HIV AIDS Determinants English
Content
Determinants of the effectiveness of HIV prevention through sport
Wim Delva, Marleen Temmerman
A societal framework of effectiveness
Having the potential to effectively curb the HIV epidemic does not however guarantee
success. Whether significant numbers of new HIV infections will be averted through sport
programmes depends on the socio-cultural and political context of the intervention, the socioeconomic context of the targeted sexual behaviour and the epidemiological context in which
individuals acquire and transmit HIV infection. (7) Figure 1 illustrates how these contextual
factors potentially attenuate the effectiveness of HIV prevention through sport at different
stages of the intervention-impact cascade.
Uptake
Efficacy
Outreach
Impact
Finances
Volunteers
Sport programmes
Behavioural change
Averted HIV infections
Co-ordinators
Sport fields
1. Determinants at the intervention level:
Is there
breathing
space for youth
sport
in the community?
Perceptions
and attitudes
Peerand
pressure,
self-efficacy
HIV prevalence
in the community
Gender Equity
STI prevalence
The socio-cultural
Financial thresholdand
for political contexts in which the youth and sport culture are embedded
participation
Social norms
Mixing patterns
are likely to affect the effectiveness
andIndependency
sustainability of HIV Sexual
prevention
through sport. A
Economic
behaviour of
untargeted groups
myriad of frameworks rooted in social science theory have been proposed to identify
structural facilitators and barriers of HIV prevention interventions and to understand how
these factors interfere with the implementation of interventions. (8-11) Although social
frameworks provide insights into the complex nature of sexual risk behaviour and healthseeking behaviour, they typically do not allow for an objective, quantitative evaluation of
prevention programmes. (12) Nevertheless, social science is imperative to determine the
socio-cultural and political appropriateness of a given intervention. Questions related to
feasibility, accessibility and affordability of sport programmes include: Is sport being
encouraged by parents, schools and governments? Do kids have the opportunities, ample
leisure time and space to play and practice sports in the community? Are local, regional and
national authorities making an effort to lower the (financial) threshold to participate in sport
and play? Are human capacity, infrastructure and financial resources in place to train and
guide the trainers and coaches, to supervise the programmes and to monitor and assess their
effectiveness? Additionally, it is essential to investigate potential sport-related sources for
stigmatisation, discrimination or formation of unfavourable stereotypes before promoting a
particular sport activity as the vehicle for life skills building and behavioural change. Social
science should however not be limited to Policy Advisory Research. When impeding and
jeopardizing factors related to the intervention and/or the target population are known,
informed actions can be undertaken and the intervention can be adapted/modified to
maximize its accessibility. In spite of the importance of establishing an acceptable, feasible
and affordable intervention, the current evidence base regarding the socio-cultural and
political appropriateness of sport programmes for HIV prevention is sparse and social science
research in this regard is urgently needed.
Lacking evidence should however not prevent us from pursuing a favourable, supportive
environment in which we can unlock the potential of sport for HIV prevention.
Acknowledging the socio-cultural and political determinants for successful implementation of
HIV prevention programmes for youth, collaborations with schools and governments as well
as efforts to involve parents are crucial. In this way, the process of adopting positive values
and building social skills through sport continues after the training and play. Anecdotal
evidence from South Africa indicates that some schools have not or incompletely
implemented “curriculum 2005” (a school-based approach to HIV prevention) because
teachers and/or parents believed that explicit information on sexuality and safe sex would
increase sexual exploration in learners. (13) Another issue demanding attention is the plight of
Children Affected by AIDS (CABA), who are particularly vulnerable to lose the opportunities
to sport and play as their work burden in the household and during income generating
activities is often extremely high. (14) Reaching these children will prove to be a growing
challenge in the light of a continuously expanding population of orphans and vulnerable
children. Lastly, governmental support and investments in long-term capacity building
through trainers and coaches and their umbrella organisations are key to ensure the lasting
legacy of current development efforts. (3)
2. Determinants at the level of sexual behaviour:
Does the intervention result in sustained behavioural change?
