Preventing and Mitigating AIDS in
Sub-Saharan Africa: Research and Data Priorities for the Social and
The official number of acquired
immune deficiency syndrome (AIDS) cases worldwide since the start of the
epidemic passed the 1 million mark near the end of 1994—a fact that was
covered in a six-sentence story on an inside page of The New York
Times (January 4, 1995). Moreover, given the chronic underreporting
and under-diagnosis in developing countries, the actual number of AIDS
cases may be four times as high. The official statistics also do not
reflect the millions of people who are infected with the human
immunodeficiency virus (HIV) but have yet to develop symptoms of AIDS.
The situation is critical in sub-Saharan Africa, where the World Health
Organization (WHO) estimates that approximately 11 million adults and as
many as 1 million children have been infected with HIV, and where basic
infrastructure, financial, and managerial resources, as well as
health-care personnel to deal with the catastrophe, are all extremely
Sub-Saharan Africa is
geographically, demographically, socially, and culturally heterogeneous,
and the extent and spread of HIV infection and AIDS have accordingly
been heterogeneous as well. Thus, it is difficult to generalize about
the AIDS epidemic in the region. There have been only a few nationally
or regionally representative seroprevalence studies conducted to date in
sub-Saharan Africa, and information is available predominantly on the
groups with the highest risk of HIV infection. Yet some overall
characteristics and trends can be seen. The most afflicted countries are
geographically concentrated: other than Côte d'Ivoire in West Africa,
they lie in a region of East and Southern Africa that stretches from
Uganda and Kenya southward to include Rwanda, Burundi, Tanzania, Malawi,
Zambia, Zimbabwe, and Botswana.
Patients seeking treatment today
probably contracted the virus years ago. Thus, no matter how serious the
situation currently appears, there will be very large increases in the
number of AIDS deaths in sub-Saharan Africa in the future. By the year
2010, demographers project that life expectancy will fall from 66 to 33
years in Zambia, from 70 to 40 years in Zimbabwe, from 68 to 40 years in
Kenya, and from 59 to 31 years in Uganda.
NEED FOR IMMEDIATE ACTION
There is encouraging evidence that
intervention programs to change behavior can be effective in preventing
the spread of HIV. Public awareness of the AIDS epidemic is extremely
high throughout Africa, and condom sales have risen dramatically across
the continent in the past few years. Other promising findings include a
recent reduction in the prevalence of HIV-1 infection among young males
in rural Uganda and evidence that treating sexually transmitted diseases
(STDs) in rural Tanzania may reduce the spread of HIV. But many
interventions have been experimental and small scale and so are not
sufficient to reverse the course of the epidemic. At the same time,
discovery of an effective vaccine or treatment shows little promise.
Furthermore, even if a vaccine or cure were developed, it would probably
not be sufficient to bring a speedy end to the epidemic—because of
imperfect effectiveness, cost, and less than universal distribution and
acceptance. In addition, many of the millions of people already infected
with HIV are unaware of their status and so represent a pool capable of
passing the virus to new cohorts. Thus, changing human behavior to slow
the speed or limit the extent of transmission will remain for the
foreseeable future the first and probably the most important line of
defense against HIV/AIDS in sub-Saharan Africa. More and better social
and behavioral research is needed to develop more effective and
acceptable preventive strategies and to find more effective ways of
mitigating the negative effects of the epidemic.
Perhaps the most important argument
for immediate action to slow the further spread of HIV is that, as
suggested above, in many parts of the region the epidemic has not yet
peaked. HIV tends to spread quickly among individuals whose behaviors
place them at high risk of infection, such as commercial sex workers and
their clients; it spreads thereafter—at first slowly and then at an
accelerated pace—into the general population. In many sub-Saharan
African countries the disease has already spread widely, but in others
it has not. Because the cost-effectiveness of prevention efforts
declines rapidly as the epidemic spreads, the timing of interventions is
crucial. Failure to control the epidemic now will mean that far more
costly and difficult interventions will be necessary in the future.
Another important reason for acting
now to revitalize programs to combat HIV and AIDS is that the region's
governments are facing a critical turning point in prevention efforts.
Since their inception in the late 1980s, national prevention programs
often have operated on the assumption that traditional health education
about HIV/AIDS would be sufficient to induce widespread behavior change.
This has not proved to be the case. The most optimistic reading of the
results of these prevention efforts is that they have been less
successful than was at first hoped. At the same time, leadership of the
global effort to fight AIDS is changing hands, creating an important
opportunity to review what has been achieved to date and to develop a
coherent global strategy for the foreseeable future. In response to a
recommendation by the executive board of WHO, and with firm commitments
to AIDS activities from other United Nations organizations, a joint
United Nations Programme on AIDS (UNAIDS) is being created to improve
coordination among the various organizations and to boost the global
Finally, for a number of reasons,
current AIDS-prevention efforts may be reaching a plateau. Agencies and
governments in developed countries are beginning to suffer from "donor
fatigue," induced partly by the realization that the epidemic is
unlikely to affect the developed world as badly as was first feared, and
partly by an inability to see how the money and effort expended on
prevention thus far have affected the course of the epidemic.
