted populations

)ddressing the se!ual behaviour of the adult population is e"ually important if HIV

preventions for youth are to be effective. Modelling e!ercises indicate that targeted

interventions for individuals engaging in highris( se!, such as commercial se! wor(ers and

migrant wor(ers effectively avert HIV infections. In &amily Health InternationalEs )V49T

simulation model, social mar(eting of condoms in combination with presumptive treatment of

/TIs were estimated to lead to a AGF decrease in HIV incidence for women using the /TI

services while a B*F decrease in HIV incidence was estimated for miners. #A'% 9ecently,

/outh )frica was the first country to present e!perimental evidence on the effectiveness of

male circumcision for the prevention of HIV infection from a randomised controlled trial.

)fter a mean followup period of '*.' months, the annual ris( of HIV' transmission in the

intervention group was >F lower than that in the control group. #A% Whether mass media

interventions such as /oul ity or


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favourable epidemiological conte!t. In this paper we described determinants of effectiveness

at three distinct, albeit interconnected levels7 determinants at the level of the intervention, at

the level of se!ual behaviour and behavioural change, and at the level of the HIV epidemic.

The latter is often overloo(ed as the final determining step to actual prevention of HIV

infections. 3n the other hand, some of the epidemiological indicators, such as HIV

prevalence, /TI prevalence and mi!ing patterns are arguably best studied and findings from

"uantitative and "ualitative research on #the determinants of% se!ual behaviour are rapidly

accumulating. In /outh )frica, some HIV prevention interventions, such as /TI screening and

treatment, and male circumcision, have been shown to effectively reduce the ris( of ac"uiring

HIV. 4vidence on the efficacy of other approaches to HIV prevention, including sport, is at

best incomplete, but often contradictory or absent. There is a strong and urgent need to fill this

data gap before an evidencebased scalingup of prevention programmes can ta(e place. )t

the same time, one must bear in mind that successfully changing se!ual behaviour is not +ust

dependent on the type of intervention, but also on the perceptions and attitudes towards the

intervention and the envisaged behavioural change.

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