No one's perceptions and attitudes are developed independently of one's cultural background
and social networks. Subsequently, (sexual) behaviour is never just a matter of making
personal choices. It always involves issues such as peer pressure and role models, selfefficacy and perceived benefits versus risks. Great lessons can be learnt from the evaluations
of school-based programmes aimed at behavioural change. A recent systematic literature
review from South Africa points out that although school-based programmes are usually
associated with improved awareness, knowledge and attitudes, very few result in actual
changes in risk behaviour. (15) Only programmes dedicating ample time to communication
skills, gender equality, self-esteem and self-efficacy training and role-plays showed to impact
on sexual behaviour. (16,17) In contrast, programmes based upon the belief that behaviour
was the result of an informed choice failed to act beyond raising awareness and more positive
attitudes and intentions. (18-20) Additionally, people’s behaviour is very often rooted in
economic and developmental realities: unemployment, poverty, migrant work and gender
inequality have been identified as the most important driving forces of the HIV epidemic in
Sub-Saharan Africa. (21-25)
In conclusion, planning of HIV prevention programmes through sport should include a
comprehensive situational analysis of barriers that could hamper sustained behavioural
changes. In addition, experience and study findings from past operations research can help
develop best practice guidelines in addressing and overcoming anticipated sources of
disempowerment.
3. Determinants at the level of the epidemic:
Will behavioural change result in a lower HIV incidence and prevalence?
According to the epidemiological framework outlined by Grassly et al., the impact of
programmes altering sexual behaviour and promoting condom usage on HIV incidence
depends on the epidemiological context, indicated by the HIV prevalence in the target
population, the prevalence of cofactors of HIV transmission (e.g. STI prevalence), mixing
patterns between the target population and untargeted populations, and the sexual behaviour
of the untargeted populations. In other words, merely proving that sport can reduce unsafe
sexual practices would not be enough to ensure significant consequences in terms of averted
HIV infections. Indeed, besides the effects of sport on sexual behaviour (delayed sexual
initiation, secondary abstinence, increased condom use, reduced number of partners, reduced
number of casual and transactional sexual contacts), the indicators for the epidemiological
context as mentioned above need to be measured as well. Obviously, the effectiveness of a
programme merely targeting secondary school boys may be seriously curtailed if most of the
learners' partners have dropped out of school already and are therefore not reached. Even
worse results may be expected if these female partners tend to have concurrent sexual
partnerships with older men because women in such relationships often lack the power to
negotiate safe sex and older men are more likely than younger men to be HIV positive.
Conversely, a programme's effectiveness may be enhanced when the epidemiological context
is known. For instance, adding promotion of STI screening and treatment through sport-based
peer education may be required when STIs are rife and disappointingly little changes in HIV
incidence are observed even after significant increases in condom usage. Garnett and
Anderson showed that dramatic increases in condom distribution may have very little impact
on HIV spread until use during sexual intercourse is close to 100% in high-risk partnerships.
(26)
The epidemiological context in South African youth
HIV prevalence and incidence in the target population
The HIV prevalence in South African youth is worrisome and, in girls, has continued to rise
since the 2002 national household survey. (27) Figure 2 shows how the HIV prevalence peaks
at a higher level and in younger age groups for women than for men. Based on weighted data
to correct for stratified, disproportionate sampling and account for non-response to HIV
testing, the HIV prevalence in the 10 to 14 year old age group is estimated to be 1.64% for
boys and 1.75% for girls. In 15 to 19 year olds a differential infection rate becomes apparent
as 3.23% of these male adolescents is infected compared to 9.40% of female adolescents. This
trend is reinforced in the 20 to 24 year olds with 6.03% of men being infected in contrast to
23.85% of women. (28) When applying these prevalence rates to the 2005 mid-year
population estimates for South Africa, more than one million young South Africans between
10 and 25 years old are estimated to be HIV positive, representing nearly one quarter of all
people living with HIV in South Africa. (29)
45
40
35
30
25
20
15
10
5
0
2–4
5– 9
10 – 14
15 – 19
20 – 24
Source: South African National HIV Prevalence, HIV Incidence,
Behaviour and Communication Survey, 2005
25 – 29
30 – 34
Age grp (years)
35 – 39
40 – 44
M ales
45 – 49
50 – 54
55 – 59
60 and
above
Females
Figure 2. HIV prevalence in South Africa for 2005, by age and gender.