Furthermore, international donors do not want to commit themselves to
providing care for the growing number of AIDS patients in countries
where expenditures on health averaged less than US $15 per capita in
1990. The most visible consequence of donor fatigue in Africa is the
withdrawal of resident advisers of WHO's Global Programme on AIDS from
national AIDS control programs. This reduction in assistance has had
enormous costs, in both human and economic terms. It also increases the
urgency for action by Africans and their governments.
We recommend research and data in
the social and behavioral sciences to improve and extend existing
successful programs and devise more effective strategies for preventing
HIV transmission, as well as support efforts to mitigate the impact of
the AIDS epidemic. Our recommendations cover five areas: the monitoring
of the epidemic, information on sexual behavior and HIV/AIDS, primary
HIV-prevention strategies, mitigation of the impacts of the epidemic,
and the building of an indigenous capacity for AIDS-related research.
Both our five key recommendations and our other recommendations are
offered with full acknowledgment of the importance of the economic,
political, and societal context of the HIV/AIDS epidemic in Africa. Our
five key recommendations are numbered separately from our other
recommendations, which are numbered by chapter in the order in which
SOCIETAL CONTEXT OF HIV/AIDS IN AFRICA
The societal context within which
people are born and raised, are initiated to sexuality, and lead their
lives strongly influences their perceptions of risk and their sexual
behavior. Social, cultural, and economic factors can act either to speed
or to retard the spread of infection. Planners and policy makers must be
cognizant of the societal context and attempt to modify it in ways that
are conducive to and supportive of change. Effective interventions must
target not only individual perceptions and behavior, but also their
Among the salient factors that
affect the size and shape of the HIV/AIDS epidemic in sub-Saharan Africa
are the age and gender composition of the population; the pattern of sex
roles and expectations within society; inequities in gender roles and
power; sexual access to young girls and the acceptance of widespread
differentials in the ages of sexual partners; rapid urbanization under
conditions of high unemployment; poverty; considerable transactional sex
fostered by limited earning opportunities for women; and lack of access
to health care, particularly treatment for various STDs. These factors
are often exacerbated by social upheavals related to economic distress,
political conflicts, and wars. Of course, there is enormous variation in
the situation from country to country; particularly noteworthy are the
differences between West Africa and East and Southern Africa.
EPIDEMIOLOGY OF THE HIV/AIDS EPIDEMIC
The global HIV/AIDS epidemic
consists of many separate, individual epidemics, each with its own
distinct characteristics that depend on geography, the specific
population affected, the frequencies of risk behaviors and practices,
and the timing of the introduction of the virus. No single factor,
biological or behavioral, determines the epidemiologic pattern of HIV
infection. Instead, a complex interaction among several variables
determines how and where HIV spreads in a population. The primary mode
of HIV transmission is sexual, with heterosexual transmission accounting
for at least 80 percent of adult HIV infections in sub-Saharan Africa.
Biological factors also influence
the spread of the epidemic by increasing or decreasing susceptibility to
the virus, altering the infectiousness of those with HIV, and hastening
the progression of infection to disease and death. Such biological
factors include the presence of classical STDs, male circumcision, and
the viral characteristics of both HIV-1 and HIV-2 and their multiple
A growing body of data suggests that
HIV cannot be considered in isolation from other STDs because it shares
with them modes of transmission and behavioral risk factors. More
important, there is evidence that other STDs may increase susceptibility
to and transmission of HIV, so that treatment and prevention of STDs may
serve as an important weapon in curbing the HIV/AIDS epidemic.
Although HIV infection rates are
high among many populations and subgroups in sub-Saharan Africa, there
is much variation in incidence and prevalence, both geographically and
by population subgroups. The probable causes of this heterogeneity in
seroprevalence include behavioral, biological, and societal factors. As
suggested above, trying to explain the phenomenon by a single
factor—such as civil war, male circumcision, STDs, or rate of partner
change—is simplistic. Instead, it appears that the simultaneous
occurrence of several risk factors for HIV transmission determines how
rapidly and to what level HIV spreads among a population and who becomes
infected. This epidemiologic diversity not only reflects differences in
sexual and other behaviors, but also suggests that the epidemic has not
reached an equilibrium in most areas.
The HIV epidemic and the demographic
structure of the population of sub-Saharan Africa will have complex
interactions over time. The population is predominantly young, in sharp
contrast with the age structure in developed countries, and many of the
behavioral factors associated with HIV transmission are common among
young people. Accordingly, the large number of people under age 15, who
will soon enter their sexual and reproductive lives, represent a
priority group for AIDS and STD prevention.
KEY RECOMMENDATION 1. Basic
surveillance systems for monitoring the prevalence and incidence of STDs
and HIV must be strengthened and expanded.
Good social science research is as
dependent as public health and medical research on reliable and valid
HIV/AIDS surveillance data. With the implementation of various
interventions aimed at controlling HIV transmission, periodic monitoring
of STD and HIV prevalence and incidence among selected populations is
essential both for assessment of the impact of these programs and for
decision making on program design and implementation.
Recommendation 3-1. More emphasis
must be placed on HIV incidence studies for monitoring trends in HIV
Although seroprevalence provides
important information regarding currently infected individuals in an
area, measuring incidence is also critically important for estimating
the rate of change in the spread of HIV infection in a given population.
