*Note: This is the Part 3 of a three-part series on the cost-effectiveness of HIV/AIDS interventions
What is Behavior Change?
Behavior change in HIV/AIDS prevention typically refers to sensitization efforts to convince a target population to stop engaging in activities that increase the risk of HIV/AIDS transmission. Behavior change strategies require a uniquely challenging intersection of behavioral psychology, sociology, anthropology, and epidemiology. According to Fishbien (1995), for a person to change his/her behavior, eight criteria must be met.
- The person forms a strong positive intention, or makes a commitment, to perform the behavior;
- There are no environmental constraints that make it impossible for the behavior to occur:
- The person possesses the skills necessary to perform the behavior;
- The person believes that the advantages (benefits, anticipated positive outcomes) of performing the behavior outweigh the disadvantages (costs, anticipated negative outcomes)-in other words, the person has a positive attitude toward performing the behavior;
- The person perceives more normative pressure to perform the behavior than to not perform the behavior;
- The person perceives that performance of the behavior is more consistent than inconsistent with his or her self-image or that it does not violate personal standards
- The person’s emotional reaction to performing the behavior is more positive than negative; or
- The person perceives that he or she has the capabilities to perform the behavior under a number of different circumstances-in other words, the person has self-efficacy with respect to executing the behavior in question.
This all means that for behavior change interventions to be successful, the intervention must be designed in such a way that takes into account the complicated factors influencing a person’s decision to engage or avoid certain behaviors.
Within the HIV/AIDS prevention realm, behavior change strategies have focused primarily on reducing transmission rates through risky activities, most often sex and drug related. In sub-Saharan Africa, most cases of HIV are related to sexual encounters or mother-to-child transmission. Sexual-based behavior change interventions on the continent have been widespread and emphasized a variety of risky behaviors. In particular, the focus has been on reducing the number of sexual partners, delaying sexual debut, and encouraging condom use. NGOs and governments have used a variety of mediums for promoting behavior change, including television/radio dramas, churches and community groups, billboards, primary and secondary school curriculum, etc.
Does Behavior Change Work?
There is little information on the reliability and cost-effectiveness of behavior change interventions in preventing the spread of HIV/AIDS. The results of a behavior change intervention take time to affect the overall HIV prevalence rate within a community, and this rate is influenced by a variety of other factors, often making the true cause of decreased prevalence unclear. However, there are two cases in sub-Saharan Africa that have received considerable attention as success stories for behavior change – Uganda and Zimbabwe.
Uganda was the first country to gain notoriety for its success in rolling back HIV prevalence. In the mid- to late-1990s, Uganda had an HIV prevalence rate of around 15%, but by the mid-2000s, the country had managed to cut its HIV rate to just 4%. Researchers like Green et al. (2006) argue that early response from Uganda’s President Yoweri Museveni and a widespread behavior change program contributed significantly to HIV prevalence decline during this time period. The behavior change model for Uganda – Abstinence, Be Faithful, and Condomize or ABC – has since been heralded by scholars and criticized by religious leaders. As Green et al. (2006) argue:
One lesson from Uganda seems to be: address the ABC factors through multiple interventions and do this through the means exemplified (and often pioneered) by Uganda: empowering women, mobilizing PLWAs and involving them in prevention, fighting stigma, involving faith-based organizations and the like. Another important element may have been the deliberate policy of fear arousal in order to combat denial, dramatize that AIDS is real and provoke Ugandans to feel at personal risk of HIV infection, unless they were willing to change behavior.
Zimbabwe presents a similar case of behavior change at the community level that might have led to significant HIV prevalence decline. From 1999 to 2009, Zimbabwe’s HIV prevalence rates were cut in half. In 2006, Gregson et al. reported findings from their Manicaland cohort study that showed correlation between decreased engagement in risky activities and a decrease in HIV prevalence. They saw a decrease in sexual partners, delayed sexual debut, and an increase in the use of condoms with casual sex as a result of their intervention. This was directly linked to lower HIV prevalence within the target community. However, Zimbabwe is a tricky case because of its high HIV/AIDS related mortality rates and increased human flight.
The Bottom Line
Behavior change interventions can and do work if they are tailored to the specific environment (sometimes this means the individual). This tailoring takes time and money. Studies have to be conducted within each community to discover what barriers to uptake exist and how to overcome these. Not to mention, it is difficult to decipher whether behavior changes were the main cause of prevention.
That being said, behavior change promotion encourages a host of healthy behaviors that prevent various illnesses and health problems, not just HIV/AIDS. In the cases where they have contributed to decreased transmission, their impact is argued to be enormous. As Green et al. (2006) puts it:
According to modeling by Stoneburner and Low-Beer (2004), behavior change, particularly partner reduction, since the late 1980s in Uganda appears to have had a similar impact as a potential medical vaccine of 80% efficacy.