In its early years, AIDS primarily affected men, but the past decade has truly seen the “feminization” of the AIDs pandemic. Women now represent 50 percent of those worldwide and 60 percent of those in sub-Saharan Africa living with HIV (WHO-UNAIDS, 2008). In response, addressing women has become a key part of comprehensive strategies adopted by organizations large and small working to halt the spread of AIDS.

Observes Ruth Massingill, PhD, of Sam Houston State University in Houston, Texas, “From the cradle to the grave, women’s health destinies are often linked to cultural traditions of female acquiescence and powerlessness, as well as gender norms that give men control of when and how women have sex."

In her work in the Department of Mass Communications, Massingill has examined initiatives in far-ranging locations that, through innovative partnerships, have used creative strategies to reduce and prevent HIV transmission in women at risk for the disease—including changing social contexts that allow HIV to spread more easily. “Although efforts to stem the spread of HIV/AIDS have a mixed record of success over the past two decades, alliances of HIV/AIDS social marketers have been able in many cases to bring about voluntary behavioral changes among both downstream and upstream audiences,” she notes, describing three such examples of effective, creative campaigns.

Latin America and Beyond: “Program M” Addresses Gender Norms to Stop HIV

Massingill notes, “Addressing gender norms—societal messages that dictate appropriate or expected behavior for males and females—is increasingly recognized as a key strategy to prevent the spread of HIV infection, particularly among young people.”

Building on its success with young men to promote attitudes of gender equality—educating them about the costs of traditional “macho” culture in a multi-country campaign called “Program H”—an international partnership launched “Program M” to encourage young women to take control of their sexual and reproductive health and autonomy.

Program M (for mujeres and mulheres, Spanish and Portuguese for “women”) grew out of the successful Program H (for hombres and homens, Spanish and Portugese for “men”), created in 1999-2000 by four Latin American non-governmental organizations (NGOs): Promundo (Brazil), coordinator for the initiative; ECOS (Brazil); Instituto PAPAI (Brazil); and Salud y Genero (Mexico). Promundo brought to the partnership years of experience working in Brazil’s favelas, or slums. PAPAI had strong community-based experience and a regional focus in Recife. ECOS had expertise working with young people in Sao Paulo on communication and sexuality, including sexually transmitted infections (STIs). Mexico-based Salud y Genero (“Health and Gender”) brought expertise in rural areas and in Central America, in gender-related educational activities in mental, sexual and reproductive health.  

Program H experience had shown many ways that young women influence young men’s views of manhood and gender norms—even encouraging “bad boy” behavior. Gary Barker, PhD, international director for Promundo-U.S., said, “Program H developed in response to a gap in evidence-based, systematic programs to engage men and boys on HIV prevention, fatherhood and related issues.” Program M sought to meet a similar need for young women.

Cover of one of Program M's core educational tools

World Education joined Promundo and its partners in 2002-2003 to develop and launch Program M, applying its expertise in program evaluation and non-formal education to promote empowerment of women and girls, as well as a strong presence in Asia.

Focused in many areas where gender norms fuel increases in HIV infections, Program M was developed from research that included a review of Latin American literature to define concepts of female empowerment, focus group discussions with young women in marginalized communities, and interviews with empowered young women. Tested in Brazil, Jamaica, Mexico and Nicaragua, the program’s educational curriculum (available online in English and Portuguese) covers many issues related to the health of young women including sexual identity, sexuality, sexual and reproductive health, HIV/AIDS, gender-based violence, motherhood, education, work and community participation.

“To promote HIV/AIDS prevention, it is important not to exclude reflection about gender norms,” said Vanessa Fonseca, senior programme officer, Promundo. As an example, she notes, “Condom use depends on skills to negotiate pleasure and power in relationships. Program M is a complete, tested, implemented and evaluated set of interventions to promote gender equality focused on young women.”