In particular, data on current incidence provide the most direct and
immediate information regarding the potential effects of a given
intervention. Together, prevalence and incidence studies can provide
information regarding the current status of the epidemic in terms of
numbers of infected individuals and the rate of spread within a given
population on an annual basis.
Recommendation 3-2. STD and HIV
prevalence and incidence data should be combined with behavioral and
Current surveillance systems are
often limited, incomplete, and inconsistent, and they rarely measure
behavioral or demographic variables. Given new, non-invasive techniques
for the collection and analysis of biological specimens (including
blood, urine, vaginal secretions, and saliva), accurate assessment of
STD and HIV prevalence and incidence can readily be combined with
behavioral and demographic information.
In conjunction with periodic
serosurveys, demographic information is needed to elucidate the
differential spread of STD and HIV infection in rural and urban settings
and variations in seroprevalence and incidence by gender, educational
level, profession, income level, age, and other demographic factors.
This type of information is critical for targeting prevention messages
to selected groups at risk of acquiring and transmitting HIV and for
projecting the effects of HIV and other STDs on a population over time.
SEXUAL BEHAVIOR AND HIV/AIDS
Patterns of sexual behavior—both
partner selection and particular practices are —clearly the primary
determinant of the spread of the HIV/AIDS epidemic in sub- Saharan
Africa. Information on sexual behavior is needed to help project the
future course of the epidemic, to develop more effective prevention
strategies, and to provide baseline data for evaluating the
effectiveness of alternative preventive strategies.
Several studies have begun to
address how sexual networks channel and potentially amplify HIV
transmission in sub-Saharan Africa. Such networking studies encompass
the role of migration, transportation systems, and local markets.
Asymmetric age matching, where young women have sexual contact with
older men, results in a young cohort of women who have been exposed to
older male partners with higher HIV prevalence; this pattern creates a
chain of infection that passes from generation to generation.
Heterogeneity in the composition of
sexual networks may have strong implications for the speed or direction
of viral transmission. Patterns of mixing between people in high- risk
core groups and others in the general population observed in sub-Saharan
African settings (in contrast to pairings confined within well-defined
core groups) can result in substantial spread of STDs and HIV among the
general population. Although much emphasis has been placed on
"high-risk" behaviors associated with multiple, sequential, short-term
relationships, there is a growing body of research suggesting that
concurrent multiple partnerships, including those that are stable and
long term (common in many African settings), may contribute
substantially to HIV transmission.
At the same time, however, networks
also serve as bases of social support and the development of behavioral
norms. Networks are a potential natural resource for behavioral
interventions. Support for behavioral change, such as acceptance of
condoms among peers, can enable individuals to negotiate these matters
more effectively when confronted with a resistant partner. Conversely,
the absence of support networks can make behavioral change more
difficult to achieve.
Recommendation 4-1. Research on
sexual networks is critical.
Population-based research is needed
to collect and analyze data on both the variables that describe
individual sexual behavior and the possible socioeconomic determinants
of the decision to have sex with a new partner or forgo protection.
Since the details of interconnected sexual networks are difficult to
deduce from the answers to individual questionnaires, there is also an
important role for social network research.
Recommendation 4-2. Researchers
need to develop more reliable ways of collecting information on sexual
behavior and to find ways of testing its validity.
There appears to be a much greater
willingness to report sexual behavior than was believed until recently,
but this field of research requires sensitivity. The challenge is to
develop definitions and appropriate vocabulary, such as for categories
of relationships, that are both specific enough to be clear to
respondents and generalizable enough to be useful to analysts and
program planners. The challenge is likely to grow as information about
high- risk behavior spreads, increasing the likelihood that respondents
will seek to give the "right" answers on questionnaires and in
interviews. Hybrid research strategies involving both qualitative and
quantitative approaches are essential. Where appropriate, and when both
privacy and confidentiality can be ensured, biological markers of sexual
activity (such as HIV or STD status) should periodically be incorporated
into behavioral surveys to allow assessment of the validity of
questionnaire responses and the extent to which the latter provide
adequate information on risk.
Recommendation 4-3. Research is
needed on patterns of sexual initiation and on the formation of sexual
norms and attitudes.
The sexual habits of a lifetime may
well be influenced by a socialization process that starts at or before
puberty, often before sexual activity begins. A better understanding of
the early influences on sexual norms and attitudes and of patterns of
sexual initiation may prove essential to promoting safer behavior. For
this recommended research to be successful, studies must include
children and prepubescent youths, as well as sexually active adolescents
and their partners. Recognition that sexuality is socially constructed
and changing rapidly is essential to broadening the research agenda and
Recommendation 4-4. More work is
needed to clarify the frequency of specific sexual practices.
Because the epidemic in sub-Saharan
Africa is being sustained by heterosexual transmission, information on
sexual behavior is needed to help develop more effective prevention
strategies, as well as to provide baseline data to evaluate their
effectiveness. Specific sexual practices—dry sex, oral sex, and anal sex
being but a few examples—may impede the success of particular
interventions, yet information about such practices is necessary for
encouraging behavioral change.
