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From People to Places: Focusing AIDS Prevention Efforts Where it Matters Most

April 28, 2003

This article is part of The Body PRO's archive. Because it contains information that may no longer be accurate, this article should only be considered a historical document.

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."

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Adapted from:
04.11.03; Vol. 17; No. 6: P. 895-903; Sharon S. Weir; Charmaine Pailman; Xoli Mahlalela; Nicol Coetee; Farshid Meidany; J. Ties Boerma

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.


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