AIDS prevention for women: a community-based approach in Botswana
Presented by Dr S. Tlou, University of Botswana, Gaborone, Botswana.
Botswana has experienced an explosive rise in the incidence of HIV infection in the past five years. As in most sub-Saharan countries the primary mode of transmission is through unprotected heterosexual intercourse, and more than half of the people who are HIV-positive are women. There have been more women than men among reported AIDS cases and the infected women are younger than the infected men. Relatively weak partner ties, frequent break-ups and occasional multiple partners put many women in their childbearing years at least at moderate risk of HIV infection from their own and their partner’s behaviour. The increasing sexual activity of unmarried teens is also increasing the vulnerability of this group.
To reach women in the community with information about HIV/AIDS, and the means to avoid infection, a nurse-managed, peer education/support model for HIV prevention was initiated in 1990. Because gender inequalities make it especially difficult for women to negotiate with their male partners to ensure safer sex practices, communication skills, assertiveness training in negotiating safer sex and correct condom use were emphasized. Many women in Botswana belong to women’s organizations, which are an important catalyst for positive change. The Botswana Council of Women, a grass-roots women’s organization which has members in all towns and villages in the country, was the main project implementor.
Before launching the intervention on a large scale, the most important behaviours that might contribute to STD/HIV transmission for women were identified through 56 in-depth interviews. Needed changes in service delivery mechanisms were explored and messages appropriate to the culture, values and resources of Botswana were developed. The findings indicated that over a third of women interviewed had only partial knowledge about how HIV is transmitted; that some women had had experience of condom use and had been successful in gaining partner cooperation to use condoms; and that women needed specific knowledge about how to use condoms correctly. Based on these qualitative interviews, the peer education intervention and manual, and a leader training programme were developed.
The intervention was then implemented in 12 workplaces in Gaborone (reaching 600 women). Most of the women targeted as peer educators worked at the University, government ministries or commercial banks and were either junior clerical and maintenance staff or secretaries and middle-managers, belonging to low- and middle-income groups. After obtaining support from the management in each site, the programme is presented to the women, a call for volunteers is made and two to five peer educators selected by the women themselves. Following a 3-day training workshop, these peer educators conduct seven sessions within peer groups of 10-15 members, with the support of a nurse-coordinator as needed.
In its third year of operation (and continued expansion) the intervention was evaluated using a pre- and post-test design. To obtain a comparison group with the same level of motivation to attend the intervention sessions, without denying the intervention to those who wanted it, delayed intervention workplaces were chosen as comparison sites for the first intervention group. When the intervention was shown to be successful, it was given to those in the comparison group (second intervention group), who were also followed-up.
Preliminary results indicate that the peer-led education sessions have had a major impact on women’s reported preventive behaviours. For example, a preliminary analysis of data shows that the proportion of women reporting always using condoms increased from 28% to 50% for the first intervention group, and from 24% to 52% for the second intervention group (Figure 1). Large increases were also seen in the percentage of women expressing confidence in their ability to use condoms correctly. Although married women found it more difficult to introduce condom use, there was an increase in condom use by women in all types of relationships. Participants also reported talking to partners, female relatives, sons and daughters, co-workers and neighbours about HIV/AIDS.
Changes in percentage of women always using condoms and expressing confidence in their ability to use condoms correctly, before and after an intervention in Botswana
As a result of the promising findings of this evaluation, the intervention has been extended to 5 rural districts in Botswana, to primary school teachers and to University of Botswana students, in Gaborone. Over 2500 people have now been reached. Following a specific request on their part, men have also been included in this project, on condition that the peer group leader remain a woman.
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