Recommendation 4-5. Research on
coercive sex, especially among adolescents, is critical.
The magnitude of the problem of
coercive sex is all but unknown, as are the circumstances under which
forced sex or rape takes place. How frequently does it happen and why?
Do the aggressors or the victims share characteristics that might
suggest a path for preventive or protective interventions? Research on
community attitudes, mores, and gender expectations that may serve to
encourage or inhibit coercive sex is urgently needed in order to
determine how to enlist community support for the curtailment of such
Recommendation 4-6. Research
aimed at achieving a better understanding of perceptions about the dual
roles of condoms is required.
Condoms help prevent the spread of
HIV/AIDS; they also prevent pregnancy. How aware are people of these
dual roles, and what weight do they give each when deciding whether to
use condoms? How often are these roles in concord and how often in
conflict? Do partners discuss this issue, and if so, what are the
negotiating mechanisms used?
Recommendation 4-7. Research on
attitudes and beliefs about and behavioral responses to sexually
transmitted diseases is required.
To develop effective strategies for
the treatment of STDs, understanding is needed about social and cultural
responses to STDs, including stigmatization. Much more knowledge about
the health-seeking behaviors of people infected with STDs, and whether
their sexual habits are altered by knowledge of infection, is also
Recommendation 4-8. Research on
acceptance of and behavioral responses to HIV vaccination is urgently
Because vaccine trials are likely to
begin with vaccines of limited efficacy, there is an urgent need to
learn whether individuals who are vaccinated increase their exposure to
HIV through riskier behavior, and if so, to determine how to mitigate
PRIMARY HIV-PREVENTION STRATEGIES
As suggested earlier, despite the
many limitations inherent in attempting to evaluate the effectiveness of
interventions aimed at HIV prevention, clear evidence is emerging that
such efforts can be successful, particularly among higher-risk groups.
At the same time, however, data from various surveillance systems
indicate that current interventions are probably not yet having a
significant impact on the epidemic at the subcontinent or even the
country level. Despite the fact that levels of AIDS awareness are
extremely high in sub- Saharan Africa, getting people to change their
behavior is difficult. Denial, fear, external pressures, social and
sexual norms, other priorities, or simple economics can keep people from
adopting healthier life-styles.
Yet getting people to change their
behavior is not impossible. Indeed, health educators in sub-Saharan
Africa have had a fair amount of success in recent years. For example,
broad-based education campaigns have persuaded large numbers of people
to have their children immunized against various childhood diseases and
have educated mothers to give their children oral rehydration formula
during episodes of diarrhea. Of course, attempting to modify more
personal behavior, such as sexual practices, is more challenging. Yet
family planning programs have been successful even in some of the most
disadvantaged countries of the world. Even the most cautious reviews of
behavioral interventions aimed at slowing the spread of HIV conclude
that although most have not been rigorously evaluated, some approaches
do seem to work. At the same time, it is important to have realistic
expectations about what can be achieved. Behavior change will never be
100 percent: some individuals will never choose to protect themselves,
while others will lapse into old patterns of behavior after a short
period of time.
To increase the likelihood of
success, interventions need to be culturally appropriate and locally
relevant, reflecting the social context within which they are embedded.
They should be designed with a clear idea of the target population and
the types of behaviors to be changed. In turn, recognized impediments in
the social environment to behavior change probably need to be
specifically addressed. Behavior-change interventions should include
promotion of lower-risk behavior, assistance in development of
risk-reduction skills, and promotion of changes in societal norms. It
must be noted that in sub-Saharan Africa, there is an urgent need to
design ways of targeting women and adolescents for prevention messages.
Basic principles of successful
intervention programs include the following:
· learning about and adapting to
· ensuring community participation,
· carefully targeting the audience,
· identifying effective strategies
· building local capacity,
· evaluating results, and
· using the results from evaluation
studies for improvement.
Successful intervention programs
should also be multidisciplinary and multifaceted and involve multiple
contacts with targeted populations. In sub-Saharan Africa, as elsewhere,
HIV-prevention messages have included promotion of partner reduction,
postponement of sexual debut, alternatives to risky sex, mutually
faithful monogamy, consistent and proper use of condoms, better
recognition of STD symptoms, and more effective health-seeking behavior.
Numerous interventions are being
implemented throughout Africa, but most are still information-based
health education campaigns. Many of the messages communicated are
generic or vague and do not address specific risk behaviors. Innovative
approaches are typically small scale and lack rigorous evaluation.
Furthermore, it is not easy to demonstrate the success of a particular
intervention because it is difficult to define and measure such outcome
variables as "better health status" and to determine whether the
intervention in question was the reason for a desired change.
Consequently, the need for solid evaluation research is still urgent.
KEY RECOMMENDATION 2. An increase
in research funding for the development of social and behavioral
interventions aimed at protecting women and adolescents, especially
girls, from infection deserves highest priority.
