MICHAEL: This session is organized with three principal objectives. Firstly, to put a spotlight on the impact of the HIV epidemic on youth around the world. Secondly, to assert that the die projections for the future scale of the HIV epidemic are not irreversible. And thirdly, to focus on the seemingly obvious but often undervalued fact that reversing those trends depends mostly on effective behavior change. So our aim here today is to for the purpose of discussion to illustrate the potential impact of targeted behavioral interventions on HIV incidence and to examine what we have learned over the past 20 years of the HIV epidemic about effective strategies for behavior change and how to measure their effectiveness. And to help us to do this today we have assembled truly stellar cast. And first it is my pleasure to introduce to you the President and CEO of the Kaiser Family Foundation, Dr. Drew Altman.

DR. DREW ALTMAN: Thank you, Michael. Thank you all so much for coming. We just did a press conference in which absolutely nothing worked. So I know everything will work today just perfectly. We have a really important presentation to follow from David Harrison and we have an absolutely wonderful panel here today so I am going to try and be brief and be really a table setter today. The charts that you have in your packs – you have a little chart pack you should look at. They’re also up here – underscore why we organized this session. HIV is increasingly an epidemic driven by youth – a youth-driven epidemic. And so HIV prevention for young people needs to be a top priority as part of a comprehensive approach. Over half, that’s over half of all new infections in 2001 were among children and teens and young adults under 25 years of age. More than four in ten younger people, 15 to 24, 16% under 15. A youth-driven epidemic. That’s the first point. Mostly younger women and girls. Mostly younger women and girls. Very important to keep in mind.

The second chart is also important. In many hard-hit countries, if not in most of the hard-hit countries, the population is disproportionately young. It is the combination of the high infection rates among young people and the more youthful populations that really creates an explosive situation that really is the basis of the problem. And it results in – you’ve been hearing lots of troubles and frightening projections, I know, at this conference. It results in this new projection which we released earlier today at the press briefing which nothing worked. Based on U.S. census data – brand new data – that are part of a comprehensive new report we’re putting out on Tuesday at 1:00 on youth and HIV. There are an estimated 13 and a half million young people, between the ages of 15 and 24, living with HIV today. If we do not do more to change the trajectory of the epidemic, if we don’t act to change things, there will be 21 and a half million young people living with HIV in 2010. And so it’s just – I think it is just obvious from these numbers that we need to make HIV prevention for young people. We really need to make it a top priority. And I think this means developing a whole new generation of HIV prevention programs that build on and take to scale the most effective prevention programs we have today. This is reaching young people, developing these programs – effective programs – is not easy. My daughter, Jessica, is in the room, and I promise you she always listens to me but she’s the exception, not the rule. It’s hard – Michael said “Yeah, right,” or she did. It is not easy. It is a challenge. Lectures don’t generally work. The scare tactics don’t often work. Young people aren’t terribly trusting of government or any establishment institutions. They don’t generally like to go to clinics. But they do listen to their parents, especially when they’re younger. They’re heavily influenced by other young people when they become teens. We do know how, and we’ll talk about that in the context of LoveLife, to make clinics and other health services more youth-friendly. And most especially, they are heavily, heavily influenced by media in all of its forms. And so for this reason at Kaiser for many years, we have been working in close partnership with major U.S. media organizations, including MTV and VET and Univision and the magazine Seventeen and many, many others to conduct the largest media-based sexually health and HIV prevention campaigns for youth in the U.S. These campaigns – we have lived with them now. They have really touched a nerve. For example, over a million young people have called the hotline as a result of these campaigns in just a short period of time. And so we’re going to focus on South Africa today. But just to make the point that this is a universal challenge. Thank you, Michael. That this is a universal challenge, including in the United States, to make the point that we need to do – there are a lot of things society is squeamish about, as you know. But we need to do what it takes to connect with young people if we are to be successful. And also, in a serious discussion, like this – just to lighten the mood in the room a little bit. I thought I would close by showing you two messages from our current campaign with MTV in the U.S. The first of which, by the way, I’m happy to tell you recently won the National Academy of Television Arts and Sciences Award for the best PSA this year. I will show this to you. I will say goodbye to you. Thank you. And when they’re over, I’ll turn you back over to Michael, I imagine. I declare we’ve had no technical problem.

