The Drum Beat 297 - HIV/AIDS Communication: Back in the Trenches?

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This Drum Beat is one of a series of commentary and analysis pieces. Thomas Tufte outlines what he calls "communication disconnects" that have led to prevention "slipping off the HIV/AIDS agenda." This commentary draws on Thomas' inaugural public lecture as full professor, given at Roskilde University, Denmark, on November 26 2004. What follows is Thomas' perspective - NOT that of the Partners collectively or individually.

We are interested in featuring a range of critical analysis commentaries of the communication for change field. These will appear regularly on the first Monday of each month and are meant to inspire dialogue throughout the month. Though we cannot guarantee to feature your commentary, as we have a limited number of issues to be published each year, if you wish to contribute please contact Deborah Heimann dheimann@comminit.com Many thanks!

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Back in the Trenches?
Urgent Call to Reinvigorate HIV/AIDS Communication for Prevention

'As the UNGASS Declaration of Commitment stated, prevention must be the mainstay of the response to the epidemic, as only by preventing new infections can the epidemic eventually be brought under control. The long-over-due-drive to expand treatment - energized by the WHO/UNAIDS initiative to provide antiretroviral therapy to 3 million people by 2005 ("3 by 5") and large influxes of funds - has mobilized activists, national governments, and the United Nations system, and now dominates the AIDS agenda at all levels. Every effort must now be made to bring the same sense of urgency and excitement to meeting ambitious prevention goals. Unless prevention remains a fundamental priority of leaders, donors and those who battle the epidemic on the ground, tens of millions more will become infected and the need for treatment will grow inexorably. As is now widely recognized, treatment can assist prevention in important ways, but treatment alone will not bring the epidemic under control' (UN Millennium Project, Working Group on HIV/AIDS, 2005 [PDF]. page 4).

Slipping off the HIV/AIDS Agenda

As the UN task force states, treatment is dominating the AIDS agenda at all levels. Having treatment centrally on the AIDS agenda is in many ways crucial - it creates a strong incentive for people to know their status, it also catalyses action on stigma and it creates the focus for political activism on HIV/AIDS. However, the point raised by the UN task force is that the pendulum has swung over, resulting in prevention today lacking fundamental priority amongst leaders, donors and those who fight HIV/AIDS on the ground. It seems as if we're back in the trenches of the 1990ies, the prevention folks against the treatment folks - pushing aside all the accomplishments towards more integrated approaches to HIV/AIDS. Or the real question today might well be: does prevention have a role to play in its own right?

Now, why this re-medicalisation of the HIV/AIDS agenda - both at the level of political leaders, major donors and key international organisations? At the community level, prevention, care and support initiatives are mushrooming in many places with severe epidemics, but funding is tight, and political leadership focused elsewhere. The urgent call by the UN Millennium Project working group on HIV/AIDS to reinvigorate prevention, getting it back on to the political agenda, is very important. It is pertinent, not only to regain centrality for HIV/AIDS prevention efforts in countries that already are heavily burdened by HIV/AIDS, but also to assure that mistakes are not reproduced now in the countries of Eastern Europe, Asia and the Caribbean with rapidly growing epidemics.

Of particular concern here is that this urgent call is challenging us, communication practitioners and scholars, involved in HIV/AIDS prevention work. It sparks questions such as: Why did prevention slip off the agenda? Are we not good at making our case? Can't we prove worthy results? From the HIV/AIDS communicators' perspective: what's not working?? The fact of the matter is that many successful steps have been taken. When the UN Communication for Development Roundtable in 2001 assembled in Managua and focused the meeting on HIV/AIDS communication, all of us present, a mix of UN-folks, NGOs and CBOs and some academics, agreed on the following achieved successes: 'HIV/AIDS communicators have been successful in broadening awareness of HIV/AIDS; increasing knowledge of how HIV/AIDS is contracted; placing HIV/AIDS in the context of human rights; increasing knowledge and demand for effective services, and, mobilising political support for national HIV/AIDS plans.' However, in the same declaration, a number of limits and problems were identified. Many communication strategies had: (1) Treated people as objects of change rather than the agents of their own change; (2) Focused exclusively on a few individual behaviours rather than also addressing social norms, policies, culture and supportive environments; (3) Conveyed information from technical experts rather than sensitively placing accurate information into dialogue and debate; (4) Tried to persuade people to do something, rather than negotiate the best way forward in a partnership process.

