Introduction:
The United States Agency for International Development and the World Bank hosted a debate concerning the HIV/AIDS epidemic. The debate had the following proposition “Behavior change in generalized epidemics has not reduced new HIV infections and is an unwise use of HIV prevention resources.” Panelists supporting the proposal had a number of reasons that they presented. They argued that the individuals carrying out behavior change implementation had not done a thorough evaluation of their work. For this reason, there are many unknowns in this strategy. For instance, scholars involved have not been able to come up with a behavior change model. Such a model is supposed to be emulated from areas where behavior change has been employed successfully. There also lacks clear scholarly articles that directly link behavior change to decreased level of HIV/AIDS infection. The panelists also argued that an approach that will ensure any changes in behavior that are adapted last forever does not exist. What has been observed is a temporary change in behaviors that expose individuals to contracting HIV/AIDS. Panelists opposing the proposal pointed out that HIV/AIDS infection and transmission is a direct result of sexual behavior. Therefore, to deal with the epidemic, behaviors that put individuals at risk should be changed in a bid to curb the infection and transmission of HIV/AIDS. They also argued that behavior change approaches have worked in relation to other health aspects like promoting breastfeeding infants. The panelists added that other changes like structural and biomedical involved a shift in how individuals behave. Without campaigns for such changes, their success would be limited. Lastly, these panelists argued that there was data to support that behavior change does reduce the number of new HIV/AIDS and transmission rates.
Argument Defending the Proposition
There are many outstanding questions about the effectiveness and results of behavior change interventions. Better research needs to be carried out to ascertain if indeed people who engage in sex can be influenced to change their sexual behavior through the use of behavioral change interventions. Given the current stress on prevention of multiple simultaneous partnerships, it is extremely difficult to introduce behavioral change through intervention for certain populations. For example it is highly unlikely that married couples who are not accustomed to using condoms will change their sexual acts because of the influence of behavioral interventions. It is also hard to support the increased interest and provision of resources for behavioral change when there is no enough backing from the scientific community on whether behavioral interventions actual lead to behavior changes in matters involving sex and sexuality. There should be more rigors in the evaluation of its effectiveness before it is recommended to a particular group or society.
The 2008 Cochrane Review came up with a meta-analysis of 58 interventions that was carried out for men who engage in sexual acts with other men. The report showed that on average, there was a seven reduction in the number of men who engaged in unprotected sex. The Cochrane Review meta-analysis showed that behavior change programs, initiatives and communication through any forum had very little impact on causing behavioral changes.
Studies carried out in Senegal, Thailand and Uganda has shown that behavioral changes are not solely responsible for the advanced progress toward the fight against HIV/AIDS. In 1991, the Joint United Nations Program on HIV/AIDS accredited the successes in fighting HIV/AIDS to the policies instigated by the government. Being a Muslim country, Senegal never had a large HIV epidemic. It was unlikely that the country will ever suffer from a generalized epidemic. Furthermore, practices such as male circumcision contributed to the high rate of success in combating HIV/AIDS in Senegal.
The United Nations also attributed the successes in Thailand to structural interventions. The government mandate to have all commercial sex workers to use condoms can be seen as a good example of a behavioral intervention. However, when looked at more closely, the law that recommended the use condoms is more of a structural intervention rather than a behavioral one. However, structural interventions are not always the best solution in case of a generalized epidemic.
In Uganda the reduction in the cases of HIV/AIDS was attributed to community mobilization and population-level avoidance. However, it is very unfortunate that the lessons learnt in Uganda did not trickle down to the rest of the countries in sub-Saharan Africa. This campaign was a structural intervention on the side of the Ugandan government.
Combination of both approved biomedical solutions and structural intervention have been proven to be more efficient in combatting the spread of HIV/AIDS than incorporation of only behavioral interventions. The utilization of biomedical interventions is more effective because they are proven to work regardless of the individual’s sexual behavior. For example, biomedical interventions such as use of anti-retroviral drugs to prevent mother-to-child transmission, circumcision, HIV vaccines, oral pre-exposure prophylaxis and use of microbicides have proven to be more effective in combatting the HIV/AIDS epidemic. Furthermore, these methods can be easily tested to prove if they are effective or not. Unlike behavioral interventions, Candidates in biomedical solutions can be subjected to rigorous scientific and biomedical evaluation to demonstrate their effectiveness.
Some of the newest behavioral change strategies like prevention for positives and cash transfers have not had enough success. They hold little promise in the fight against HIV/AIDS. Currently, there is no behavioral method that guarantees that individuals who test positive for HIV will cease to engage in behavior that puts them at more risk of exposure or spreading of the virus, as a result of knowing their HIV status. Behavioral change experts can argue that the cash transfer approach can evoke desirable behavioral changes. However, when the payment ends, it is more likely that individuals will revert back to their old ways. This is because view this as a job more than a beneficial practice that can impact positive behavior to their life that prevents them from acquiring HIV.