The relatively lower prevalence rates in youth compared to the adult population may generate
a false sense of comfort and control. In fact, they hide/disguise shockingly high HIV
incidence rates: using advanced testing essays, the HIV incidence among youth aged 15–24
years was estimated at 3.3% in 2005. Highly alarming is the fact that females in this age
group have an eight-times higher HIV incidence than males (6.5% compared to 0.8%). These
findings are consistent with data on sexual behaviour indicating that youth have a high turn
over of sexual partners and that a sizable proportion becomes sexually active early in
adolescence. Reasons for the increased susceptibility of girls include biological factors
(cervical ectopy, incomplete vaginal lining, larger surface of mucosal membrane) and
difference in mixing patterns: a high proportion of girls tend to sustain sexual relationships
with men who are older (and therefore more likely to be HIV positive). Additionally, forced
sex and sexual violence may also contribute to their vulnerability to HIV infection.
The prevalence of cofactors of HIV transmission
Additionally, STI prevalence rates are high in South African youth – especially in females –
justifying intensified efforts to improve STI screening and treatment in these groups. In a
South African community-based study, the prevalence of Chlamydia trachomatis was 3.5%
for males aged 15-19 and 9.1% for females of the same age. Neisseria gonorrhoeae was
prevalent in 1.1% of 15 to 19 year old males and in 3.5% of their female counterparts. (30)
Mixing patterns between the target population and untargeted populations
While boys and young men tend to have sexual partners of their own age groups, this is not
true for many of their female counterparts. Through high-risk – and often transactional – sex,
these women are at high risk for HIV acquisition, thus introducing the virus into the sexual
networks of younger age groups. These mixing patterns have important implications for the
design and implementation of HIV prevention interventions: An isolated intervention only
focussing on youth is unlikely to have a significant impact on HIV incidence and HIV
prevalence rates.
Sexual behaviour of the untargeted populations
Addressing the sexual behaviour of the adult population is equally important if HIV
preventions for youth are to be effective. Modelling exercises indicate that targeted
interventions for individuals engaging in high-risk sex, such as commercial sex workers and
migrant workers effectively avert HIV infections. In Family Health International’s AVERT
simulation model, social marketing of condoms in combination with presumptive treatment of
STIs were estimated to lead to a 39% decrease in HIV incidence for women using the STI
services while a 48% decrease in HIV incidence was estimated for miners. (31) Recently,
South Africa was the first country to present experimental evidence on the effectiveness of
male circumcision for the prevention of HIV infection from a randomised controlled trial.
After a mean follow-up period of 18.1 months, the annual risk of HIV-1 transmission in the
intervention group was 60% lower than that in the control group. (32) Whether mass media
interventions such as Soul City or LoveLife attenuate the HIV incidence in South Africa is far
more unclear. Although associations have been described between exposure and HIV
prevalence, no causal relationship nor an association with changing sexual behaviour could be
shown. (2,33)
Conclusions
Significant reduction of the HIV incidence in youth through sport requires feasible, accessible
and affordable sport programmes that are effective in promoting safe sexual behaviour in a
favourable epidemiological context. In this paper we described determinants of effectiveness
at three distinct, albeit interconnected levels: determinants at the level of the intervention, at
the level of sexual behaviour and behavioural change, and at the level of the HIV epidemic.
