HIV Prevention and Behavior Change

You don't have to speak Swahili to understand what this advertisement means.

I snapped this picture in Tanzania earlier this year. It's displayed outside a hospital in southeastern Tanzania, and the picture speaks for itself: a leering, middle-aged man shoots a suggestive look at a schoolgirl, identified by the iconic blue and white uniforms that students wear all over the country.

The text means, "Protect the ones you love from Fataki."

Fataki, I learned from a quick Google, in a character from a Tanzania-wide HIV prevention campaign to curb trans-generational sex. In radio skits, banners, brochures, you name it, Fataki represents the local sugar daddy. He lures young women into relationships with promises of money, cellphone airtime, rides in his fancy car. He doesn't pay for sex, per se, but he uses his money and status in subtly coercive ways.

I was happy to see such open, obvious advertising about partner reduction and transactional sex. As I've learned more about HIV prevention, I've become convinced that behavior change is almost as important as access to condoms and sexual education. One can't work without the other.

This campaign is partially paid for by the President's Emergency Plan for AIDS Relief, U.S. government money to fight HIV that's notoriously had lots of conservative strings attached. Had I seen this ad a year ago, I probably would have dismissed it as unrealistic abstinence-only propaganda.

But behavior change works. Behavior change - in combination with access to condoms, comprehensive sexual education, open discussion about HIV and sexually transmitted infections in general, all that good liberal stuff.

My main data point backing up that statement is Uganda, the landlocked east African country that's always cited as a success story in the overwhelming tragedy of HIV in Africa. While HIV prevalence shot up across the continent throughout the 1990s, Uganda's declined.

It's hard to track exactly why Uganda was such an anomaly - part of the problem with public health in general. So as the U.S. Congress debated the 2002 bill that authorized millions of dollars for PEPFAR, Democrats and Republicans chose predictable party lines: condoms vs. abstinence, mutually exclusive and diametrically opposed.

The consensus from most public health sources I respect, however, is that it was precisely the combination of the two that turned Uganda into a success story. (A success story that unfortunately seems to be waning in the 21^st century, as HIV incidence there is slowly rising again.)

One important aspect of that story is the Ugandan Ministry of Health's famous "zero grazing" campaign. Taking its name from the "O" shape that tethered livestock make in the grass around them as they graze, the campaign emphasized delayed sexual activity, reduction in the number of one's sexual partners, faithfulness within marriage, and last but not least, condom use.

People at all levels of Ugandan society took responsibility for the "zero grazing" ethos - it wasn't imposed by moralistic outsiders, but rather was a collective, integrated response to the catastrophe of HIV there.

That's why I like this advertising campaign, at least what I've seen of it. It doesn't preach to people not to have sex, and it doesn't foolishly tell people not to use condoms. But it shows young women - and their communities - that they don't have to put up with transactional sex and coercive power dynamics. And it shows them that their health depends on it.

Here, a similar version of the Fataki ad, warning people in Gonder, Ethiopia about human trafficking: