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This publication documents the experience of the world's largest international HIV/AIDS prevention project, which was implemented by FHI and its partners in 45 countries. It describes lessons learned during AIDSCAP, with examples and project profiles, in 10 technical and programmatic areas: behavior change communication, improving prevention and treatment of sexually transmitted diseases, prevention marketing, policy development, behavioral research, evaluation, gender and HIV/AIDS, management, AIDS care and support, and cross-border interventions. Table of Contents 1. Behavior Change Communication: From Individual to Societal Change 2. Improving STD Prevention and Treatment 3. Prevention Marketing: Condoms and Beyond (See Below) 4. Policy Development and HIV/AIDS Prevention: Creating a Supportive Environment for Behavior Change 5. Behavioral Research: Using Results to Design Behavior Change Interventions 6. Evaluating HIV/AIDS Prevention Programs: Developing New Tools for Meaningful Measurement 7. Women, Men and HIV/AIDS: Building Gender-Sensitive Programs 8. Managing HIV/AIDS Programs and Building Capacity to Sustain Prevention Efforts 9. Prevention and Care: Mutually Reinforcing Approaches 10. Crossing Borders: Reaching Mobile Populations at Risk 3. Prevention Marketing: Condoms and Beyond The use of marketing techniques and systems to promote and deliver methods of protecting public health -- known as social marketing, is a key HIV/AIDS prevention strategy. The basic approach involves packaging, pricing and presenting a product or behavior to appeal to the target market and engaging the participation of wholesalers and retailers in distribution and conventional trade promotions. Mass media are often used to convey the benefits of the desired behavior for a particular target audience. Social marketing has been applied in a wide range of public health programs, including family planning, child survival and malaria prevention. These projects commonly make use of the existing logistics systems that supply the commercial networks delivering most daily necessities. The most successful projects depend on subsidized products to ensure retail prices that are within the buying power of most people in developing countries. The advantages of a social marketing approach to promoting condoms for HIV/AIDS prevention include the ability to make products available to people when and where they need them and to saturate geographic areas of special interest with a product. The privacy -- even anonymity -- of the commercial transaction between a vendor and customer is another benefit. And social marketing is a cost-effective strategy: even with a highly subsidized product, the cost of distribution, from intermediate warehousing to the actual delivery of product into the hands of the user, is borne by the purchaser, not by a donor or the public health system. The success of condom social marketing (CSM) efforts has led to a new interest in expanding the use of marketing strategies in public health programs. Such prevention marketing can be used to encourage health-promoting behaviors, as well as other prevention "products." Improving Access, Increasing Sales FHI worked with its social marketing subcontractor, Population Services International (PSI), and other organizations to make condoms accessible, affordable and attractive to millions of people. By June 30, 1997, the total number of condoms sold by social marketing projects and distributed for free by NGOs had exceeded 254 million. AIDSCAP-supported CSM projects sold 87 percent of those condoms (almost 222 million) in eight countries.
In those countries AIDSCAP strengthened existing CSM operations, providing the support needed to expand sales outlets to new areas and to target marketing efforts to reach critical audiences. In fact, each of these CSM projects enjoyed a marked increase in sales under AIDSCAP support. For example, in Ethiopia the PSI project's sales rose 141 percent, from 829,000 a month before the AIDSCAP program in that country began to 2 million a month in September 1996. AIDSCAP support also boosted monthly sales by more than 100 percent in Haiti and Nepal. Perhaps even more important, AIDSCAP-supported CSM projects succeeded in providing reliable supplies to otherwise difficult-to-reach groups and individuals at high risk of HIV infection by adapting traditional commercial logistics systems. Innovations such as the use of nontraditional sales outlets (bars, restaurants, kiosks and other small retailers), NGO sales agents and dedicated sales forces increased sales while ensuring that condoms were available to those who needed them most. Impressive sales figures were achieved despite formidable obstacles in almost every country. In Ethiopia, for example, the CSM project was forced to ration condoms due to limited supplies. The internecine war in Rwanda claimed the lives of four PSI staff and forced the project to suspend sales for almost a year, prompting PSI to distribute free condoms in Rwandan refugee camps (Box 3.1). Political violence and an economic embargo in Haiti also posed safety concerns and logistical challenges to the PSI project there (Box 3.2), and Brazil was plagued by both tariff and regulatory barriers that restricted sales and complicated the administration of CSM operations. That CSM projects were able to overcome these challenges to record such remarkable successes is testament to the resilience and pragmatism of the social marketing approach. It is also an indication of the great unmet need for condoms in many countries throughout the world. AIDSCAP's experience suggests that providing convenient access to affordable condoms is the most effective way to meet that demand.