COMMERCIAL:

FEMALE SPEAKER #1: Every one of your partners had sex with.

MALE SPEAKER #1: It will be quick, right? There’s a bunch of other people I need to have sex with tonight.

FEMALE SPEAKER #1: Protect yourself. Use a condom. To get more information on safer sex call 1-888-BE SAFE 1.

DR. DREW ALTMAN: There are two messages you saw at the left. Two seconds of the second one.

MICHAEL: Why don’t we move on. I think you get the general idea. And we’d be happy to give you the tape if anybody is interested. The report to which Drew referred will be released on – officially released on Tuesday and will be immediately available on the Kaiser website. Hard copies will be available in due course. We’re now going to turn to the very specific and to a program in which we, as the Kaiser Family Foundation, obviously we have a very direct interest. What we presented here in the hope of illustrating a much broader discourse around the need for targeted behavioral interventions in the effort to stem the HIV epidemic among young people. So I introduce to you now, Dr. David Harrison, who is the CEO of LoveLife from South Africa.

DR. DAVID HARRISON: Thank you very much. Before I start I’d like to introduce you to some of our young people that have joined us from South Africa and form the LoveLife team. Literally in ten seconds each, would you mind just introducing yourself. Starting with you, Tina. Just stand up and say hi.

TINA: Hi, everyone. I’m Tina from South Africa. [several inaudible words].

FEMALE SPEAKER #2: Hi, everyone. My name is [several inaudible words] that have dedicated to making a difference in the life of other young people out there. Thank you.

MAYAN SHEETH (MS?): Hi. My name is Mayan Sheeth. I’m one of the Central Groundbreakers, which is a TV series – reality TV show getting out to all the youth there.

GAMO HANO (MS?): Hi. My name is Gamo Hano (MS?) from Cape Town, South Africa. I’m one of the students in the (MS?).

DJ: (MS?) My name is DJ. I’m one of the positive icons of South Africa.

MALE SPEAKER #2: Hello. My name is (MS?). I’m one of the [several inaudible words].

DR. DAVID HARRISON: Thank you very much. Assertiveness is one of the traits of LoveLife as you’ve obviously seen. I really one to make five points this afternoon. I’d like to show some evidence that HIV prevention can work in generalized epidemics. But the question is how. What programs make a difference? Secondly, to boldly state that LoveLife has got few excuses for failure. Third, I’d like to make the case for design of prevention for young South Africans and I’ll explain. Fourth, that projections to date point to high returns. And fifth, there is early evidence. We’re not coming here claiming success of a program. But there’s early evidence, based on intermediary indicators that we’re at least on the right track. I think the evidence as it stands at the moment is that discrete interventions like VCT sexually transmitted infection controlling and condom use have been shown to be cost-effective. And a lot of these examples have come largely from countries in which the epidemic is concentrated all from high-risk populations in more generalized epidemics. We’re beginning now to have some sort of quantification of the impact of behavior indicators. Studies that are beginning to show the relative impact that reduction in the number of partners is having. The effect of condom use delays in the onset of sexual debut. And that in turn has helped us to really finesse our modeling. We’re able to say that if these behavioral mediators follow a projected part this is going to be the impact. Despite that there are very few national success stories and even worse, we’re not quite sure what makes the difference. And that’s really, I think, the importance of presenting LoveLife to you as a case study today. In that it is a large national intervention that meets many of the critical successor factors for success. And just given the fact that the epidemic is so advanced, both in South Africa and around the world, we don’t have the luxury to wait until we have definitive evidence of prevalent declines. We must be willing to show work in progress. And that’s really the spirit in which we’re presenting the study this afternoon.