An important step in arresting the
spread of AIDS in sub-Saharan Africa is to recognize that, although
African women have relatively high autonomy by the standards of
developing countries, their low and separate status remains a major
obstacle to HIV prevention. In many societies, the presence of
unmarried, postpubertal girls is a new phenomenon. Guidelines for their
sexual behavior and that of others toward them are not well established;
their low social status makes them particularly vulnerable. Moreover, in
many areas of sub-Saharan Africa, high HIV incidence has been detected
among adolescents and young adults, especially girls. Research on which
to base the design of culturally relevant programs targeted to
adolescents and to adults who might be their sexual partners is an
KEY RECOMMENDATION 3. More
evaluation research is needed to correlate process and outcome
indicators—such as reported condom sales and behavior change—with
reductions in HIV incidence or prevalence.
Rigorous designs, such as controlled
intervention studies to assess the effectiveness of different prevention
approaches, are needed. To date, few rigorous evaluations of
intervention programs in sub-Saharan Africa have been conducted.
Evaluations that have been reported often lack precision in their
measurement of risk behaviors and are therefore not very informative. As
a result, few strategies can demonstrate whether they are effective.
Barriers to rigorous evaluation research include lack of human
resources, expertise, financial resources, and equipment. Overcoming
these barriers requires major changes in research infrastructure.
Nevertheless, it is a priority to begin now a few large- scale
behavioral interventions, including adequate baseline surveys,
multiround surveys, and longitudinal studies with comparison cohorts,
even if these interventions are relatively expensive. It is only with
these types of studies that more definitive information on the
effectiveness of various interventions, which is so desperately lacking
for most studies in sub-Saharan Africa, can be obtained. The longer such
studies are delayed, the longer will exist the uncertainty about which
HIV-prevention strategies work best, for whom, and under what
circumstances. In the interim, basic program evaluation and some
formative and operational research can be completed, and such work
should be required by donors as part of program implementation awards.
Recommendation 5-1. Interventions
that promote gender equality deserve high priority as AIDS-prevention
strategies in every country.
Women's primary source of risk is
their society-wide subordination, not their lack of knowledge.
Governments can effect change in many ways to empower women: reducing
the financial necessity for multiple partnerships by changing laws to
give women equal access to training and jobs, equal rights of
inheritance and property ownership, equal access to education, and equal
wage scales; enacting and enforcing laws against rape; building the
capacity of women for collective action; and educating everyone about
women's rights. Enhancing the status of women is a long-term strategy
that would have many beneficial effects for development, in addition to
the likely effect of reducing the transmission of HIV and other STDs.
Recommendation 5-2. In the short
term, a female-controlled vaginal microbicide that would allow women to
protect themselves without their partner's participation is an urgent
research and development priority for international donors.
A microbicide is not a quick-fix
substitute for the fundamental structural reforms necessary to achieve
gender equality, but rather a temporary and partial response to this
problem as it influences HIV transmission. Yet in the same way that the
use of spermicides by women can reduce fertility, the use of a
microbicide could, in and of itself, help arrest the spread of HIV.
Recommendation 5-3. Research is
needed to address the HIV-prevention needs of several other populations
with marked vulnerability, particularly the mobile and the
There is a need to reach mobile
individuals and groups with comprehensible and acceptable programs,
particularly where linguistic and cultural barriers exist between
migrants and the local population. Ways of effectively providing
preventive services to the disenfranchised populations in the
ever-growing urban slums and in refugee camps need to be developed; a
major challenge to such programs is the lack of resources and social
support for individuals in such settings.
Recommendation 5-4. Additional
research should be conducted to determine the impact of specific STD
interventions on the incidence of HIV infection within defined
Research is needed to determine the
extent to which STDs help cause HIV infection, to examine the importance
of the behavioral synergy of STD and HIV transmission, and to design
more effective intervention programs. There is a need for assessment of
the relative efficacy and feasibility of various interventions for STD
treatment and sexual behavior change in reducing HIV transmission. This
research includes assessing the effects of programs that target
individuals at high risk of acquiring and transmitting STDs, as well as
the effects of community-based STD programs. The interventions
themselves could comprise STD education, condom distribution, increased
STD screening, and mass antibiotic therapy. Data on the effectiveness of
these interventions, particularly those focused on decreasing STD
prevalence, are essential for evaluating the impact of STD reduction on
the spread of HIV. Behavioral research on ways of ensuring acceptance of
various STD control strategies should be directly integrated into the
Recommendation 5-5. Research is
needed to assess the effectiveness and cost- effectiveness of the
syndromic approach to STD diagnosis and treatment.
Clinical testing for STDs is
expensive and not widely accessible. Therefore, research is needed on
better ways to identify STDs more accurately through symptoms. In
addition, new screening methods, including urine-based assays for
chlamydia and gonorrhea and self-administered vaginal swabs for
trichomonas culture and bacterial vaginosis gram stain, should be
incorporated into research. Efforts are needed to make these techniques
available and affordable in developing-country settings for
surveillance, diagnosis, and validation.
Recommendation 5-6. For long-term
program planning and resource allocation, cost-effectiveness studies
should be incorporated in donor research work and the cost-
effectiveness of HIV prevention compared with that of other health
Few intervention evaluations have
adequately assessed effectiveness in terms of behavior change or
seroincidence declines, much less cost-effectiveness. Results of
evaluation studies currently in progress in several countries in
sub-Saharan Africa are expected to provide data on the
cost-effectiveness of various HIV-prevention strategies. However,
determining the effectiveness of HIV-prevention strategies is
methodologically complex and will take several more years to complete.
