Despite the current attention given to controlling the AIDS
epidemic in sub-Saharan Africa through treatment, there exists an
equally urgent need to improve prevention efforts. Although
focusing on core groups, particularly sex workers, has been
promoted as a cost-effective and strategic intervention to limit
HIV transmission in Africa and elsewhere, there is little
evidence in sub-Saharan Africa of the effectiveness of such
interventions on limiting the spread of HIV to the general
population. National sexual behavior surveys suggest that sexual
mixing in many parts of sub-Saharan Africa is diffuse and dynamic
and only to a limited extent focused on commercial sex work.
The authors propose an innovative method that shifts the
focus from risky people to risky places. This method, called
PLACE (Priorities for Local AIDS Control Efforts), systematically
identifies places where new sexual partnerships are formed and
identifies areas where people with high rates of new partner
acquisition can be reached without either assigning or defining
membership in groups that can carry stigma. The focus is on new
partnerships because rates of new partner acquisition are a major
force driving HIV and other STD epidemics. The authors evaluated
PLACE assessment in four urban applications in South Africa.
The first application was in a township in Cape Town
(population 80,000) in the Western Cape Province and was then
subsequently implemented in the Eastern Cape Province townships
of East London (population 100,000) and Port Elizabeth
(population 60,000). The protocol was also tested in the business
district of Port Elizabeth (population 12,000). Interviewers
asked over 250 informants per area to identify public sites where
people meet new sexual partners, whereby such sites were mapped
and visited. A knowledgeable person onsite was interviewed about
the site and its patrons, and individuals socializing at sites
were interviewed about their sexual behavior.
More than 200 sites in each township and 64 sites in the
central business district were identified and visited. Township
sites shared some similarities, with more than 75 percent being
small local drinking places, called shebeens, which typically had
fewer than 30 patrons during busy times. In the business
district, sites were more likely to have 100+ patrons and bars,
taverns, bottle stores, nightclubs, streets and hotels replaced
the informal shebeens.
In each area, men and women socializing at sites reported
high rates of new sexual partners and low condom use. Almost half
of the 3,085 men and 1,564 women interviewed while socializing
reported having a new sex partner in the last four weeks; one-third reported meeting a new partner at the site of the
interview. The internal consistency between the key informant,
the site representative, and the individual interview data is
perhaps the strongest evidence of the high rate of new partner
acquisition. Less than 15 percent of township and only 20 percent
of business district sites had condoms available.
Although the partner acquisition rates in this study cannot
be generalized to the entire township population, estimating the
proportion of people participating in these place-based networks
is important. The sites described in this study are likely to be
the last setting prior to sex accessible for prevention efforts
in the township. The PLACE studies highlight that AIDS prevention
messages and condoms were unavailable at sites where their impact
could be largest.
Due to limited resources for HIV prevention programs and
monitoring and evaluation of AIDS prevention, there exists an
urgent need for pragmatic methods in selecting where to focus
public health interventions. The authors concluded, "any scale-up
of prevention programs requires methods that are feasibly
implemented at low cost in a reasonable period of time by non-professional staff. The PLACE approach appears to be such a
method. Gaps in AIDS prevention were quickly identified as well
as priority sites for condom distribution and AIDS education."
Back to other CDC news for April 28, 2003
This article was provided by CDC National Prevention Information Network.
It is a part of the publication CDC HIV/Hepatitis/STD/TB Prevention News Update.