The latter is often overlooked as the final determining step to actual prevention of HIV
infections. On the other hand, some of the epidemiological indicators, such as HIV
prevalence, STI prevalence and mixing patterns are arguably best studied and findings from
quantitative and qualitative research on (the determinants of) sexual behaviour are rapidly
accumulating. In South Africa, some HIV prevention interventions, such as STI screening and
treatment, and male circumcision, have been shown to effectively reduce the risk of acquiring
HIV. Evidence on the efficacy of other approaches to HIV prevention, including sport, is at
best incomplete, but often contradictory or absent. There is a strong and urgent need to fill this
data gap before an evidence-based scaling-up of prevention programmes can take place. At
the same time, one must bear in mind that successfully changing sexual behaviour is not just
dependent on the type of intervention, but also on the perceptions and attitudes towards the
intervention and the envisaged behavioural change.
References
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Benard, B. Fostering Resiliency in Kids. Educational Leadership. 1993; 51: 44-48.
2.
Ommundsen Y. Can sports and physical activity promote young peoples' psychosocial health? Tidsskr Nor
Laegeforen. 2000; 120: 3573-3577.
3.
Koss JO, Alexandrova A. Essay: HIV/AIDS prevention and peace through sport. Lancet. 2005; 366: S3-4.
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Mwanga O. HIV/AIDS at risk adolescent girls empowerment through participation in top level football and
EDUSPORT in Zambia. Master thesis. Norwegian University of Sport and P.E. 2003.
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research. AIDS. 2000; 14: S22-32.
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on the basis of social science theory. J Community Health. 1992; 17: 259-269.
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14: S3-10.
13. Sexuality – Beyond Reproduction Seminar, University of Cape Town. Cape Town; 16-09-2005.
14. Siaens C, Subbarao K, Wodon QT. Are Orphans Especially Vulnerable? Evidence from Rwanda. World Bank,
2003. Washington, DC.
15. Delva W. et al. Prevention of sexual transmission of HIV in South Africa: a systematic review of effectiveness and
costs. Forthcoming.
16. Magnani R, Macintyre K, Karim AM, Brown L, Hutchinson P, Kaufman C, Rutenburg N, Hallman K,
May J, Dallimore A. The impact of life skills education on adolescent sexual risk behaviors in KwaZulu-Natal,
South Africa. J Adolesc Health. 2005; 36: 289-304.
17. Harvey B, Stuart J, Swan T. Evaluation of a drama-in-education programme to increase AIDS awareness in South
African high schools: a randomized community intervention trial. Int J STD AIDS. 2000 Feb;11(2):105-11.
18. Petersen I, Bhagwanjee A, Bhana A, Mahintsho Z. The development and evaluation of a manualised participatory
HIV/AIDS risk reduction programme (Sex and Risk) for tertiary level learners: a pilot study. African Journal of
Aids Research. 2004; 3: 93-100.
19. James S, Reddy PS, Ruiter RA, Taylor M, Jinabhai CC, Van Empelen P, Van den Borne B. The effects of a
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respect to sexually transmitted infections among secondary school learners in South Africa. Health Promot Int.
2005; 20: 157-165.
20. Visser MJ, Schoeman JB, Perold JJ. Evaluation of HIV/AIDS prevention in South African schools. J Health
Psychol. 2004; 9: 263-280.
21. Lurie MN, Williams BG, Zuma K, Mkaya-Mwamburi D, Garnett G, Sturm AW, Sweat MD, Gittelsohn J, Abdool
Karim SS. The impact of migration on HIV-1 transmission in South Africa: a study of migrant and nonmigrant men
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22. Kalichman SC, Simbayi LC, Kagee A, Toefy Y, Jooste S, Cain D, Cherry C. Associations of poverty, substance use,
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National HIV prevalence, HIV incidence, Behaviour and Communication Survey, 2005.
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33. Scheepers E. Soul City 4 – Evaluation Results. http://www.soulcity.org.za Last accessed 12-01-2006.
Wim Delva, Marleen Temmerman
A societal framework of effectiveness
Having the potential to effectively curb the HIV epidemic does not however guarantee
success. Whether significant numbers of new HIV infections will be averted through sport
programmes depends on the socio-cultural and political context of the intervention, the socioeconomic context of the targeted sexual behaviour and the epidemiological context in which
individuals acquire and transmit HIV infection. (7) Figure 1 illustrates how these contextual
factors potentially attenuate the effectiveness of HIV prevention through sport at different
stages of the intervention-impact cascade.