In the meantime, since resources are insufficient and may well decline
further, efficient resource utilization is paramount. Thus, basic
analysis of overall program costs and specific intervention costs is
critical. Simple cost analyses and cost-effectiveness estimates could
provide data that would be helpful for public health decision making and
Recommendation 5-7. Operations
research should be a high priority.
The growth of the HIV/AIDS pandemic
in the past 20 years in sub-Saharan Africa has led to the development of
institutional and community-based responses and a corresponding need for
operations research to improve the effectiveness, cost- effectiveness,
and quality of these responses. Primary research needs include scaling
up successful experimental interventions, improving the effectiveness
and reducing the cost of existing programs, examining the
cost-effectiveness of linking HIV prevention with HIV/AIDS care, and
improving the sensitivity and specificity of criteria for targeting
Recommendation 5-8. Research
should be undertaken to measure the impact of female-controlled barrier
contraceptive use on HIV transmission.
Studies should be undertaken to
determine the effectiveness against STDs and HIV of female-controlled
barrier contraceptives such as female condoms and spermicides. This
research should encompass field-based studies of the acceptability of
these methods. Moreover, greater efforts need to be made to integrate
appropriate HIV/AIDS-prevention messages and programs for STD diagnosis,
referral, and treatment into family planning programs.
Recommendation 5-9. Behavioral
research is needed to develop effective pregnancy-related HIV counseling
Given the rapid spread of HIV among
women in sub-Saharan Africa, perinatal transmission continues to have a
major impact on infant and child morbidity and mortality among
populations with a high HIV seroprevalence. Studies using modified
treatment regimens with Zidovudine (AZT), hyperimmune gammaglobulin,
vitamin A, vaginal washes, and other means of intervention should be
undertaken to determine their overall effectiveness and
cost-effectiveness in decreasing HIV perinatal transmission.
MITIGATING THE IMPACT OF THE EPIDEMIC
AIDS will have a large social,
psychological, demographic, and economic impact on both individuals and
societies. In addition to the physical suffering and grief caused by the
disease, AIDS can lead to social and economic hardship, isolation,
stigmatization, and discrimination.
As noted above, even if transmission
of HIV were halted today, millions of Africans who are currently
infected would still develop AIDS and die over the next 10 to 20 years.
But transmission has not ceased. To the contrary, evidence from a
variety of populations in Africa suggests that seroprevalence either is
continuing to climb or has leveled off at discouragingly high levels.
For at least the next several decades, the HIV/AIDS epidemic will
continue to ravage African prime-age adults and their children with
death rates as much as 10 times higher than they would otherwise have
Although not immediately visible,
the cumulative mortality effects of this "slow plague" will be
substantial. Increases in infant and child mortality will be accompanied
by increases in adult mortality and reductions in life expectancy.
Population growth will decline more rapidly than expected, and the
populations in sub- Saharan Africa in the year 2000, particularly among
the countries in the main AIDS belt, will be somewhat smaller than those
projected in the absence of AIDS. In many of the worst-afflicted
countries, deaths will more than double during the 1990s as compared
with the number estimated without AIDS. These additional deaths will put
increasing strains on already overburdened health-care systems and on
individual households trying to manage with limited economic resources.
Care and support for orphans will be a growing concern, and traditional
inheritance and other legal rights will be challenged.
Relatively little research has been
conducted on the economic consequences of adult morbidity and mortality.
AIDS is one of several diseases with potentially great economic
significance for developing countries. Diseases such as malaria and
measles are far more prevalent in Africa, yet there are reasons to
believe that the economic impact of AIDS will be greater. The long
incubation period of HIV implies that the economic impact of existing
levels of infection would be felt for 10 years or more even if all
infection were to cease today. The benefits of averting a case of HIV
are very high relative to other diseases.
Whether directed at individuals with
AIDS and their households or at other levels of social organization,
mitigation interventions divert scarce resources from other uses,
including efforts to prevent transmission. Thus, the value to society of
any mitigation intervention should be as least as great as the cost of
the resources devoted to the effort. Research on this issue might
improve the efficiency of current expenditures, as well as justify a
case for or against additional spending.
KEY RECOMMENDATION 4. Research on
mitigating the impact of the disease should focus on the needs of people
A great deal more is known about
designing and implementing HIV-pre-vention programs than is known about
providing care to the millions of people in sub-Saharan Africa already
infected with the virus. Simple, cost-effective solutions to daily
living problems faced by persons with AIDS, such as palliative care,
part-time home care, and group counseling, may make larger, more
expensive interventions unwarranted.
Recommendation 6-1. Research
efforts to evaluate the impact of HIV/AIDS on individuals, households,
firms, economic sectors, and nations are badly needed.
Research on impact should
incorporate both qualitative and quantitative approaches to data
collection and should evaluate both short- and long-term effects. Of
particular interest is research that would permit an understanding of
the impact of HIV/AIDS on poverty and on individual decision making.