What has happened in these more recent years has been a growing acknowledgement of bridging communication approaches - more diffusionist strategies based on behavioural sciences and social marketing mixing with strategies focused on empowerment, participation and social change. Despite this bridging, HIV/AIDS communication for prevention is slipping off the HIV/AIDS agenda, and part of the reason for this is the lack of successful communication strategies as well as the lack of ability to learn from successful principles and practices of communication. Rather than getting back into the trenches of the 1990ies, the challenge today - in times of a strong treatment agenda - is to reassess our communication science, our communication models and our communication practice when putting HIV/AIDS prevention on the agenda.

One challenge seems to be that HIV/AIDS campaigns are not achieving the participation of their audiences in problem-definition nor in problem-solving action. Research suggests that a lot of health communication does not resonate with the needs, interests, competencies and potential abilities to act that audiences may have. The Freire'an strategy of 'conscientization' responds to exactly this: it engages people in participatory processes of reflection, action and reflection, thereby identifying the problems of their society and seeking solutions to them (Freire 1968). Recalling the problems identified at the 2001 Roundtable, and following a Freire'an strategy, I would suggest three communication-related issues whereby HIV/AIDS communication strategies for prevention could improve:

1. Increasing Attention to the Audiences. This includes a stronger emphasis on considering audiences as active citizens with citizen identities. They must be at the heart of developing and implementing strategies that concern them and their communities. Increased audience attention is also about improving in-depth analysis of sense-making processes when monitoring and evaluating communication interventions.
2. Articulating Cultural Citizenship. This implies a much stronger recognition of popular culture as a resource and ally in developing communication strategies. Inviting popular cultural genres, be it drama, music or storytelling, to be at the heart of communication strategies is a first step towards articulating a feeling of cultural citizenship and thereby articulating action and commitment (Tufte 2000: 227pp).
3. Recognising Contexts and Communication Environments. This is a general call for improved analysis of the broader communication environment that HIV/AIDS interventions operate within. This can improve a realistic assessment of the role one specific communication intervention may or may not have. There is far too strong a drive to flag the impact of single interventions, instead of understanding the broader contexts, the multiple mediators and the complex synergies that social communication spurs. Recognising contexts and communication environments will lead to more comprehensive and complex designs of interventions.

Communication Disconnects - Communication Challenges

Following the above three principles, I would like to wrap up this commentary by outlining three key challenges which grow out of what I have identified in the course of my own research in recent years. Having focused on assessing HIV/AIDS communication practices mainly in Sub-Saharan Africa, but also with some experiences from Central America and Eastern Europe, I have identified 3 key 'communication disconnects'. These are points, or issues, where previous HIV/AIDS communication practice does not connect with the lifeworlds and real lives of the people:

a. Communication Rights, Representation and the Public Sphere

Disconnect: There is a big discrepancy between the immensity of the HIV/AIDS problems on one side and the thundering silence found in many local communities on the other side. The strong stigma associated with HIV/AIDS is at the centre of this communication disconnect. It results in an invisibility instead of visibility of people living with HIV/AIDS, and it results in the absence of their voice in the public sphere. People living with HIV/AIDS have a natural right - and need - to speak out about their experience, but they are not present.

The first challenge is for communication practices to address issues of communication rights, especially ensuring voice and visibility to people living with HIV/AIDS. Giving voice and visibility to those that suffer the direct consequences of HIV/AIDS, provides two functions:

• First, it allows people living with HIV/AIDS (PLWHA) to speak about their concerns. Given this voice, and also seeing the audience responding to their message can spark empowerment, increased motivation and commitment.
• It also allows people and communities living with HIV/AIDS the possibility of recognising the situation better and seeing the relevance of speaking out to such a degree that it may empower them to de facto speak with others about their concern.

Considering the stigma and silence surrounding HIV/AIDS, the most important element here is to conquer a space in the public sphere and create a 'speech environment' where HIV/AIDS can be openly recognised and talked about.

b. Popular Culture and Cultural Citizenship

Disconnect: there is a lack of connection between on one hand: (1) the content of the mediated communication and (2) the media language used (including genre, aesthetics, format and language) and on the other hand the life-worlds and lived experiences of the audiences.

The second challenge is to move beyond a concern for messages and information only to also communicate lessons, situations and actions rooted in popular culture and social realities. This implies moving from individual-oriented persuasion strategies towards individual and collective-oriented social communication strategies.