Uptake
Efficacy
Outreach
Impact
Finances
Volunteers
Sport programmes
Behavioural change
Averted HIV infections
Co-ordinators
Sport fields
1. Determinants at the intervention level:
Is there
breathing
space for youth
sport
in the community?
Perceptions
and attitudes
Peerand
pressure,
self-efficacy
HIV prevalence
in the community
Gender Equity
STI prevalence
The socio-cultural
Financial thresholdand
for political contexts in which the youth and sport culture are embedded
participation
Social norms
Mixing patterns
are likely to affect the effectiveness
andIndependency
sustainability of HIV Sexual
prevention
through sport. A
Economic
behaviour of
untargeted groups
myriad of frameworks rooted in social science theory have been proposed to identify
structural facilitators and barriers of HIV prevention interventions and to understand how
these factors interfere with the implementation of interventions. (8-11) Although social
frameworks provide insights into the complex nature of sexual risk behaviour and healthseeking behaviour, they typically do not allow for an objective, quantitative evaluation of
prevention programmes. (12) Nevertheless, social science is imperative to determine the
socio-cultural and political appropriateness of a given intervention. Questions related to
feasibility, accessibility and affordability of sport programmes include: Is sport being
encouraged by parents, schools and governments? Do kids have the opportunities, ample
leisure time and space to play and practice sports in the community? Are local, regional and
national authorities making an effort to lower the (financial) threshold to participate in sport
and play? Are human capacity, infrastructure and financial resources in place to train and
guide the trainers and coaches, to supervise the programmes and to monitor and assess their
effectiveness? Additionally, it is essential to investigate potential sport-related sources for
stigmatisation, discrimination or formation of unfavourable stereotypes before promoting a
particular sport activity as the vehicle for life skills building and behavioural change. Social
science should however not be limited to Policy Advisory Research. When impeding and
jeopardizing factors related to the intervention and/or the target population are known,
informed actions can be undertaken and the intervention can be adapted/modified to
maximize its accessibility. In spite of the importance of establishing an acceptable, feasible
and affordable intervention, the current evidence base regarding the socio-cultural and
political appropriateness of sport programmes for HIV prevention is sparse and social science
research in this regard is urgently needed.
Lacking evidence should however not prevent us from pursuing a favourable, supportive
environment in which we can unlock the potential of sport for HIV prevention.
Acknowledging the socio-cultural and political determinants for successful implementation of
HIV prevention programmes for youth, collaborations with schools and governments as well
as efforts to involve parents are crucial. In this way, the process of adopting positive values
and building social skills through sport continues after the training and play. Anecdotal
evidence from South Africa indicates that some schools have not or incompletely
implemented “curriculum 2005” (a school-based approach to HIV prevention) because
teachers and/or parents believed that explicit information on sexuality and safe sex would
increase sexual exploration in learners. (13) Another issue demanding attention is the plight of
Children Affected by AIDS (CABA), who are particularly vulnerable to lose the opportunities
to sport and play as their work burden in the household and during income generating
activities is often extremely high. (14) Reaching these children will prove to be a growing
challenge in the light of a continuously expanding population of orphans and vulnerable
children. Lastly, governmental support and investments in long-term capacity building
through trainers and coaches and their umbrella organisations are key to ensure the lasting
legacy of current development efforts. (3)
2. Determinants at the level of sexual behaviour:
Does the intervention result in sustained behavioural change?