When South Africa is taken as a case study, studies have shown that there is lack of positive results from the decades of behavioral change intervention. This behavior change interventions have been in place for decades. Statistics from South Africa have demonstrated that behavioral interventions have not contributed to the decrease of the HIV/AIDS pandemic in the country. As a matter of fact South African has about a fifth of all the HIV infections globally. More than 90 percent of South Africans proclaim themselves to be very religious. Over the decades, there have been numerous calls for South Africans to practice monogamy. However, the public have always ignored sexual messages that are put across by media campaigns. A lot of money and resources has been invested in behavior change messaging but the epidemic still persists.
Evidence:
Circumcision is a biomedical intervention strategy. The table above demonstrates its impact. The percentage of HIV-1 seroprevalence is less for countries with a high percentage of circumcised males compared to countries with a low percentage of circumcised males. This is a biomedical intervention strategy that has proven to be highly efficient in managing HIV/AIDS.
Graph showing the trend in Tuberculosis occurrence with time in anti-retroviral treatment Source: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2887494/
Anti-retroviral treatment involves administering drugs to individuals that have been infected with HIV/AIDS. The graph above shows the effectiveness of this biomedical intervention strategy. This is with regard to a reduction in the number of Tuberculosis incidences as an individual continues with the treatment.
Graph showing the % GDP per capita spent on intervention strategies in Africa Source: http://www.biomedcentral.com/1471-2458/9/S1/S5/figure/F1
The graph presented above shows the cost of implementing behavioral, biomedical and structural strategies to manage the HIV/AIDS epidemic. The proposers argue that funding behavior change campaigns is a waste of financial resources that would have otherwise been used for development. One can depict from the graph that behavioral strategies take up the least percentage of the gross domestic product compared to the other two intervention strategies for countries in Africa. This shows that the behavioral change programs should not be deprived off funding, rather, the other two forms of mitigation strategies should downscale their budget.
Graph showing the number of people infected with HIV/AIDS in Thailand. Source: Joint United Nations Program on HIV/AIDS, 1998
The graph presented above shows the number of people infected with HIV/AIDS in a study carried out in a sample population in Thailand. It is vital to note that the number of people recorded with new HIV/AIDS infections drops steadily from 1990 to 1996. This can be attributed to the campaigns that promoted a change in behavior to prevent HIV/AIDS infections and transmissions. This data demonstrates that behavior change campaigns can be used to manage the HIV/AIDS epidemic.
Changes in sexual behavior among men in Uganda Source: WHO/GPA surveys, 1989 &1995.
HIV prevalence among pregnant women in Uganda Source: HIV/AIDS surveillance report, STD/AIDS control program, Ministry of Health, Uganda, June 2001.
Uganda has been able to document the benefits of behavior change campaigns. The behavior change programs begun during the mid-1980s. These programs involved campaigns that created awareness concerning HIV/AIDS among the country’s population. The campaigns also encouraged the youth to delay their first sexual encounter. These awareness programs went a notch higher in the 1990s where condom use was widely promoted. The use of voluntary counseling and testing was also promoted during that time. The period between 1989 and 1995 witnessed a reduction among its young population engaging in sex. Ugandans were also classified as less likely to have multiple sexual partners compared to people in the neighboring regions. The graphs presented above show the change in men’s sexual behavior and the HIV/AIDS prevalence rate among pregnant women. Both graphs demonstrate the effectiveness of behavior change campaigns.
Argument Opposing the Preposition:
I oppose the proposal presented in this debate. This is because HIV/AIDS infection and transmission depends on human behavior. Therefore, investing in efforts that will transform risky behavior to health conscious behavior among individuals is critical. Critics point out that information dissemination does not translate to automatic adaptation of the information. However, this can be mitigated by having a professional approach to disseminating such information. The primary task involves dealing with attitudes. Changing peoples’ attitude towards the subject of HIV/AIDS is challenging. However, once the attitude is transformed, implementing action plans aimed at dealing with HIV/AIDS becomes easy.
The biomedical front is not as cost effective as it tries to portray itself. This is with regard to dealing with HIV/AIDS infection and transmission. For instance, a cure or vaccine for HIV/AIDS has not yet been created. The only medication involved includes post- exposure treatment and anti-retroviral treatment. Clinical experiments that try to come up with the vaccine and treatment for HIV/AIDS have failed numerous times. These failures are highly cost ineffective as they do not produce results despite the heavy investments made. There also lacks a sure way to measure if the failed tests and experiments offer any progress in the biomedical department.