Reaching Those At Risk
AIDSCAP's most significant and successful adaptation of the contraceptive social marketing model was to emphasize sales through nontraditional outlets to reach those at greatest risk of HIV infection. Sales through wholesalers and large commercial outlets are more efficient, but much less likely to provide access to condoms at the times and in the locations where people usually engage in high-risk sex. For example, pharmacies are rarely located in red-light districts, and most are not open for business late at night. By giving sales agents incentives to market condoms through nontraditional outlets, AIDSCAP provided convenient access to low-cost condoms at thousands of strategic locations.
The association between NGOs and social marketing is not a natural one. Social marketing specialists operate in the commercial sector, appealing to profit motives rather than altruistic goals. NGO staff who provide assistance to the poor may object philosophically to selling anything to their clients or members. But both groups recognize the urgent need to ensure a reliable condom supply to NGO clients and members, and that common ground enabled AIDSCAP to foster productive relationships between social marketing operations and NGOs. All social marketing operations were coordinated with the activities of other AIDSCAP partners -- primarily NGOs -- to ensure that target populations received comprehensive HIV/AIDS prevention services. Some NGO personnel even acted as condom sales agents. For example, Ethiopian youth and Nigerian sex workers trained by AIDSCAP as volunteer educators sold condoms to their peers. In a number of countries, NGOs emerged as significant retailers of condoms. For example in Haiti, where government condom distribution ceased during years of political turmoil and traditional social marketing efforts were unable to reach those living in the most poverty-stricken or remote regions, the AIDSCAP-supported PSI social marketing project sold condoms at wholesale prices to NGOs, who in turn sold them to their clients at retail (Box 3.2). NGO staff learned that the (highly subsidized) retail price was bearable to their clients, experienced the superior performance of the private sector delivery system, and generated funds for their organizations through the small profits they received. Skeptical at first of the ability of NGOs to handle retail products, the social marketing managers saw NGO staff account for an increasing share of their sales, reaching 25 percent of the 540,000 condoms sold every month. The success of this strategy led to replication in several other countries. PSI managers of AIDSCAP-sponsored programs in Tanzania, Rwanda and South Africa trained more than 2,300 NGO staff as condom sales agents.
In Brazil, AIDSCAP's social marketing partner DKT do Brasil could not rely on NGO sales agents to increase access to condoms for NGO clients because Brazilian law barred nonprofit organizations from the retail trade. Instead, AIDSCAP provided separate funds to DKT to ensure that sales efforts were particularly intense in the geographic areas served by the NGOs. Ordinarily DKT would have concentrated its resources on the most efficient (low-cost) sales, which in Brazil means large sales to chain stores and to the biggest retail outlets. With the additional resources from AIDSCAP, the social marketing operation was able to hire promodoras who sold to smaller outlets, ensuring adequate supplies of low-priced condoms in the areas where the NGO clients lived and worked. A dedicated sales force also proved an effective strategy for reaching groups targeted by the AIDSCAP program in Nepal. These sales agents concentrated their efforts on the highways into the country from India -- a known route for transmission of the virus -- in nontraditional outlets such as tea shops, liquor stores and roadside stands. As a result of these efforts, condom access along the highways increased dramatically (Box 3.3).
The efficiency of social marketing projects and their ability to recover costs tempts donors to make them entirely self-sustaining. But it is donor support that allows social marketing to sell condoms at an affordable price. For example, in Nepal, where social marketing is an important component of the AIDSCAP program, the retail price for a condom is less than U.S.$0.01. In Brazil, on the other hand, subsidies are not available and government taxes and regulations discourage condom imports. There the cost is $0.30 per condom, largely because management is forced to sell them at a price that finances new supplies. This price makes it highly unlikely that Brazil's poorest citizens will buy condoms. Social marketing operations can be self-sustaining, but at a cost. HIV/AIDS is increasingly a disease of the poor, and social marketing efforts will have less of an impact on the epidemic if condoms are not available at affordable prices.
