Scaling Up Control Strategies
Throughout the history of STI control, tension has been apparent between those who support prioritizing resources for the small proportion of people with the most sexual contacts and those who advocate spreading prevention, screening, and treatment resources more thinly over the entire population. Opponents of prioritization argue that most of the people who practice the riskiest behavior are hard to find and that attempts to find them would expose those individuals to stigmatization and repressive measures.
A group of researchers at the University of North Carolina has developed and applied a novel approach to STI interventions that has demonstrated in several countries that finding the people who practice the riskiest sexual behavior without targeting them as individuals is possible (Weir and others 2003). As an example of this approach, consider its application to Madagascar, a country where risky sexual behavior had previously been thought to be too common to be identified or to be distinguished from less risky behavior.
In May 2003, the Malagasy Steering Committee, which consisted of representatives of the Ministry of Health, local government officials, and other knowledgeable experts, selected five towns judged to be at high risk for STIs for a pilot study. The Priorities for Local AIDS Control Effort (PLACE) method applied in these towns was, first, to interview adults at random on the streets of the city to find out where people go to meet and socialize and, second, to visit and collect data on these locations and the people who frequent them.
In each of the five cities, the informants tended to agree on the most frequented sites. They identified between 70 and 267 unique socialization sites of various types, ranging from bars and restaurants to beaches and brothels. Interviews with people frequenting the sites revealed them to be much more sexually active than the average Malagasy adult. According to the 1997 demographic and health survey, 13 percent of women outside the capital city, Antananarivo, had two or more sexual partners in the previous year. In contrast, the percentage of women at the socialization sites who had had more than two partners ranged from 46 to 68 percent. According to the demographic and health survey, only about 3 percent of women outside Antananarivo had four or more partners in the previous year, but the percentage of women at the study sites having this many partners was 10 times larger. The men interviewed at these sites were even more sexually active than the women.
The pilot study also investigated whether information on or products for prevention of STIs, HIV, or both were available at the socialization sites. In the five towns, the proportion of sites where condoms were available on the day of the visit varied from 27 to 54 percent. These percentages are not negligible and are undoubtedly much higher than they were 10 years ago, and the availability of condoms at so many of these sites is a tribute to the success of the condom social-marketing campaign. However, the statistics also indicate substantial room for improvement, for example, by distributing condoms in 100 percent of identified socialization sites. The feasibility of such a program is enhanced by information from the PLACE study that more than 80 percent of the owners or managers of these sites expressed their willingness to host STI and HIV prevention programs, and more than half were willing to sell condoms.
Researchers have carried out similar PLACE studies in Burkina Faso, Ghana, South Africa, and elsewhere. Unfortunately, in none of these countries has this extensive risk mapping been followed by the implementation of prevention programs at all the identified locations. Until such programs are implemented and evaluated, no African country will be able to claim that it has scaled up the most effective type of STI prevention to population levels.