Research is needed to ascertain whether decreased life expectancy
reduces willingness to save or invest in financial and real assets, in
human capital, and in the relationships necessary to maintain social
interactions. In the long term, the impact of HIV/AIDS on sub-Saharan
Africa will depend on the strength and malleability of social and
economic networks in accommodating the changes that are occurring.
Recommendation 6-2. Since the
attempt to assist directly every affected household would be financially
nonsustainable, research is needed on criteria for determining which
households and communities should be targeted for assistance and which
institutions should deliver that assistance.
The epidemic has already affected
millions of households in sub-Saharan Africa and will continue to do so
for at least the next 20 years. Efforts to mitigate the effects of the
disease have been uncoordinated and poorly targeted, and their ability
to provide solutions for those infected and their families remains to be
Recommendation 6-3. Discovering
the optimal roles of government, nongovernmental organizations, and
donors in HIV/AIDS prevention and mitigation is critical and requires
Governments are now moving to
decentralize and privatize AIDS programs by contracting, licensing, or
franchising activities to various types of nongovernmental institutions.
Research is needed on the determinants of the effectiveness of
nongovernmental organizations, including those not devoted primarily to
AIDS prevention and mitigation, in a variety of AIDS prevention and
mitigation activities. Care is needed in defining the technical
assistance needs and the absorptive capacities of nongovernmental
organizations, to enhance their roles in research and prevention and to
avoid overload and inefficient use of scarce resources.
BUILDING CAPACITY FOR AIDS-RELATED
If useful research on HIV/AIDS is to
be undertaken and its results are to be applied appropriately and
effectively, the necessary infrastructure must be in place, a
prerequisite that is often lacking in sub-Saharan Africa. As a result,
virtually all research undertaken to date has been possible only with
technical cooperation and foreign assistance from the international
community. Thus, beyond the immediate challenge of identifying the
critical research questions, there remain enormous practical challenges
of actually obtaining the answers.
Key aspects of a basic
infrastructure for conducting effective research include access to
adequate funding, skilled labor, and appropriate technology, as well as
sufficient managerial and administrative capacity to plan, execute,
monitor, and evaluate studies. Even in developed countries, amassing the
resources required to undertake complex research endeavors is difficult,
and these difficulties are multiplied many-fold in sub- Saharan Africa.
Many of the region's universities have been badly neglected in recent
years. The poor preparedness of matriculating students, entirely
inadequate salaries for all levels of professional and support staff,
neglect of buildings and libraries, and a lack of core funds necessary
to move institutions into the technological age have contributed to the
universities' slow demise and the widespread departure of their
faculties to the private sector.
Many of the findings from the
research that has been conducted have not been adequately disseminated,
so that results are not widely known across the continent. As a
consequence, the contributions of social and behavioral scientists have
not been fully utilized. In addition, inadequate coordination of
research efforts has resulted in duplication and the need to "reinvent
These structural problems are
compounded by donor policies and practices that result in short-term
studies that do not allow sufficient time for local capacity building,
the predominance of expatriate personnel in most projects, and at least
the perception among the recipients of donor assistance that projects
address donor rather than local priorities. Yet the dominance of
international donors in AIDS research in Africa is the result of a lack
of domestic funding for such research in the region: many of the
region's governments appear complacent about the magnitude of the
epidemic and have so far contributed little to HIV/AIDS research.
In the long run, it is essential to
help sub-Saharan African countries develop their own research capacity
by strengthening their universities and augmenting the technical skills
of their researchers. There is considerable debate and controversy,
however, about how best to achieve this goal. Regardless of what the
best mechanisms may be, no significant progress is likely to be made
until the region's governments understand that they must put AIDS more
squarely on their own research and policy agendas. Clearly, a major
constraint on the amount of HIV/AIDS research that is undertaken is
inadequate funding. Potential sources of funding include communities,
private-sector firms, the public sector, and international donors.
Because it is unlikely that donors are going to increase significantly
their levels of funding in the near future, the governments will have to
find additional resources. Given the weak economic position of most
sub-Saharan African countries, however, it will be difficult to persuade
their governments to pursue more vigorous research agendas in the near
KEY RECOMMENDATION 5. Linkages
between sub-Saharan African institutions and international research
centers must be established on a wide range of activities, including
teaching, research, and faculty and student exchanges. International
donors should seriously consider establishing a sub-Saharan African AIDS
research institution with a strong behavioral and social science
There is a critical need to
strengthen research institutions in sub-Saharan Africa. Linkages with
international organizations, especially if built on an evolving and
well- defined research agenda, can help local institutions develop and
assist local researchers by providing relatively secure long-term
funding, offering support for the preparation of data and manuscripts
for publication and dissemination, and providing in-country technical
assistance and research training. Experience in a number of settings has
demonstrated that such long-term collaboration, in addition to
contributing significantly to understanding of the HIV/AIDS epidemic, is
mutually beneficial to all institutions involved; it could be very
successful in providing highly skilled African researchers with support
and the possibility of remaining in their country of origin.
