How behaviour change campaigns can help fight AIDS and Covid-19
As the world reels under the Covid pandemic, there is another epidemic that hasn’t still loosened its grip. Since it was proclaimed as a pandemic in 1981, HIV/AIDS has claimed more than 33 million individuals and contaminated around 0.7 per cent of the total populace. There are over two million people living with HIV in India, making it the third-largest country with the HIV epidemic in the world.
Covid has inevitably taken over attention from HIV. The UNAIDS report on the global AIDS epidemic shows that the 2020 targets will not be met because of deeply unequal success. Covid-19 risks have blown the HIV progress way off course. Missed targets have resulted in 3.5 million more HIV infections and 820 000 more AIDS-related deaths since 2015 than if the world was on track to meet the 2020 targets. In addition, the response could be set back further, by 10 years or more, if the Covid-19 pandemic results in severe disruptions to HIV services.
There are, of course, important differences between HIV and Covid-19, including modes of transmission, incubation and infectiousness periods. Any response to Covid-19 must be strategically tailored to the pandemic’s unique attributes. However, lessons learnt from the HIV response offer sound guidance for fighting Covid-19 — on building political commitment, engaging communities, prioritising research and accountability, galvanising innovation in service delivery, mobilising sectors beyond health and grounding responses in the principles of human rights and equality. Strategic, planned efforts to leverage HIV infrastructure can optimise the health impact and sustainability of Covid-19 responses.
Implementing community-led service models require flexibility and far-reaching health policy change, such as encouragement of task-shifting for clinical service delivery, endorsement of service delivery by lay providers and approval of new, community-centred health tools, such as HIV self-testing kits. Community workers go door to door to deliver essential testing and treatment services, build demand for testing, prevention and treatment services and provide peer support that improves retention in care.
Most people with Covid-19 will have mild cases that can be managed in the community. In many low and middle-income countries with fragile health systems, community-based management will be needed for more severely affected people owing to the scarcity of health resources. An intervention in a low-income setting with the objective of increasing counselling and testing may need to address the following:
1. the stigma of being tested and/or of testing positive;
2. quality of patient–counsellor interactions;
3. facility capacity, supplies, and environment; and
4. access to those facilities by infrastructure, such as good roads and public transportation.
There are three key lessons from HIV that should be implemented in tackling Covid:
1. Covid-19 responses should place affected communities at the centre of the response: in governance and planning, direct service delivery and community monitoring and accountability.
2. Covid-19 responses should be grounded in human rights and equality, with particular attention being paid to creating an enabling environment and removing punitive, arbitrary and discriminatory legal and policy measures that increase marginalisation and undermine access to essential prevention and treatment services.
3. To be effective, Covid-19 responses must be multisectoral and address social and structural inequalities that increase vulnerability and slow service uptake.
I have been a part of many community-led initiatives for HIV prevention as part of Aastha Parivaar. The institution’s initiatives are carried out by 13 community-based organisations (CBOs) in Mumbai, Thane and Pune, in conjunction with partner organisations and projects.
The effect of behavioural strategies could be increased by aiming for many goals — for example, the delay in onset of first intercourse, reduction in the number of sexual partners, increase in condom use, etc.) that are achieved by the use of multilevel approaches (couples, families, social and sexual networks, institutions, and entire communities) with populations, both uninfected and infected with HIV. We could tie a similar strand that just like HIV, presently there is a need to get the fundamentals of Covid prevention to be agreed upon, funded, implemented, measured, and achieved in a comprehensive and sustained manner. Access to prevention information, messages, skills, and technologies is essential and a fundamental human right during times of crises.
The CBOs have support groups for people living with HIV that organise a meet every month and conduct exposure visits to various organisations. These exposure visits provide support in areas including nutrition, finance and legal advice. Tackling fear and instilling acceptance that HIV could be contracted by an individual or his/her dear ones gets addressed. These meetings also throw light on the experiences of HIV-positive sex workers and allow the CBOs to gain a better understanding of the medical needs of the members. Opportunity for empowerment is also seeded via nominations for positions such as Group Leader, which acts as a psychological boost. These leaders are then responsible for the planning and implementation of support groups, mentored by professional Project Counsellors.
Since sexual behaviour typically does not occur in public, it is difficult to motivate protection when potential transmission occurs and making it almost impossible to verify reports of what people say they have or have not done. Use of social institutions like places of faith, schools, workplaces can help as a breeding ground for behavioural change. Not only do they offer the opportunity to reach a large number of high-risk individuals, but also effectively leverages peer networks and leaders, channels for diffusion of innovation, and media and other educational or motivational approaches.
Community engagements need diffusion of innovation and the involvement of influential leaders in the community - trusted trendsetters whose actions, attitudes, and views influence those of other members through interactions in existing social relationships. Diffusion of innovation was first applied to HIV prevention in a series of community-level outcome trials. This approach to HIV prevention relies on nine core elements that are clustered under three main headings: developing momentum, exposure, and repetition; delivering effective, theory-based HIV prevention messages; and initiating and sustaining risk reduction conversations.
Community-based testing is particularly important, as the stigma of HIV and the criminalisation of populations at high risk of HIV discourages many people from attending clinics and health facilities. Similar to HIV, we need to address several facets of Covid‐19 stigma to effectively reduce it. These include exposing and eliminating racism and xenophobia and recognising the social processes of othering already experienced by persons blamed for Covid‐19 (including stigma and socio‐economic exclusion experienced by immigrants.
The power imbalance between men and women means women are often unable to negotiate condom use or protect themselves from the risk of HIV infection in other ways. There is HIV prevention medication like PrEP that can be added to the choices for FSWs (Female Sex Workers) to prevent contraction. While the use of condom is imperative to attain full efficacy of PreP, the intake by women is also a psychological boost for most to feel better secured against HIV. However, this gendered imbalance in terms of societal attitudes and information asymmetry must be monitored for adverse impacts on tackling the Covid pandemic as well.
There was a study undertaken by Durbar Mahila Samanwaya Committee and Sonagachi Research & Training Institute, Kolkata titled DRISHTI, to assess the effectiveness of the use of community-based caregivers to address mental health-related problems among the sex workers. As designed the study looked into the prevalence of depression among the FSWs, and to find out any association between socio-demographic and sex-related factors with depression.
Community-based, peer-led interventions proved to be highly effective among brothel-based FSWs, in India and in other regions. Potential community-based programming in the context of brothel-based sex work could include prevention initiatives, including screening program, as well as counselling and group therapy, utilising both peers and multidisciplinary teams of health and social workers.
The lessons on emanating mental and stress disorders during pre and post-HIV campaigns could be put to use to the Covid scenario as well. Covid-19 is an isolating experience as well. In many cases, it has led to the loss of livelihood, which can have a spiralling effect on an individual’s psyche. Sensitisation programmes have helped with HIV and could do the same for Covid-19.
While a conclusive end to both the pandemics seems far, addressing Covid-19 is a priority. However, in attempts to curb one pandemic, we would be doing a grave injustice to sideline the three-decade-long efforts to end HIV. In a resource-restrained country like ours, we can find a way to integrate solutions for both pandemics as behaviour change and collaboration are the foundation to success for both.
For HIV, we should continue our focus on testing, prevention through the condom and new tools such as PrEP and treatment. And as for Covid-19, we should continue to test and treat and be open-minded to soak in the learnings from HIV prevention.
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