Like Program H, Program M was first introduced in Brazil and Mexico and has since been adapted and implemented in countries as diverse as Peru, India and Tanzania. This social marketing program uses after-school programs, educational workshops, youth-led peer education campaigns and other community outreach strategies. Activities engage youth, their influencers and communities in critical reflections on gender and help young people build skills to act in more empowered, equitable ways. Among the materials is a wordless animated video—"Once Upon a Girl"—that follows a girl from childhood through household roles to sexuality and intimate relationships. The group education curriculum builds on the video to promote discussion and critical reflection on gender norms. A student-led multimedia campaign, Entre Nos (Between Us), in Rio de Janeiro featuring a radio soap opera extended the program into the community.

World Education played an important role in creating an evaluation scale for Program M. The custom Gender-Equitable Women (GEW) scale drew on the GEM scale for Program H but with new items based on qualitative research with young women. The partners also developed an index to measure young women’s perceived self-efficacy in terms of condom use, peer pressure, violence prevention and enlisting social/community resources. Notable results have included an increase in participants’ knowledge of issues related to sexual and reproductive health.

Over time, the partners have increasingly offered Programs M and H together.

In scaling-up the programs, the partners targeted school settings to reach students, teachers and education officials alike. In 2005, Promundo, the International Center for Research on Women and CARE International began testing the approach in schools in Brazil, India and the Balkans. By 2011, the programs had reached more than 2,100 teachers and 5,000 students in Brazil, and collaboration with officials led to accreditation of a Web-based teacher training portal. Staff contributed to policy-level discussions with Brazilian health and education officials about youth vulnerability to HIV/AIDS and sensitizing local officials to gender norms and sexual/reproductive health.

In India, Promundo collaborated with three states, the International Center for Research on Women, CORO, Tata Institute of Social Sciences, Ritinjali and Sangath to tailor Programs M and H—creating the Sakhi-Saheli education manual for young women and Yari-Dosti for young men. Group education sessions and a week-long school campaign used role play, debates, discussions, student-designed posters and fun, educational activities in 45 schools to raise awareness of gender equality. In the Balkan adaptation of Program H (Budi Musko), students were given flip-cams to create their own videos about gender norms to share stories using social media. A similar program is beginning with young women.

Barker sees as keys to the programs’ success the questioning of gender norms and the use of creative, adaptable tools that travel well, even to low-literacy areas. In addition, the custom evaluation scale is applied to the youth and teacher training components to establish that, following program implementation, “you should be seeing attitudes that look like this,” says Barker.

“Program M brings a different take on gender issues and sexual and reproductive health,” says Valeria Rocha, deputy director of World Education’s Monitoring and Evaluation Partnership Program. “Program M doesn’t have a judgmental character, and it’s important for young people to feel OK communicating questions and anxieties. It’s a package that helps to address HIV/AIDS in a very direct way.”

Programs M and H have been tested, adapted and implemented successfully with partners around the world—elsewhere in Latin America, in the Caribbean, the United States, South and Southeast Asia, sub-Saharan Africa, the Balkans, and in such post-conflict settings as Burundi and Democratic Republic of Congo. The two programs have been recognized by the World Bank, UN Development Programme, UN Population Fund, UNICEF and WHO as promising practices to promote gender equality. Hopes for the programs’ future include expansion to other setting and countries, especially English-speaking regions.

Uganda: “Sugar Daddies” Program Targets Cross-Generational Sex

According to a 2011 report from UNICEF, UNAIDS, UNESCO, UNFPA, ILO, WHO and The World Bank, people aged 15-24 accounted for 41 percent of new HIV infections in 2009 among those over age 15. Globally young women make up more than 60 percent of young people living with HIV, and in sub-Saharan Africa, 72 percent.

“Young women are at great risk,” says Massingill. “Social norms in many developing countries have created an environment in which girls as young as 15 are encouraged to exchange their bodies for modest financial support, entering empty sexual relationships with men who are a generation or more older.”

