For the period 2010-2014, the African Comprehensive HIV/AIDS Partnerships
(ACHAP) is focusing on strengthening HIV prevention interventions among young
people aged 15-29, including an emphasis on young women and girls.
Approach: To inform programme development, this review focuses on the major
factors that drive HIV infection and explores interventions that have illustrated
important learnings and demonstrated effectiveness for HIV prevention.
HIV/AIDS Policy and Epidemiological Context in Botswana: Botswana has
followed a sequenced strategic response to the HIV epidemic, and prevalence declines
have been noted among youth aged 15-24. However, the epidemic remains severe,
and incidence levels are high – especially for females in their 20s. Young females are
biologically more susceptible to HIV than males, and are also vulnerable as a product
of a range of practices related to sexual partnerships. Likelihood of HIV infection is
high, even among young women who only have one partner. For example, a study of
youth in South Africa found that HIV prevalence was 15.2% for females who had
ever had one partner, 23.1% for those ever having had two partners and 28.5% for
those ever having had three partners.
Main Risk Factors: Vulnerability to HIV infection among young women is directly
related to an interplay of factors including sexual debut and early fertility in a context
where late or non-marriage is an established pattern; where immediate needs and
consumer-related wants in a context of poverty, unemployment or low income flow
into transactional and inter-generational sexual relationships; where high partner
turnover and concurrent sexual partnerships have become normalised; and, where risk
is further accentuated by alcohol consumption and mobility. Physical violence is a
related factor. HIV risk flows directly from sexual partnerships with men who are at
higher risk for HIV – either as a product of being older and thus in a higher HIV
prevalence pool, or as a product of risky practices such as having concurrent sexual
partners. Sub-populations of young females additionally at risk include orphans and
youth with disability. There is also a need to integrate the large proportion of young
females already living with HIV into prevention programming.
Approaches: Although there are no absolute certainties in determining ‘what works’
for HIV prevention programming – largely as a product of limitations related to
evaluation – there are types of programmes and lessons learned from programmes that
inform the Botswana context. School-based interventions, facility-based and
community-based health services and mass media have been identified as effective,
while broader lessons for effective programming centre around comprehensive
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approaches that include engaging youth in intervention design, addressing
communities as a whole and using traditional networks for intervention delivery.
There are no ‘one size fits all’ programmes, and adaptable community-wide
approaches are necessary. Although biomedical approaches to incidence reduction
have been proven using randomized controlled trials (RCTs), social interventions
have not achieved demonstrable impacts on incidence. Reviews and other research
noted reservations about peer-led programmes and microfinance programmes for
youth. Lessons for programmes addressing intergenerational sex include promoting
dialogue, offering explicit information about risk, emphasizing adult roles in caring
for young females and promoting safety.
Mass media is recognised as providing an important backdrop to key focal areas for
communication, and must be complemented by communication processes closer to
grassroots level, including interactive dialogue and harnessing horizontal networks of
communication. Overlapping strategies at the community level are noted to be
effective, especially if they are endorsed and promoted through leadership advocacy.
Drawing Together the Evidence: A vital element of a new vision for HIV
prevention programming is a shift from individual-centred approaches, to a
comprehensive approach that engages with people in relationships, peers, families and
communities. A review exploring the ‘next generation’ of HIV prevention strategies
notes that the most efficacious interventions move beyond individualised orientations
and engage participants with interactive activities including one-on-one, small group,
community-level skill building and dialogue. Incorporating community perspectives
in identifying health priorities and guiding the intensity and sequencing of support
through programmes is thus a necessary part of HIV/AIDS programming. This
involves a shift in perceptions of AIDS governance that is focused on supporting a
broad based social response that is led on many fronts.
Related strategies include networking with local leaders, churches, schools, politicians
and the like, incorporating reiteration of the importance of mobilising HIV response
and building coalitions. Approaches also need to take into account the varied and
unstable nature of ‘families’ in the Botswana context, as well as noting wide
variations in community structures and dynamics – although the small population of
the country represents an opportunity for a coordinated comprehensive approach.
Existing programmes could also readily be drawn into an intensified, rigorously
defined national-level programme to address HIV prevention among young females.
Defining a Way Forward: An ecological change model provides a means for
clarifying domains of intervention, including defining exacerbating and mitigating
factors. Evaluation of interventions is key, and progamme plans should include
baseline data and mid-progamme assessment.