Chapter 22

This final overview draws on the papers selected for this volume and other sources to identify obstacles to sexual behaviour change in the African AIDS epidemic. Limitations to existing interventions and possible new interventions are then discussed. Obstacles to behavioural change are identified as the adherence to the present sexual culture; the refusal of leaders to recognize or come to terms with the situation; the sanguine acceptance of death; the silence about the epidemic and the reasons for this; and the limited number of relationships in which condoms are acceptable. It is argued that the existing sexual culture must be largely accepted and interventions determined within it; that attitudes to death must be accepted or sensitization programs must be aimed at all unnecessary deaths and not solely at AIDS deaths; that the silence must be broken by the leadership; and that priority should be given to ensuring maximum use of condoms where they are most likely to be accepted, in commercial sex and in adolescent relationships. Community-based approaches are encouraged, but, among those aimed at limiting infection, success is anticipated to be most likely among adolescents and possibly sex workers. The major focus of educational programs must be changed. There is already sufficient knowledge of AIDS in most communities, and the limited success of intervention programs in controlling AIDS cannot be ascribed to limited knowledge. The papers published in this book were selected from a conference which came at the end of twelve years’ social and demographic research on the sub-Saharan African AIDS epidemic (see Preface). Those involved in the research program had increasingly identified the central problem in containing the epidemic as being the very limited change in sexual behaviour. Explaining the reasons for this lack of change seemed to be the most promising way for developing better interventions and showing why past interventions had not been more successful. In addition to trying to meet its objectives by presenting analyses of African research, the conference also attempted a comparative approach by presenting African findings with others from Asia, the Pacific and Australia. 1 Because less behavioural research has been undertaken on the AIDS epidemic in Asia and the Pacific, this volume contains only five of the fourteen papers presented on the region, and because the Australian epidemic cannot be easily compared with that of sub-Saharan Africa only one of the five papers presented on this country has been included.