No one's perceptions and attitudes are developed independently of one's cultural background
and social networks. Subsequently, (sexual) behaviour is never just a matter of making
personal choices. It always involves issues such as peer pressure and role models, selfefficacy and perceived benefits versus risks. Great lessons can be learnt from the evaluations
of school-based programmes aimed at behavioural change. A recent systematic literature
review from South Africa points out that although school-based programmes are usually
associated with improved awareness, knowledge and attitudes, very few result in actual
changes in risk behaviour. (15) Only programmes dedicating ample time to communication
skills, gender equality, self-esteem and self-efficacy training and role-plays showed to impact
on sexual behaviour. (16,17) In contrast, programmes based upon the belief that behaviour
was the result of an informed choice failed to act beyond raising awareness and more positive
attitudes and intentions. (18-20) Additionally, people’s behaviour is very often rooted in
economic and developmental realities: unemployment, poverty, migrant work and gender
inequality have been identified as the most important driving forces of the HIV epidemic in
Sub-Saharan Africa. (21-25)
In conclusion, planning of HIV prevention programmes through sport should include a
comprehensive situational analysis of barriers that could hamper sustained behavioural
changes. In addition, experience and study findings from past operations research can help
develop best practice guidelines in addressing and overcoming anticipated sources of
disempowerment.
3. Determinants at the level of the epidemic:
Will behavioural change result in a lower HIV incidence and prevalence?
According to the epidemiological framework outlined by Grassly et al., the impact of
programmes altering sexual behaviour and promoting condom usage on HIV incidence
depends on the epidemiological context, indicated by the HIV prevalence in the target
population, the prevalence of cofactors of HIV transmission (e.g. STI prevalence), mixing
patterns between the target population and untargeted populations, and the sexual behaviour
of the untargeted populations. In other words, merely proving that sport can reduce unsafe
sexual practices would not be enough to ensure significant consequences in terms of averted
HIV infections. Indeed, besides the effects of sport on sexual behaviour (delayed sexual
initiation, secondary abstinence, increased condom use, reduced number of partners, reduced
number of casual and transactional sexual contacts), the indicators for the epidemiological
context as mentioned above need to be measured as well. Obviously, the effectiveness of a
programme merely targeting secondary school boys may be seriously curtailed if most of the
learners' partners have dropped out of school already and are therefore not reached. Even
worse results may be expected if these female partners tend to have concurrent sexual
partnerships with older men because women in such relationships often lack the power to
negotiate safe sex and older men are more likely than younger men to be HIV positive.
Conversely, a programme's effectiveness may be enhanced when the epidemiological context
is known. For instance, adding promotion of STI screening and treatment through sport-based
peer education may be required when STIs are rife and disappointingly little changes in HIV
incidence are observed even after significant increases in condom usage. Garnett and
Anderson showed that dramatic increases in condom distribution may have very little impact
on HIV spread until use during sexual intercourse is close to 100% in high-risk partnerships.
(26)
The epidemiological context in South African youth
HIV prevalence and incidence in the target population
The HIV prevalence in South African youth is worrisome and, in girls, has continued to rise
since the 2002 national household survey. (27) Figure 2 shows how the HIV prevalence peaks
at a higher level and in younger age groups for women than for men. Based on weighted data
to correct for stratified, disproportionate sampling and account for non-response to HIV
testing, the HIV prevalence in the 10 to 14 year old age group is estimated to be 1.64% for
boys and 1.75% for girls. In 15 to 19 year olds a differential infection rate becomes apparent
as 3.23% of these male adolescents is infected compared to 9.40% of female adolescents. This
trend is reinforced in the 20 to 24 year olds with 6.03% of men being infected in contrast to
23.85% of women. (28) When applying these prevalence rates to the 2005 mid-year
population estimates for South Africa, more than one million young South Africans between
10 and 25 years old are estimated to be HIV positive, representing nearly one quarter of all
people living with HIV in South Africa. (29)
45
40
35
30
25
20
15
10
5
0
2–4
5– 9
10 – 14
15 – 19
20 – 24
Source: South African National HIV Prevalence, HIV Incidence,
Behaviour and Communication Survey, 2005
25 – 29
30 – 34
Age grp (years)
35 – 39
40 – 44
M ales
45 – 49
50 – 54
55 – 59
60 and
above
Females
Figure 2. HIV prevalence in South Africa for 2005, by age and gender.