Biomedical intervention strategies include the use of practices like circumcision and taking anti-retroviral drugs. This has been demonstrated by the data showing the effectiveness of circumcision and anti-retroviral treatment. These interventions cannot be adapted by members of society just like that. They have to be introduced using a community conscious approach. The behavior change programs are the only forums that are sensitive to the community. This makes behavior change a vital component in the other two intervention measures.
Health conscious lifestyles have alleviated the number of new HIV/AIDS infections and reduced the transmission rate of HIV/AIDS. This is evident in most third world countries. The prevalence of HIV/AIDS has reduced in such areas after empowering masses of people with information concerning HIV/AIDS. These include information concerning use of condoms, having a single sexual partner, campaigns against stigmatization of infected individuals and the use of services such as; voluntary counseling and testing, anti-retroviral treatment and post-exposure treatment. Forums that are part biomedical would not have gained popularity in these countries without behavior change campaign. Such campaigns are in form of; theatre acts, programs broadcast through televisions, newspapers and radios as well as social sites.
Behavioral change experts argue that behavioral change is at the center of the epidemic. Sexual behavior plays a central role in the spread of HIV. These experts argue that behavioral change has worked at the population level and, therefore, it will be unwise to exclude the impact behavioral change brings in the fight against the HIV pandemic. Experts in this field also argue that the basic prevention strategy should be to promote collaboration or a combination of different intervention as they try to understand the most prevailing factors of transmission behind the epidemic. They have described that the thinning out of sexual network has the potential to be an effective strategy in the mitigation of the impact of concurrent or multiple partner infection during the stage of acute infection.
The experts in the field of behavioral change have argued that behavioral intervention have in the past worked in other fields of medicine and public health. HIV/AIDS, being a category under these fields, instigation of behavior change cannot be immediately ruled out as a solid solution to help in the fighting of this epidemic. Some of the fields where behavior change has worked include oral rehydration, breastfeeding, and female genital mutilation. To make behavior change work in the prevention and combatting of HIV, experts propose that the main area of concentration should be promoting behavior change through the use of multiple coordinated channels rather than just the mass media during campaign. This should be done in order to evoke a community response from a wider audience.
Experts have also argued that for effective HIV prevention intervention to take place, there is the need to incorporate behavioral changes. They have argued that biomedical solutions such as circumcision should be followed by counseling session in order to incorporate knowledge and instill responsible sexual behavior and practice.
Experts also argue that behavioral change is important because medical experts and personnel have the moral obligation to inform and warn individuals of immediate and clear danger that may result into medical complications. This is effective in helping individuals avoid engaging in unsafe sexual acts. Thus, they help reduce the number of people who contract HIV.
Counter-argument:
Critics have argued that there lacks data linking behavior change to a decrease in the HIV/AIDS transmission and infection rate. This argument points out that one cannot conclude that behavior change programs are as effective as presented. This is a challenge for the supporters of behavior change. It is vital for scholars to conduct researches concerning how changes in attitude and behavior have attributed to proper management of HIV/AIDS. There are comprehensive reports with regard to how behavior change influenced Uganda and Thailand positively. Similar reports concerning other countries and other aspects of behavior change like a shift in gender discrimination should be compiled.
Conclusion:
HIV/AIDS is an international problem that interferes with economic and social structures. There are different approaches that are aimed at managing this epidemic. There have been a significant number of structural and biomedical interventions that have been proposed. However, they have been challenged by lack of implementation or usage in various regions. For instance, the use of voluntary counseling and testing centers is not as popular as it should be. This is mostly observed in third world countries. Adoption of circumcision is also a challenge in some regions. Some cultures do not condone circumcision. Such a biomedical approach requires campaigns to promote its implementation. Such campaigns that seek to modify the behavior of populations enhance the implementation of biomedical strategies. This shows that presenting populations with structural and or biomedical solutions alone do not guarantee their adoption by people. The stakeholders involved have to promote these plans of action among the populations.
This is why behavior change programs cannot be ignored, as they are a highly effective way of managing the HIV/AIDS epidemic. Organizations, nations, and expert should sit down and come up with full package that encompasses behavioral, change, structural change, and biomedical strategies in order for them to beat the HIV/AIDS epidemic. The strategies proposed should have a strict guidelines and evaluation of each step in order to verify their level of effectiveness. Governments should also make it a priority to make sure all the citizens have access to cheap but very high quality medical care. This way, people will have first-hand information about their health and get enriched with knowledge of how to keep themselves health and away from unsafe practices.
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