In Uganda, a national survey showed HIV infection rates four to six times higher among women aged 15-24 years than men of the same age. In considering the cause, PACE (formerly Population Services International/Uganda) and its partners, including the Straight Talk Foundation and Johnson & Johnson, identified one behavior that was clear: young women were dating men 10 or more years older—an age group in which HIV prevalence was much higher.

Cross-generational sex—non-marital sex between a young woman and a man at least 10 years older—is widespread in sub-Saharan Africa and a deep-seated social norm in many areas. Previously overlooked as harmless, this practice is now seen as a significant contributor to the spread of HIV. Findings from a PSI/Uganda survey supported anecdotal indications that the practice was particularly pervasive on university campuses and that the motivation for young women centered on satisfying material wants, not true needs, as these relationships were primarily transactional.

Two posters from the “Sugar Daddies” campaign in Uganda.

n response, PACE and its partners launched the “Sugar Daddies” campaign in 2004-2005 to raise awareness of the dangers of these relationships. Target audiences were young women 15 to 24, older male partners (actual and potential), parents (who often encourage such relationships) and the community. The initial pilot program focused on three universities in Kampala. Funding from YouthAIDS allowed expansion to 10 of the country’s largest universities. Financial and technical assistance from the Johnson & Johnson Foundation and the Straight Talk Foundation supported the program’s expansion into secondary schools, to arrest the practice of cross-generational sex even earlier.

The campaign employs interpersonal communications and peer-education activities through social support groups, “Go Getters Clubs,” at universities. Similar clubs have begun in secondary schools, initially during school holidays but increasingly within the curriculum. Life skills camps and workshops are conducted at schools and other locations. A multimedia public awareness campaign has featured recognized male role models such as Uganda’s Minister of Ethics and Integrity Tim Lwanga urging men to “stop preying on young girls.” Internships help prepare young women for careers, teaching them they can fulfill their own economic needs. Social media is a new element of the campaign, which created a text messaging center and trained young women to send their peers informative or motivational messages linking to Facebook and to respond to questions submitted via text.

Uganda’s Office of the First Lady was very instrumental in paving the way for expansion into secondary schools. The Uganda Ministry of Health, CHAIN Foundation and Organisation of African First Ladies Against HIV/AIDS have also been partners in expanding the program. Johnson & Johnson continues to provide funding and conduct evaluation.

Dr. Susan Mukasa, executive director of PACE, says the program has seen success as well as challenges. “Because of this campaign, now it’s a shame to men who would do this [cross-generational sex]. Now the men don’t come to universities directly but send someone to find the girls. We’re looking at how our program design can address this current situation.”

Further, Uganda’s economic situation now has young women not just wanting but needing support from “sugar daddies,” to help pay for their education, for instance, not just for a cell phone. “We have to think of income-generating strategies to meet serious needs. It is no longer sufficient to try and just change their attitudes,” says Mukasa. “But looking at this age group, the HIV infection rate has gone down, and relationships now are more between girls and boys of the same age.”

The campaign’s strong results have led to its serving as a model in Kenya, and the government of Lesotho is considering a similar program. In Uganda, the “Sugar Daddies” campaign influenced the strategies of the Y.E.A.H. (Young Empowered and Healthy) Campaign, which is supported by UNICEF, Uganda Red Cross, Save the Children, Health Communication Partnership, USAID and others.

A 2010 study of six Ugandan universities by the East African Community/African Medical and Research Foundation’s Lake Victoria Partnership determined that “HIV prevalence was highest among those who had a cross-generational partner in the 12 months preceding the survey (3.2 percent).” So the “Sugar Daddies” partners know that more work remains. Its goals include involving school administration more closely, integrating the training more fully into school curricula and expanding into primary schools.

As Mukasa observes, “This is one program that’s really touching the heart of the girls who participate.”

United States: “New Faces of HIV” Put an African-American Face on the Disease

The United States, of course, has not escaped the ravages of the AIDS pandemic. Massingill cites an earlier campaign in Houston’s Harris County that used local HIV-positive volunteers to promote testing among a high-risk group. She says, “To help dispel the detachment of anonymous billboards and posters, eight HIV-positive African-Americans in Houston put their faces on an HIV prevention and education campaign.”

