The Behaviour Change Strategy

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other long-term relationships, in particular during special situations such as pregnancy and breastfeeding, as well as during the window period after HIV testing.

Specific messages and support are required to assist people living with HIV in avoiding passing on HIV. People living with HIV shall be involved in and targeted through testing and counseling, posttest support groups, AIDS serving organizations, home-based care and health facilities. Persons living with HIV must be involved in prevention efforts at all levels including as employees of AIDS service organizations, experts and volunteers. Community action plans need to address specific risks in their local context such as widow inheritance, polygamy, girl pledging and others. DAACs and WAACs shall be supported in developing their capacity to monitor and expose specific unlawful practices like property grabbing, forced sex and others.

Outcome area 3: Increased Utilization of HIV Prevention Services

Health service providers should be trained to avoid negative attitudes towards persons accessing HIV prevention services. All community leaders and members must be supportive to other community members who have accessed HIV prevention services like testing, counselling and prevention of mother-to-child transmission. Family planning service providers should be trained to promote male and female condom use among couples who do not know their HIV status and refer them for testing. Testing and counseling will be promoted, particularly for couples and persons who suspect that they may be HIV positive.

Outcome area 4: Improved Institutional Frameworks to Address Behavioural Change

District AIDS Action Committees and their partners need to involve district stakeholders in developing systematic behavior change responses. All districts and communities will need committed leaders, an action plan for behavioural change, a regular meeting forum to discuss progress and committed teams who join this vision to make a difference.

Challenges being faced by the behavior change strategy:

The increasing prevalence of HIV infection, coupled with the current global economic slowdown, portends a drastic funding shortfall for addressing the HIV/AIDS pandemic in both the short and long run. By the year 2031, when the pandemic enters its 50th year, funding needed for developing countries could reach $35 billion annually -- three times the current level, according to a paper coauthored by Robert Hecht. Even then, more than 1 million people will be newly infected each year; some 33 million people worldwide are infected currently.

Many pregnant women in Africa can choose to undergo HIV tests, but few can choose to have elective Caesarian sections done due to lack of resources. Recommending voluntary counseling and testing to pregnant women, without offering them the options of voluntary caesarian sections and/or anti-retroviral treatment (ART), might be questionable ethically. Nurses working in prenatal clinics and midwifery units throughout Africa might grapple with these and other ethical issues on a daily basis.

Since AIDS is a terminal illness with many manifestations, clinical uncertainties abound and knowledge is in a constant state of flux” (Barbour, 1995, p. 213). This changing state of knowledge about AIDS complicates nurses’ decision-making processes. For many years it was believed that HIV could not be transmitted in breast milk. Health care workers in Africa fervently advocated breast-feeding to save babies’ lives. Then it became known that breast-milk from HIV positive women could cause HIV−negative babies to become HIV positive.

Any people in Africa visit traditional healers prior to or concurrently with formal health care services. Nurses form bridges between the traditional and formal (Western) health care systems in African countries because nurses are familiar with both these systems. However, referral to one rather than the other health care system might cause conflicts for nurses should the patient’s condition deteriorate. The simultaneous use of ART and traditional remedies, such as the African potato, renders ART useless as no changes occur in CD4 counts despite the conscientious taking of ARTs, if taken with the Africa potato. Considering the expense of ART, this practice could waste millions of Africa’s scarce health care dollars. Thus nurses need to teach patients not to take any medications in addition to ARTs. Perhaps the greatest challenge concerning ART is educating the PLWA/Hs that ART is never a cure but merely a lifelong control measure for AIDS. This is a foreign concept to many African people who consider illnesses to be attributable to specific causes which get cured by addressing the identified cause(s). ART could be an emergent risk factor, if PLWA/H believe that ART cures them, they might resort to unprotected sex infecting others, and re-infecting themselves with other HIV strains. These infections, subsequent to ART, are likely to be “super infections” with ART resistant strains of HIV (UNAIDS, 1999, p.

Beliefs about HIV transmission might also remain rooted in cultural perceptions that the disease results from witchcraft or from the breaking of social norms and taboos (Ingstad, 1990, p. 36), which cannot be addressed by taking lifelong medications. Many PLWA/Hs might be unable to comprehend the complicated nature of being immunologically compromised. This might make it difficult to comprehend why sexual abstinence or the use of condoms could prevent deaths from tuberculosis or pneumonia; without any apparent connection between sexual intercourse and the chest. This lack of understanding might be reflected in the belief that the abbreviation “AIDS” indicates “American ideas to decrease sex”, making AIDS-related messages irrelevant to African men and women. Nurses face major challenges in transmitting effective health education messages about HIV/AIDS to Africans who might not comprehend the functions of the immune system, and thus also cannot understand the consequences of being immune compromised.

Successes met by the by the behavioral change strategy

The scientific literature and documented national experience clearly demonstrate the effectiveness of HIV prevention in changing sexual and drug-using behaviors. Notwithstanding the strong evidence base for HIV prevention, policy makers and affected communities still express a need for such information and/or misunderstand what is known.

The distinction commonly made between behavioral and biomedical tools for HIV prevention is a false one. Not only do behavior change programs depend on the existence of essential technologies—such