The relatively lower prevalence rates in youth compared to the adult population may generate
a false sense of comfort and control. In fact, they hide/disguise shockingly high HIV
incidence rates: using advanced testing essays, the HIV incidence among youth aged 15–24
years was estimated at 3.3% in 2005. Highly alarming is the fact that females in this age
group have an eight-times higher HIV incidence than males (6.5% compared to 0.8%). These
findings are consistent with data on sexual behaviour indicating that youth have a high turn
over of sexual partners and that a sizable proportion becomes sexually active early in
adolescence. Reasons for the increased susceptibility of girls include biological factors
(cervical ectopy, incomplete vaginal lining, larger surface of mucosal membrane) and
difference in mixing patterns: a high proportion of girls tend to sustain sexual relationships
with men who are older (and therefore more likely to be HIV positive). Additionally, forced
sex and sexual violence may also contribute to their vulnerability to HIV infection.
The prevalence of cofactors of HIV transmission
Additionally, STI prevalence rates are high in South African youth – especially in females –
justifying intensified efforts to improve STI screening and treatment in these groups. In a
South African community-based study, the prevalence of Chlamydia trachomatis was 3.5%
for males aged 15-19 and 9.1% for females of the same age. Neisseria gonorrhoeae was
prevalent in 1.1% of 15 to 19 year old males and in 3.5% of their female counterparts. (30)
Mixing patterns between the target population and untargeted populations
While boys and young men tend to have sexual partners of their own age groups, this is not
true for many of their female counterparts. Through high-risk – and often transactional – sex,
these women are at high risk for HIV acquisition, thus introducing the virus into the sexual
networks of younger age groups. These mixing patterns have important implications for the
design and implementation of HIV prevention interventions: An isolated intervention only
focussing on youth is unlikely to have a significant impact on HIV incidence and HIV
prevalence rates.
Sexual behaviour of the untargeted populations
Addressing the sexual behaviour of the adult population is equally important if HIV
preventions for youth are to be effective. Modelling exercises indicate that targeted
interventions for individuals engaging in high-risk sex, such as commercial sex workers and
migrant workers effectively avert HIV infections. In Family Health International’s AVERT
simulation model, social marketing of condoms in combination with presumptive treatment of
STIs were estimated to lead to a 39% decrease in HIV incidence for women using the STI
services while a 48% decrease in HIV incidence was estimated for miners. (31) Recently,
South Africa was the first country to present experimental evidence on the effectiveness of
male circumcision for the prevention of HIV infection from a randomised controlled trial.
After a mean follow-up period of 18.1 months, the annual risk of HIV-1 transmission in the
intervention group was 60% lower than that in the control group. (32) Whether mass media
interventions such as Soul City or LoveLife attenuate the HIV incidence in South Africa is far
more unclear. Although associations have been described between exposure and HIV
prevalence, no causal relationship nor an association with changing sexual behaviour could be
shown. (2,33)
Conclusions
Significant reduction of the HIV incidence in youth through sport requires feasible, accessible
and affordable sport programmes that are effective in promoting safe sexual behaviour in a
favourable epidemiological context. In this paper we described determinants of effectiveness
at three distinct, albeit interconnected levels: determinants at the level of the intervention, at
the level of sexual behaviour and behavioural change, and at the level of the HIV epidemic.
The latter is often overlooked as the final determining step to actual prevention of HIV
infections. On the other hand, some of the epidemiological indicators, such as HIV
prevalence, STI prevalence and mixing patterns are arguably best studied and findings from
quantitative and qualitative research on (the determinants of) sexual behaviour are rapidly
accumulating. In South Africa, some HIV prevention interventions, such as STI screening and
treatment, and male circumcision, have been shown to effectively reduce the risk of acquiring
HIV. Evidence on the efficacy of other approaches to HIV prevention, including sport, is at
best incomplete, but often contradictory or absent. There is a strong and urgent need to fill this
data gap before an evidence-based scaling-up of prevention programmes can take place. At
the same time, one must bear in mind that successfully changing sexual behaviour is not just
dependent on the type of intervention, but also on the perceptions and attitudes towards the
intervention and the envisaged behavioural change.
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