New research into HIV prevention among the “choice disabled” — vulnerable groups who are less able to make the right choices to protect themselves — has led to a groundbreaking national trial for HIV prevention in Botswana.
Three years of research in southern Africa revealed important pointers for preventing HIV infection among those who are unable to make choices to protect themselves, even when they have the knowledge to do so.
Tackling the spread of HIV
With HIV rates as high as 33%, prevention is critical in tackling the HIV epidemic in sub-Saharan Africa. But prevention strategies have generally been designed for and are more accessible to those in a position to make preventive decisions and who have access to services when they need them.
A survey carried out by CIET Trust among 15-to-29-year-olds in Botswana, Namibia, and Swaziland found that those who struggle with poverty, low levels of education, income disparity between partners, and intimate partner violence are at higher risk of HIV infection. These factors constrain choice and increase the likelihood of HIV infection. They are structural disadvantages beyond the control of the individual. The risk of HIV increases in line with the number of these structural factors present, according to the IDRC-supported research.
Reduced cases among young women
In a randomized controlled trial of HIV prevention, researchers sought to adapt existing HIV prevention efforts to increase their effectiveness among the choice disabled, thereby reducing the effects of structural disadvantages. Through an audio drama about gender violence and HIV, and workshops aiming to empower young women, the researchers helped young women start making choices and created an enabling community environment for them to do so. They also educated local services about the needs of the choice disabled, especially young women. A related project, also supported by IDRC, provided training to boost the capacity of emerging African researchers and policymakers in the socio-cultural aspects of HIV, epidemiological methods, and evidence-based planning.
The trial interventions had the most impact among young women in Botswana. At the end of the three-year project, 22% of young women in control communities in Botswana were HIV-positive, compared with only 11% of the young women in communities who received the intervention package.
Dangerous misconceptions can lead to high-risk behaviours
The baseline study in Botswana, Namibia, and Swaziland looked at commonly held beliefs around male circumcision and the prevention of HIV. This topic was of interest for IDRC, in light of a concerted push by donors for voluntary male circumcision as a way of protecting men from acquiring HIV infection.
The impact of male circumcision on HIV rates in the rest of the population may not be as straightforward as many donors believe. The study uncovered examples of the misconceptions that surround male circumcision, for example, that it can prevent a man who is already infected with HIV from passing on the infection. This is a dangerous belief, as it can lead to high-risk behaviour. The researchers concluded that stronger efforts are needed to educate people that male circumcision is not fully protective for men and it does not protect women from contracting HIV from men who are already infected.
Much of the work carried out on HIV to date has focused on it as a medical problem requiring a clinical fix, but structural factors are also responsible for sustaining the epidemic. Implementing interventions that address these factors and measuring their impact on HIV infection are key to halting the epidemic.
In Botswana, the results of the CIET Trust research led the government to commit to making existing national poverty alleviation programs more accessible for young women at high risk of HIV. IDRC is investing further in Botswana’s efforts by supporting a cluster randomized controlled trial of this strategy, following the 2013 visit by the former Governor General of Canada, His Excellency the Right Honourable David Johnston and IDRC President Jean Lebel.
By refocusing its support programs towards the choice disabled, the Botswana government is putting the people at the heart of the HIV epidemic at the centre of its prevention efforts.