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HIV/AIDS |
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Behavioral Data Collection in HIV-Related Risk Behaviors |
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To respond promptly and effectively to the HIV/AIDS pandemic, complete and reliable information is needed about the attitudes, beliefs and practices of communities at risk, particularly about the sexual and drug-taking behaviors that can spread HIV. Monitoring changes over time in these behaviors and attitudes is essential to maintaining appropriately-designed programs. Different data collection methods deliver different results with varying degrees of cost and complexity. To use resources most efficiently, a national program must decide what mix of methods to adopt, with what frequency and on what scale. These choices will reflect the country's political and social environment, its research capacity, available resources and the stage of the country's epidemic. Recommendations have been developed for a set of minimum behavioral data collection efforts for each stage of the epidemic. These recommendations assume that HIV sero-surveillance is in place or being developed according to the joint United Nations Programme on HIV/AIDS (UNAIDS)/World Health Organization (WHO) guidelines for second-generation HIV surveillance systems. Drawing on the experience of several organizations and countries in collecting behavioral data, these recommendations are intended to help national programs set up efficient behavioral assessment and monitoring programs to assist in program design, direction and evaluation. The main objective of the recommended behavioral surveillance systems is to use a consistent sampling strategy in multiple rounds of data collection to track trends in key indicators over time. Several HIV-related behavioral data collection methods and instruments have been standardized; all collect information necessary to calculate standard indicators listed in the UNAIDS publication "National AIDS Programmes: A Guide to Monitoring and Evaluation." The choice of methods and instruments depends on one's data collection needs. Two general approaches to quantifiable behavioral data collection exist. One approach used for general population surveys (such as in the General Population AIDS Indicator Survey and the UNAIDS General Population Survey) is based on household sampling, where respondents are recruited from households. Specific applications are tailored to meet national objectives with respect to geographic coverage or age stratification. The second approach is more suitable for observing persons who are not adequately captured in general household surveys and whose behaviors may put them at a particularly high risk of HIV infection. Examples include commercial sex workers (CSWs), injection drug users (IDUs), men who have sex with men (MSM), out-of-school youth, and military or migrant populations. Behavioral questionnaires for these groups use sampling strategies based on mapping and on previous efforts to obtain access to these groups (behavioral surveillance surveys). Preliminary assessment. Developing any system of behavioral data collection should begin with a careful preliminary assessment of the behavioral situation. The assessment will have several components: a review of existing behavioral studies and data sources in the country, a rapid assessment of risk behaviors, mapping of where the risk is and who is at risk, and formative qualitative research to identify opportunities, barriers and appropriate approaches to promoting behavior change. Rapid assessments, mapping methodologies, and qualitative research approaches are especially relevant when studying risk behavior in hard-to-reach populations about which little may be known. These methods both complement the formative evaluation efforts and help prioritize prevention activities. These approaches -- review, rapid assessment, mapping and qualitative research -- deliver two major benefits:
Without this information, developing relevant prevention programs is difficult if not impossible. Qualitative approaches are particularly valuable for prevention program designers because they allow respondents to express their own concerns, rather than just respond to concerns expressed by the researchers. If such information is applied intelligently, it is likely to spur prevention programs that are more appropriate for particular communities. Behavioral data collection in a low-level epidemic (less than 1 percent prevalence in the general population and in high-risk groups). In low-level epidemics -- where the risk of HIV infection is likely to be concentrated in those with higher levels of risk behavior -- HIV prevalence studies should focus on those with higher risk behaviors. Depending on the country, these persons might include CSWs and their clients, IDUs or MSM. But because risk behavior also may exist in the general population, the links between higher- and lower-risk populations should be investigated. At this stage, collecting information on behavior can uncover potential flash points for HIV infection and raise public awareness of the dangers posed by not taking action to keep HIV prevalence at low levels. It also might suggest what must be done and for whom. Behavioral data collection in a concentrated epidemic (less than 1 percent prevalence in the general population but more than 5 percent prevalence in high-risk groups). In a concentrated epidemic, HIV may remain confined to circles of people with higher risk behavior because there are few links between those groups and the general population. It may remain concentrated because there is little risk behavior in the general population. Or, where links and generalized risk behavior may exist, HIV may not have infected a sufficient number of individuals to cause explosive growth. In that case, it may be just a matter of time before the epidemic becomes generalized. In a concentrated epidemic, behavioral data collection is critical when determining which of these scenarios is the case and when designing and measuring the success of appropriate interventions. At the concentrated stage, countries should continue sero-surveillance activities in the groups where infection is concentrated and begin monitoring HIV in the general population, especially in youth. Used together, serological data and behavioral data can produce a clearer picture of the epidemic. Behavioral data collection in a generalized epidemic (more than 1 percent prevalence in the general population). Groups with particularly high levels of risk behavior may continue to drive new infections in a generalized epidemic, but the pattern of HIV spread goes far beyond higher-risk individuals and their immediate partners. By the time an epidemic becomes generalized, the major risk behaviors are usually clear. Systematic and repeated behavioral data collection in the general population is essential when explaining changes in prevalence and when tracking changes in behavior over time. It must also focus on identifying risk behaviors that have been neglected or that have not responded to prevention efforts. Resources
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