'Letting Them Die': Why HIV/AIDS
Prevention Programmes Fail. Catherine Campbell. Bloomington: Indiana University Press,
2003. 214pp.
The HIV/AIDS epidemic
continues to spread. Daily, the epidemic’s toll is felt by families,
communities, businesses and nations. For twenty-five years, within each of
these levels, a variety of programs have been designed and implemented to
strengthen prevention efforts. It has proven especially difficult to develop
programs that incorporate a range of activities that will reach multiple
audiences and address the multiple factors that place people at risk of
HIV/AIDS.
Catherine Campbell’s book is
the most comprehensive review to date of one multi-faceted prevention program.
I read the book shortly after talking with people in Namibia about their experiences with a workplace-based
HIV/AIDS prevention program. The views of participants in that Namibia project closely echo the observations of Campbell about a community-based HIV/AIDS project in South Africa, the focus of this book. Her analysis of the many
elements that determine the effectiveness of an HIV/AIDS project is applicable
to many projects across Africa. Unfortunately, too, her conclusions that even
well-resourced projects often fail to achieve their goals—and fail to stem the
epidemic—are widely applicable. The question, then, is why, after a quarter of
a century, have national and international responses to the epidemic achieved
so little? Campbell’s study goes a long-way toward answering this
question.
Campbell moves her analysis beyond what has been the center
of most HIV/AIDS projects: the focus on changing individual sexual behaviors.
She looks at the mix of social, economic and policy determinants of sexual
behavior within the context of one community-based HIV/AIDS prevention project.
She seeks to show how the initial conceptual framework that informs project
design and implementation leads to success or failure at subsequent stages of
the project. She argues that HIV/AIDS projects need to be formulated with an
understanding of the economic and social pressures that exist at and on local
communities. At the same time, those projects must recognize that gender, class
and social power relationships will shape how a project is perceived and
manipulated by members of communities.
One of most insightful
sections deals with the project’s efforts to involve in the project women who
sell sex. The women were recruited to be peer educators. They were expected to
interact with other sex workers, with clients and community members to raise
awareness about HIV/AIDS and promote prevention. All of the women were poor,
had little control over their work and had no experience as facilitators for
change. A lengthy process of recruitment and training occurred. The process was
hindered by the power of a community “Chief” who sought to gain financially
from the project. Eventually, the obstructionist “Chief” was killed and
replaced by a younger man who promoted greater democratic involvement in
community affairs. Over time, the role of women—and the project’s peer
educators—was enhanced by this turn of events.
Campbell argues at that both community and national levels,
project participants must feel they have a voice in decision-making processes.
The peer educators gained a level of that confidence through the respect they
achieved. But, the channels for participation were relatively narrow. As with
the peer educators I observed in Namibia, the efforts of those described by Campbell were limited by the gaps that occurred early in the
project’s conceptual and design stages.
Creating and implementing
multi-dimensional projects are not easy tasks, particularly given the implosion
of many public health systems, the skepticism of communities toward promises of
improvements in living conditions, and the options available to both women and
men to make a living in contemporary Africa. Unlike many
of the international and national agencies focused on HIV/AIDS issues, Campbell does not argue that more money is the initial
requisite for improved projects. In essence, her analysis argues for design
teams with broader perspectives than has been the case to date. In turn,
improved design of HIV/AIDS programs will take into account a wider range of disciplines
and the lessons they have learned. Indeed, one is struck in Campbell’s assessment and in reviewing other HIV/AIDS
programs how little has been learned and applied from the experiences of fifty
years of community development work.
The book offers many
valuable insights for HIV/AIDS planners and practitioners. One would ask of Campbell to distill her analysis into a shorter, more concise
format that will be read and used by the people who now shape HIV/AIDS
programs.
Bill Rau
Takoma Park, MD