In fact, AIDSCAP's experience suggests that condom social marketing efforts can actually help boost for-profit sales. In Brazil, for example, the CSM project managed by PSI affiliate DKT do Brasil stimulated a stagnant commercial condom market by aggressively promoting its brand in public and by challenging barriers to imported condoms. As a result, the total number of condoms sold in a year tripled to 135 million in 1995, and the market gained at least five additional condom importers. A similar effect was documented in Thailand, a country that distributes millions of free condoms. An audit by FHI partners John Snow, Inc., and PSI showed that as the number of condoms distributed in the public sector increased, the demand for commercial condoms also rose. This demand encouraged three companies to open local condom manufacturing plants. The government was able to cut back on free distribution as the private sector condom market grew, rising from about 1 million to 60 million a year from 1985 to 1995. Mass Media Marketing
The climate for mass media messages about HIV/AIDS and condoms has improved substantially over the past five years. The image of Bishop Desmond Tutu endorsing condom use on South African television may have shocked some viewers there, but was perhaps even more surprising to social marketers who for years had battled to gain access to mass media. As recently as 1990, the word "condom" was prohibited in advertising by the Government of Kenya, requiring a wide range of subtlety and creativity on the part of social markers. Today, more explicit advertising is permitted there and in many other parts of the world.
Targeted marketing has sometimes been misunderstood to mean developing brands and advertising messages that appeal directly or even exclusively to sex workers and their clients or to men who have sex with men. Such an approach associates condom use with behavior that is condemned by society and requires condom buyers to identify themselves as people who practice that behavior. Portraying condom users in the media as happy, successful, "normal" people helps those whose lack of acceptance in society has been a barrier to their obtaining condoms. When mass media conveys the message that "everybody" uses condoms, members of marginalized minorities can enter a store and buy a condom without drawing attention to their social status. In Tanzania, for example, one television ad showed dozens of people -- well-dressed young men and women, athletes, families with young children -- singing the upbeat "Salama" condom theme song. In a Haitian ad, a beautiful young woman holds a Pant brand condom package and says, "Pant -- It's for me." Then a man puts his hand lovingly on hers and corrects her: "It's for us." Such advertising helped boost condom sales among groups targeted by HIV/AIDS programs and the general population.
NGO personnel proved extremely successful sales agents, expanding condom access to areas seldom reached by traditional CSM projects. Another effective way to target marketing efforts is to hire a dedicated sales force that sells to smaller outlets in neighborhoods where target audiences live and work.
In countries with mature epidemics, much of the general population is the target audience; in others, a more inclusive approach reduces the stigma often associated with condoms and discourages the perception that HIV/AIDS affects only marginalized groups. Expanding Social Marketing The ability of social marketing to move physical goods within the convenient reach of target audiences and to create an effective demand for them has yet to be fully exploited, at least in part because of donors' hesitations about becoming further involved in commodity supply. For example, using social marketing to make supplies of latex gloves available near medical facilities and promoting the idea that it is a client's responsibility to supply the gloves might well be less costly than making the investments in public sector logistics systems required to ensure adequate supplies to physicians. As other HIV/AIDS prevention products become available, such as female condoms, appropriate virucides, and STD and HIV/AIDS drugs, social marketing may provide a more efficient means of delivery than traditional public health systems. Marketing Prevention Throughout the world, advertisements for toothpaste, soap and cars show happy, attractive people seeking to enjoy the thrill of being alive, conspicuously helped by the product of the moment. The same approach has made condom use less problematic in areas with strong social marketing programs, and it could also be used to promote less tangible "products." HIV/AIDS prevention programs need to tap the power of the media to influence behavior by marketing healthy sexual behavior as an attractive lifestyle. Changing Norms Condom social marketing has a positive impact on social norms, but the degree to which it does and mechanisms through which it operates are not well understood. From Brazil to Ethiopia to Nepal, AIDSCAP evaluations have found evidence that individual sexual behavior is changing. It is likely that condom social marketing and other HIV/AIDS prevention efforts are contributing to more long-term changes in social norms as well, but it is too early to detect such change. The experience of family planning programs in reducing fertility rates in many countries during the past 30 years, however, shows the potential for normative change through social marketing. Investing in Condom Supplies Meeting the demand for condoms created by social marketing is a major challenge. For years USAID has been the only donor providing significant condom supplies for public health and family planning programs. Although additional donors (notably the European Community and the German development agency) have recently entered this area, most are reluctant to support commodity supply -- particularly when the commodity is considered controversial. Governments in the developing world also shrink at the cost projections for adequate condom supplies. For example, it would cost a social marketing project U.S.$25 million to supply the country of Ethiopia alone with an adequate number of condoms. But experience to data suggests that investments in adequate condom supplies would save millions of lives. A serious effort to contain the spread of the virus will require political will and resources to provide enough condoms to everyone who needs and wants them. |
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