(November 2007) As the world prepares to observe World AIDS Day on December 1, researchers and policymakers alike will take stock of what's working and what isn't in the battle against the HIV/AIDS epidemic.
In the world of HIV prevention, policy researchers and program officers have long puzzled over why information and educational campaigns have failed to significantly change behaviors in Africa.
Some experts believe that many people are in denial about AIDS in Africa and that part of the problem is that talking about AIDS or sex is taboo. Many assume that Africans don't think they can do anything to prevent themselves from catching HIV. Others contend that people are afraid to be tested, because they fear social stigma.
During the course of this study, local villagers recalled and wrote down thousands of conversations related to AIDS. It is clear that discussions about AIDS are not taboo, said Susan Watkins, professor of sociology at the University of Pennsylvania, who presented findings at a Population Reference Bureau policy seminar sponsored in part by the National Institute of Child Health and Human Development. "People are worried," she said. "They're talking to each other."1
Nor were locals fatalistic. Conversations recorded in the journals were full of suggestions about the best way to prevent HIV. Talking about sex didn't seem to be taboo, either. When discussing sickness or the death of people whom they suspected had AIDS, the Malawians would perform "social autopsies," discussing the symptoms, medical history, and even sexual biography of the person to determine whether the illness appeared to be sexually transmitted.
As part of Watkins' study in Malawi, HIV tests were also performed. While fear of social stigma or ostracism may have prevented people in some places from going to get tested, Watkins noted that people were not afraid to gather in public near the tents where results were shared in private. People were not worried that others in their community knew that they have been tested, she said. She attributed a low rate of testing in other communities to logistics: High transportation costs to test sites may prevent many from getting tested.
Uncovering Attitudes and Beliefs
Typically, getting at what people really think can be a challenge. Surveys and interviews may not give individuals adequate time to respond or people may not feel enough at ease to divulge their true thoughts on a topic. It's also possible that when approached by interviewers with clipboards, people may slant their answers, if they think participation has perks.
To learn what people get around the problems associated with standard interviews and learn what people really think, Watkins and other researchers asked several people who lived in or near specific villages in rural Malawi to be their eyes and ears. These individuals went about their daily activities and if they overheard or participated in conversations on AIDS, they were to write them down in a journal. In some cases, the local villagers sometimes dictated their recollections of recent conversations to Watkins. No journals were rejected, although in some cases, Watkins asked for clarification. Since 1999, some 700 journals have been written and sent to Watkins.
While the validity of the findings depends on the accuracy of the participants' recollections and whether they may have acted for an audience, Watkins noted that the journals capture the diversity of views to which people are exposed in their daily lives. Some statements, such as "an immediate change of behavior will protect us" were more credible, because they were made to peers, not to an interviewer. Watkins noted in an article that on some topics, journal entries were consistent with survey data and semistructured interviews.
Rewriting the ABCs of Prevention
Although many people in rural Malawi worry about becoming infected with HIV, typical programs—that promote abstinence before marriage, fidelity after, and if those are not the case, consistent condom use—are incompatible with longstanding assumptions.2 These preventive prescriptions were challenged in many conversations, because they fundamentally contradict a view expressed by both Malawian men and women who believe sex is enhanced by a variety of sexual partners and think condoms inhibit enjoyment of sex.
Discussions with men on prevention strategies tended to focus not on strict fidelity, but on compromises. They might involve a reduction in the number of extramarital partners and more deliberation and care taken in selecting partners, even tapping into local knowledge to learn as much as possible about the sexual history of a potential partner. Many said condom use was more acceptable than in the past, particularly with risky partners.3
Local prevention strategies in rural Malawi were similar to those described in research from other countries, Watkins notes. Men elsewhere also have formulated strategies of fewer partners and more careful selection. Wives suspect their husbands are unfaithful, and the share of people who belong to churches in which marital fidelity is a central tenet of the faith has grown.4
Watkins contends that what's on the agendas of HIV prevention programs must change to more accurately address how people think and behave at the local level. Such an approach could lead to more effective program design in the war against HIV/AIDS.
Sandra Yin is associate editor at the Population Reference Bureau.
- Susan Watkins is also visiting research scientist at the California Center for Population Research, University of California-Los Angeles. Susan Watkins, "Misconceptions, Ours and Theirs: Improving AIDS Interventions" (presentation made at Population Reference Bureau Policy Seminar, Washington, DC, Sept. 19, 2007); and Jere Behrman et al., "Social Networks: The Malawi Diffusion and Ideational Change Project" (Powerpoint presentation).
- Susan Cotts Watkins, "Navigating the AIDS Epidemic in Rural Malawi," Population and Development Review 30, no. 4 (2004): 695.
- Watkins, "Navigating the AIDS Epidemic in Rural Malawi": 690-5.
- Watkins, "Navigating the AIDS Epidemic in Rural Malawi": 698.