Sunday, March 17, 2013

In South Africa, an HIV campaign with a personal touch struggles to show its relevance

A Banake field worker talks to a family in Khayelitsha. Photo by Nicole Safker.
NOTE: This was originally published on the Knowledge4Health Blog on March 5, 2013.

Residents of Khayelitsha worry about a neighbour’s daughter who is only 13 but does not go to school because she cannot afford transport. She was raped by an old man. Her mother does not care and drinks a lot, swears at her about the rape and hits her. The child wants to go to school, so she went to stay in a neighbour’s home. The neighbour is also struggling and cannot afford the transport and school fees.  Banake Initiative Field Worker Diary

This is only one of many heart-breaking stories from the notes of field workers involved in an effort to improve communication among families affected by HIV/AIDS and encourage them to use HIV prevention services in Khayelitsha, the largest township of Cape Town, South Africa. The notes reveal shocking callousness and indifference on the part of township residents, but also compassion, like the neighbor who gave shelter to the 13-year-old girl.

The Banake Initiative was started in 2009 by DKT South Africa, an affiliate of DKT International, whose normal approach is focused on getting affordable health products and services to low-income people through the private sector. However, DKT decided that a different approach was required in South Africa, where HIV prevalence of people 15-49 has been stuck at around 17% since 2003 (the fourth highest rate in the world) despite years of work by many well-financed programs and the excellent availability of condoms (In November 2012, UNAIDS announced that the rate of new infections in South Africa had been reduced by 41% between 2001 and 2011).


The DKT South Africa website explains the reason for the shift in strategy:
Since the advent of the HIV/AIDS pandemic in Southern Africa, huge sums of money have been spent on mass media to change sexual behaviors that put people at risk of contracting HIV. Yet it is nonsensical to expect 30-second advertisements to meaningfully change the way you conduct your sex life. The problem with advertisements, pamphlets, hoardings and other transmissions is that they oversimplify HIV/AIDS prevention. They tell you what you should do —use condoms, get tested, cure STIs [sexually-transmitted infections], get circumcised — but cannot go into necessary detail on how to accomplish these difficult tasks.

So the architects of Banake decided to eschew mass media and focus on the hard work of door-to-door, people-to-people communications, funded for three years with DKT’s own money. Khayelitsha, with a population of over 400,000, was chosen because it has a high incidence of HIV but is underserved by HIV prevention programs. Living conditions in Kyayelitsha are appalling: 70% of residents live in shacks of wood and corrugated metal, according to the Inter Press Service. Residents report high levels of crime, gender-based violence and stigma towards people living with HIV.

Banake recruited Xhosa-speaking field workers in Khayelitsha and trained them on family planning, peer education, counselling, communication and AIDS treatment. The field workers then visited households of HIV-infected people, encouraging them to discuss these issues within the family and to use HIV prevention services. At the time they started, Banake found that only about 10% of the households they met had ever discussed health issues in the family. They had too many other pressing issues to deal with — unemployment, drug abuse, crime and violence.

Almost every month in 2010 and 2011, data was collected on a sample of households on the number of discussions held, people who participated in the discussions, people contacted by family members to discuss health issues and health services utilized. The following impacts were observed as monthly averages:
  • People discussing health topics in the family increased dramatically from 10% before the project started to 87.5% in 2011.
  • People helping a family member access health services increased from 20% before the project to 55% in 2011.
  • People seeking health services for themselves increased from 55% to 88% in 2011.
The Banake staff members were pleased by the results, and the community members they visited felt the field workers made a huge difference by helping families discuss issues they had never discussed before, either out of embarrassment or fear.

“Face-to-face discussions help to build the kind of community response that is necessary to sustain the fight against HIV/AIDS,” said Regina Mlobeli, director of the Banake Initiative. “Although these discussions are challenging, the field workers have managed to stimulate discussions in about 70,000 families. As a result, many topics that are normally impossible for family members to discuss are now discussed in the presence of a caring outside person. This is a good strategy for reducing the stigma associated with HIV.”
However, Mlobeli said there were considerable challenges:
  • Men were often reluctant to talk: They were quiet or just left when sensitive topics came up.
  • Religion kept some families from discussing certain issues.
  • Community members were so overwhelmed by socio-economic issues like poverty, crime and alcohol and drug abuse that health became a low priority.
  • Field workers become discouraged quickly when encountering such horrendous socio-economic problems.
“This is probably why large projects employ mass media for dissemination of educational messages,” said Mlobeli. “Although not very effective, this strategy does not have the challenge of dealing with large numbers of demotivated individuals.”

And even when field workers get people to seek health services, residents may still encounter problems in obtaining that care.  They often face long waiting times, rude health workers and security staff and poor quality health care.

In February 2012, DKT South Africa closed its doors after three years because it could not secure donor funding and turned Banake over to local management, which continues to seek funding. Since April 2012, Banake has not had the resources to continue the door-to-door work of HIV prevention. However, demand for this personal approach continues but Banake has been able to continue its work to some extent with bits of funding from various donors:
  • Three field workers visited 2,100 households, educating and promoting family hygiene to prevent diarrhea, with funding from Tiger Brands.
  • Eight field workers worked to prevent violence against women, creating violence-free areas by painting messages on walls, with support from the Western Cape Network on prevention of violence against women and children.
  • In Port Elizabeth, 10 fieldworkers were trained to do health promotion and reached 60 households, with funding from the Community Chest.
Since it still gets regular requests for help, Banake has started using support groups as a creative and cost-efficient alternative. Thus, Banake created a women’s group that does “educare,” (where kids are looked after by the women), gardening and counselling, and is keen to do door-to-door HIV prevention in 2013. Another group — formed of young people who were raped, abused, addicted and/or abandoned —has already started going door-to-door.

Mass media still gets most of the available funding for behaviour change communications campaigns in HIV prevention in South Africa. But the future of initiatives like the Banake Initiative will show whether government and donors also envision a place for a more personal type of communication that addresses the messy, intimate and complicated details of HIV infection and how to avoid it.

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