Behaviour Change, but on what basis? HIV rates Down in Zimbabwe

Two things that make me cringe: when people talk about “behaviour change” in relation to HIV prevention, and when people write off subtle differences in meaning by saying “it’s just semantics”.  The recent news about HIV prevalence being down significantly in Zimbabwe got me thinking about both of these things.  Semantics is the study of meaning, and it can relate to a whole range of disciplines, but the most common use of the word has to do with “choosing the right term with just the right connotations”.  I realized, in reading the reports about Zimbabwe that my problem is not so much with behaviour change as a piece of the HIV prevention puzzle, but with all the extra “meaning baggage” that comes with advocating exclusively or primarily for behaviour change.

I compared a number of sources for this story (in addition to links throughout, this one), and here’s what can be agreed upon.  In 1997, an estimated 29% of adults were living with HIV in Zimbabwe.  One decade later in 2007, that number had fallen to 16%.  To determine the reasons for this significant decline, a study was launched, supported by the UN Populations Fund, the UN HIV/AIDS Program, the Zimbabwe Ministry for Health and Child Welfare, and Wellcome Trust.  The study, which was based on large demographic surveys, interviews and mathematical modeling, reported a significant reduction in extramarital sex.  A number of explanations are offered for this reduction:

1. a devastating collapse in the economy meant men could no longer afford to buy sex or pay for multiple girlfriends;
2. changing sexual norms, including fewer women going to beer halls to hook up;
3. sexually transmitted infections (STIs) becoming “a badge of shame” rather than a “proof of masculinity”;
4. higher marital rates for Zimbabweans compared with neighbouring countries (this is not an intuitive connection for me, but anyway …); and,
5. Zimbabwe has a “home-based” care model, leading to “tangible fear of death among family and friends”.

Condom use reportedly did not rise, but was already higher than in surrounding countries, at 60% for extramarital sex.  The study authors admit that AIDS education campaigns “probably” helped.

We all know that there are behaviours that result in HIV transmission, and that some behaviours create a higher risk for HIV transmission than others – sharing needles and having unprotected sex, for example.  Obviously, having unprotected sex with a number of people, especially when those people are also having unprotected sex with a number of other people, is “high-risk” as far as HIV transmission is concerned.  It’s important to know this, so that we can all take steps to … yes … change our behaviour so that we reduce the risk of becoming infected and/or infecting others with HIV.  The best ways to reduce the risk associated with vaginal and anal sex is to use condoms, especially in those high-risk encounters.  This is a behaviour change conclusion that can be drawn because of increased knowledge and understanding about how HIV is transmitted and prevented.

Here’s what rubs me the wrong way about the way this study is being presented.  The behaviour change that is being promoted here is not based on increased knowledge, but on “tangible fear” and moralistic “be faithful” messages …  no wait, actually it’s probably just the byproduct of devastating economic decline (!) and what sounds like a shoddy healthcare system which means people die at home instead of in a hospital setting with consistent treatment and care (!!!).  Is this sustainable prevention?  Is this what we want to be promoting?

And here’s where it is about semantics for me – it’s about the subtle meaning, the implications of carrying a behaviour change banner first and foremost.  The problem with the A and B of the ABC prevention model (Abstinence, Be faithful, Condoms) is that they set people up for failure, because as much as abstinence and monogamy sound nice, they don’t seem to work for a whole lot of people.  The implication is that being celibate or monogamous is “better”, and that is itself up for debate.  Even those who believe wholeheartedly in these principles seem to slip up more often than not.

I believe changing behaviour is a part of the fight against HIV, but that it’s secondary.  It results from education about how HIV is transmitted and how to prevent it, as well as access to the tools necessary to prevent it (condoms and clean needles).  Hopefully it can’t result solely from fear, morality and economic collapse, because I’m afraid these are not strong bases on which to build and move forward.

- Miriam

This was posted on Friday, February 25th, 2011 at 10:00 am and is filed under Daily Moments, HIV Prevention, News, Research . Feel free to respond, or trackback. Read our comments policy.

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  Donna February 25, 2011 at 12:54 pm

  I too have a problem with the words “behaviour change” because it puts so much moral responsibility on the individual in question. This is often used against the most disenfranchised among us. Think about low-income single parents whose children may be fighting obesity because of too much junk food and downtime. We all know a healthy eating & living plan requires time, money, community support and consistent energy. How many fighting the effects of poverty also have time to do that daily? Personal accountability is always important but so is not taking responsibiility or shame on for the system (be it government, educational, consumer, etc) that hinders the process.See More

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