Setting Government Priorities in Preventing HIV/AIDS - Finance & Development -March 1998 - Martha Ainsworth

Behavior change is key The biological characteristics of HIV determine, to some extent, the rate at which it spreads, but human behavior plays a critical role in transmission. People who have many sexual partners and do not use condoms, and people who inject drugs and share unsterilized injecting equipment have the greatest risk of contracting HIV and unknowingly infecting others. Typically, the virus first spreads quickly in a series of small epidemics among those with the riskiest behavior; it then spreads more slowly from them to lower-risk individuals in the population at large. How quickly and extensively an HIV/AIDS epidemic spreads in a given population depends largely on the extent to which people with many sexual partners mix with people with fewer partners. The World Bank Research Report Confronting AIDS: Public Priorities in a Global Epidemic finds that people who engage in high-risk behavior do act to reduce their risk of contracting and spreading HIV when they have the knowledge and means to do so and a supportive community. The report highlights three strategies to reduce risky behavior: providing information, lowering the costs of safer behavior, and raising the costs of risky behavior. Awareness. Knowledge of how extensive HIV infection is in one’s community, how the virus is transmitted, and how to avoid contracting it will induce some people to behave more safely—for example, by using condoms, reducing the number of sexual partners, sterilizing injecting equipment, or avoiding needle sharing. In Thailand, the announcement in 1989 that 44 percent of sex workers in the northern city of Chiang Mai were infected with HIV is believed to have contributed to the growing use of condoms, even before the launching of large-scale government programs. Condom use by young adults in the United States doubled in the mid-to-late 1980s because of growing awareness of the risk of contracting HIV. But knowledge alone is unlikely to change individual behavior enough to stop the HIV/AIDS epidemic. Many of the individuals who engage in high-risk behavior are likely to make decisions based on what they perceive to be their own risk of contracting HIV, while ignoring the risks to which their actions expose others. Even when considering their own risk of infection, many people persist in risky behavior because the costs of safer behavior are clear and immediate, while the benefits are uncertain and distant. Lowering the costs of condom use and safe injecting behavior. Condoms are highly effective in preventing HIV transmission, but they entail costs—not only the money and time spent buying condoms, but potential inconvenience and embarrassment and, for some people, reduced pleasure. Reducing these costs will encourage more people to use condoms and lead to lower rates of HIV transmission. In Kinshasa, Democratic Republic of Congo, a program that offered sex workers free condoms, treatment for other sexually transmitted diseases, counseling, and group discussions had impressive results. A mere 11 percent of the sex workers had used condoms on an “occasional” basis before the program; afterwards, more than two-thirds reported using condoms on a “consistent” basis. The incidence of HIV—the number of new cases over time—dropped by twothirds. At the same time, mass marketing of highly subsidized condoms—known as “social marketing”—in Kinshasa increased the willingness of clients to use them. Sixty developing countries now have condom social marketing programs, both for the prevention of sexually transmitted diseases and HIV infection and for family planning. Injecting drug users face substantial costs in adopting safer behavior. For people who are truly addicted, drug treatment programs are often difficult to get into and