Recommendation 7-1. The number of
African scientists well trained to conduct research on HIV and AIDS must
Research capacity in sub-Saharan
Africa cannot be improved without an increase in the number of
well-trained local researchers. Four possible ways to introduce and keep
more researchers in the field are to (1) integrate more graduate
students and young professionals into all new AIDS-related research
initiatives; (2) establish small grants programs to fund the projects of
young researchers; (3) adjust pay scales to attract and retain talented
professionals; and (4) provide other incentives for researchers to
remain in their home institutions, including small-scale research
grants, fewer teaching or administrative responsibilities, and more
opportunities for international travel. Providing technical assistance
to local researchers is an important priority. Local researchers could
benefit from workshops that would help them design research projects,
prepare research proposals, identify potential sources of funding, write
reports describing interim results, and prepare final manuscripts for
submission to peer-reviewed journals.
Recommendation 7-2. Each national
AIDS control program should establish a local AIDS-information center
that would develop and maintain a database of all AIDS- related research
conducted in the country.
These centers should be linked via
available technology, such as the Internet. They should also have AIDS
databases on CD-ROM (CD-ROM-equipped computers are available in most
national AIDS control program offices.) In addition, national and
regional conferences should be held to provide forums at which
researchers can discuss their research plans and present their results
to a larger group of local researchers than those that attend
Recommendation 7-3. There is an
urgent need for sub-Saharan African countries to establish and
periodically update research priorities at the regional and national
levels, providing a basis for discussions with donors on AIDS-related
It is important to reduce the
proportion of donor-driven research taking place in the region.
Recommendation 7-4. International
organizations and donors should utilize existing local resources to the
fullest extent possible.
It is paradoxical that donors
underutilize existing talent in the region. Utilizing local expertise
can strengthen local institutions, generate employment, and create
opportunities for talented researchers in sub-Saharan Africa.
Recommendation 7-5. Greater
dialogue between researchers and policy makers is necessary.
Not only is there an urgent need to
increase indigenous capacity to conduct research, but there is also a
need to better synthesize and translate research findings into effective
prevention and control programs and policies. Otherwise, prevention
programs will be only marginally based on local needs or tailored to
local conditions, and research will be even more undervalued and
underfunded. Researchers need to do a better job of drawing out the
policy implications of their work, and planners and policy makers need
to articulate more clearly to researchers what information they need for
effective planning and programs.
Recommendation 7-6. If more
effective strategies for AIDS prevention and mitigation are to be
developed in the future, better coordination among donors is needed,
particularly sharing of information about which prevention and control
efforts work and which do not.
The role of the new cosponsored
United Nations Programme on AIDS (UNAIDS) will be critical to future
work. Success will also require greater political will and commitment on
the part of the governments of sub-Saharan Africa and other countries.
CONCLUSION: THE NEED FOR BETTER
BEHAVIORAL AND SOCIAL SCIENCE RESEARCH
Because AIDS is an epidemic firmly
rooted in human behavior, driven by economic, cultural, and social
conditions, the behavioral and social sciences are essential to
identifying solutions for its control. Yet to date, most funding for
HIV/AIDS research has been devoted to biomedical studies of the nature
of the virus as a logical starting point for identifying a vaccine or a
cure. All too often it has been implicitly assumed that behavioral and
social science research should take place only because there are
currently no effective vaccines or treatments for the disease, as if the
discovery of a vaccine or a cure would eliminate any further need for
such research. This assumption that the availability of treatment solves
all problems is simply not true. For example, the resurgence of
tuberculosis has become one of the world's most serious health problems,
even though a cure that is 95 percent effective has been available for
almost 50 years.
Effective prevention of HIV/AIDS
will require enormous and continued commitment in order to achieve
lasting changes in human behavior. No one set of
interventions—behavioral or medical—will be sufficient by itself to
combat the epidemic. More behavioral and social research is needed to
develop effective and acceptable preventive strategies to refine
successful programs and to help find more effective ways of mitigating
the negative impacts of the epidemic.
The interpretation and utility of
much epidemiological, behavioral, and social research have been limited
by the lack of a multidisciplinary approach. Data on reported behavior
change may be difficult to assess in the absence of biological
validation that such change is reducing STD/HIV infection. Efforts to
model the demographic effects of the HIV/AIDS epidemic are hindered by a
paucity of data sets that combine fertility, mortality, migration, and
other sociodemographic information with HIV serology. Conversely,
serological studies that fail to collect adequate behavioral data miss
an important opportunity to assess the effects of key factors in the
spread of HIV, such as sexual practices and sexual networks within given
populations. The design, execution, and analysis of clinical trials for
STD control, HIV vaccines, antiretroviral drugs, and genital barrier
methods and virucides all depend on appropriate behavioral research to
guide enrollment; ensure adherence to trial protocols; and permit
adequate interpretation of epidemiological results, including the very
basic need to control for differential behavioral change between study
Until new research is available, it
is critical to keep trying the existing strategies that are believed to
be most effective, as well as designing new and innovative ones. The
epidemic is forcing people to rethink their values and behavior, and is
changing the social context. Strategies and policies must be responsive
to the ever-changing situation, as well as receptive to the findings of
research being carried out throughout the region. An effective
partnership between research and program interventions will be key to
lessening the spread and impact of the HIV/AIDS epidemic in sub-Saharan