Focusing on audience relevance and recognition of lessons and situations is about recognising change as a process. Drama, for example, as an expression of popular culture constitutes a space for different social groups to be recognised and to feel recognised, thereby contributing to the articulation of a citizen identity. This can be useful in HIV/AIDS communication but also as a strategy to address many other issues.

c. Power Struggles and Change Processes

Disconnect: The immense contradiction between the solutions proposed in campaign initiatives and the actual need for much more far-reaching solutions.

The final challenge is that of addressing unequal power relations in society. It is the most important of the challenges, but also the most difficult. It is an underlying condition which is seldom put at the forefront of HIV/AIDS communication interventions. Key changes in social and economic inequalities are, however, crucial if we really want to get to the core problems of underdevelopment and HIV/AIDS. Often, it is argued to be beyond the ability of HIV/AIDS communication interventions. I would rather argue that the problems, then, have been defined too narrowly.

Reinvigorating Prevention Now

The difficulty in communicating about HIV/AIDS is that HIV/AIDS is related to love, sexuality and relationships, issues that are the most intimate of our private sphere, and yet at the core of the HIV/AIDS pandemic. Sexuality is in many places a taboo to talk about, and love is often regarded as a strictly private matter. And discussing relationships is again dependent on cultural context. Many of us working in HIV/AIDS communication have not been good enough communicating about HIV/AIDS and, especially, sexuality in these varied contexts. As the recently published Africa Commission Report from the UK states: 'AIDS will not be checked until those combating it take on board cultural factors about poverty and choices, traditions and beliefs, perceptions of life and death, witchcraft and ancestral punishment, power hierarchies and gender norms, social taboos and rites of passage, control of female sexuality and the demand for male virility and pressures for widows to marry close relatives of a husband recently dead from AIDS.' (Africa Commission Report, page 42)

Successful strategic communication is about articulating identification, recognition and action. It is about establishing relations of trust. This is the case not least in these times of insecurity, of wars against terrorism and with transformations of society resulting in what the Indian anthropologist Arjun Appadurai calls 'a new order of instability in the production of modern subjectivities' (Appadurai 1996). Successful communication articulates trust, promotes feelings of security and belonging and leads to reflection and action. No wonder that royal weddings as we saw them in Denmark and Spain last year become the largest media events in the history of television, not least here in my country, Denmark. They were the perfectly orchestrated love stories, articulating a strong sense of unity and belonging and social mobilisation.

HIV/AIDS communication, although communicating about love and romance, has another objective. It is about enhancing sustainable development processes, and about tackling the problems that enable HIV/AIDS to keep spreading. I have in this presentation outlined some of the challenges; the aim must be to overcome these elements of communicative disconnect. Only by challenging our science of communication and our current communication practice can we better make the case to reinvigorate HIV/AIDS prevention to political leaders, donors and international organisations.

Thomas Tufte
Roskilde University, Denmark
ttufte@ruc.dk

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Bibliography

• Appadurai, Arjun (1996). Modernity at Large. Cultural Dimensions of Globalisation. London and Minnesota: University of Minnesota Press.
• Freire, Paulo (1968). Pedagogy of the Oppressed. New York: Seabury Press.
• 8th Communication for Development Roundtable website (2001/2002). The Communication Initiative.
• Tufte, Thomas (2000). Living with the Rubbish Queen. Telenovelas, Culture and Modernity in Brazil. Luton: University of Luton Press [click here for a summary].

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Please participate in a Pulse Poll on this same theme -

Rather than getting back into the trenches of the 1990ies, the challenge today - in times of a strong treatment agenda - is to reassess our communication science, models and practice when putting HIV/AIDS prevention on the agenda.

Do you agree or disagree?

VOTE and COMMENT - click here!

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RESULTS of past Pulse Poll

The Commission for Africa Report "basically confirms what African NGOs and Governments have been saying all along. Core structural adjustment policy conditionality associated with debt and aid packages for Africa for the last two decades have been destructive to human security and economic growth. With this report, the World Bank and IMF must stop."
- reaction to the report signed by 7 African and regional civil society organisations and networks.

Agree: 92.86%
Disagree: 0.00%
Unsure: 7.14%
Total number of participants = 14

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This issue of The Drum Beat is meant to inspire dialogue and conversation among the Drum Beat network.

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This issue of The Drum Beat is an opinion piece and has been written and signed by the individual writer. The views expressed herein are the perspective of the writer and are not necessarily reflective of the views or opinions of The Communication Initiative or any of The Communication Initiative Partners.

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