In 1999, the city of Houston had declared a state of emergency on HIV in its African-American community. Influenced by the goals of the task force formed to address this crisis, the Harris County Hospital District and Houston Department of Health and Human Services launched a social marketing campaign in 2002 to raise awareness, decrease stigma, and increase testing, especially among African-American women, who accounted for 77 percent of the HIV-positive women in Harris County.

A poster from the Houston, Texas (USA) Faces of HIV awareness program.

Formative and qualitative research with African-American women and other high-risk groups shaped the campaign’s central message, ‘We look just like you, but you don’t have to be like us. Do the right thing. Get tested.’

The Harris County Hospital District engaged local AIDS advocacy and community groups as partners. One such group was Project LEAP (Leadership-Education-Advocacy-Participation). Funded by the county, LEAP is a six-month advocacy leadership training program for HIV-positive individuals.

Dena Fontno-Gray, LEAP coordinator at the time, is now manager of the HIV Prevention Program for the City of Houston Health and Human Services. She says, “We weren’t seeing African-Americans or women in HIV campaigns then, but we heard [from the community], ‘the more it looks like me, I’ll pay attention.’ There hadn’t been an effort to market to communities of color.”

Gray and several LEAP participants agreed to be photographed for the “New Faces of HIV” campaign, for brochures, posters, postcards, stickers and local public service ads.

Gray observes, “The campaign was unique in that it used real people at a time when the African-American community was really getting exposed [to HIV]. People with HIV were willing to step forward and reveal their status and show the role that ‘positives’ can play.”

The campaign also used partners that at the time were considered non-traditional: churches, school districts, city and state officials and businesses.

The campaign launched on World AIDS Day 2002, with a press conference that produced substantial media coverage, including the front page of the Houston Chronicle and stories by all five local TV stations and three local radio stations. Radio and transit ads as well as posters helped further raise awareness of the campaign, and postcards were mailed to 87,000 households in areas with the highest prevalence of HIV/AIDS among African-Americans. Materials were distributed citywide at HIV testing events and other locations. A campaign telephone hotline, staffed for more than a year in a partnership with United Way, provided answers to the public’s questions and offered connections to HIV testing and services.

Program evaluation tracked the number of HIV tests, hotline calls, materials distributed and audience reached via news coverage. Tracking showed that HIV testing by Harris County and the City of Houston increased in the months following the launch.

“The campaign helped get the Hospital District more involved in prevention,” says Nancy Miertschin of the Harris County Hospital District. “The campaign activities led us to in-reach, with the goal of getting any HIV-positive people within our organization into care. That has evolved into what’s now one of the biggest programs in the country for routine HIV screening—everyone who comes into the ER, is having blood drawn and doesn’t opt-out, is tested.”

“New Faces of HIV” has also influenced other local and national HIV awareness and education campaigns in the United States, including the City of Houston’s “It’s Real” campaign and “Hip Hop for HIV” program.

The Common Thread

Notes Massingill, “Although these three empowerment projects were worlds apart in language and culture, each targeted highly vulnerable groups and demonstrated important lessons for future initiatives. As a result, once-taboo topics such as explicit discussions about sexual practices, use of condoms and gender equity are now part of the international dialogue.”

Tapping into the notion of empowering women to take control of their health, each campaign then went further and broke new ground in the process: personalizing the AIDS epidemic for women of color in the United States, changing cross-generational sexual habits that fostered HIV transmission in Uganda, and changing underlying attitudes in many countries about gender roles that contribute to HIV and other public health threats. The results have improved HIV testing rates, reduced HIV incidence in young women and engaged men as well as women in dialogue to transform gender norms that impact sexual health. Collectively, these initiatives have brought creative new tools to help turn the tide not only on the “feminization” of AIDS but on the pandemic overall.

By Heather Jameson