LoveLife meets many of the criteria for success. Many of the factors that are regarded as critical for success and are real problems for other countries trying to implement successful programs, we have very high level of public and political supports. We do have a strong diverse funding base, although our needs are projected to double within the next three years. We have major cost-sharing partnerships with, for example, the South African Broadcast Corporation, the National Railways, the two largest prints media in the country. And LoveLife in two and a half years has managed to attain unprecedented scale and scope. We’re really putting it forward as an example that has got few excuses for failing, if in fact its assumptions are correct. I’d like to make a case for brand driven, a design of prevention for young South Africans and design of prevention, both in the sense – the medical sense of design of (MS?) that is very targeted, but also in the sense of designer jeans. The evidence is and these are projections, but really based on H & Nat’l surveys in South Africa that we can at least say that the rates of increase in HIV prevalence in South Africa is beginning to decrease. We – the infection is maturing. And the incidence appears to be reaching a peak in many of these age groups. They’re obviously lots of limitations and lots of qualifications that needs to be put on extrapolation from H & Nat’l surveys. But let’s assume that this is correct. But still, we see that new infections amongst young people is sustaining this epidemic. It’s sustaining the prevalence at one in four sexually active South Africans. The highest rate of new infection for girls is in the 15- to 20-year age group. The highest rate for boys is in the 20- to 24-year age group. By the age of 25, 60% of new infection has happened. And this coupled with the fact that 42% of the South African population is under 18, we have this huge youth bulge moving through becoming sexually active now just at the time that the epidemic is peaking. The consequences that over the course of their lifetimes, the cumulative probability of infection for a young person age 15 or below, is now about 50%. If we’re going to do something about this epidemic, if – even if it is starting to plateau, but if we’re going to truncate that plateau and start to bring about significant declines, we have to go to the main point of infection. We have to starve this epidemic of its oxygen. And that means stopping young people from getting infected. If we can stop or significantly reduce the infection rates amongst successful cohorts or young people we will make a huge difference in this epidemic. And this epidemic and the type of incidence graph that I’ve shown you is driven by the high-risk sexual behavior of young South Africans. The median age of first penetrative sex is about 16.8. Fifty percent of young South Africans have had penetrative sex by that age. Half of sexually active teenagers say they’ve had more than one partner in the past year. And you can see that there’s actually a very long tail of a significant proportion. Twenty percent of 15- to 17-year olds who say they’ve had more than three sexual partners. Ten percent who say they’ve had more than ten sexual partners. And erratic condom use. So those 60% of young people say they used a condom in the last sexual encounter. You can see when we ask them over the course of the last year, roughly the same numbers of young people say they never use a condom, they occasionally, they always used a condom. And have a look particularly in the younger age group where among 14 years of age, almost half say they never used a condom. And this is even more marked amongst sexually active young women. Thirty-eight percent of 12- to 14-year olds who’s sexually active say they – that they never use a condom. And there’s a very strong association between transactional sex and age of sexual debut amongst young women. And we can see the dynamic behind this is all the men forcing or coercing girls – young girls into having sex without a condom. What – I mean this is obviously on the one hand – this is what’s driving the epidemic. This is why we have such high rates of infection in South Africa and why it will be sustained unless we can do something about it. But this skewed risk profile – heavily skewed towards the high-risk side also provides an opportunity for intervention. If we can bring about a moderate shift in the risk profile of young South Africans – if we can take this curve that is so heavily skewed towards the high-risk side and move a substantial member of young people towards less risky sexual behavior, we have the opportunity to dramatically reduce the high-risk infective pool.

To a large extent, lifestyle factors predict sexual behavior. Gender, education, income, age determine whether or not young people are going to have sex or not. But there are also factors that are immune to intervention that determines some of the – that predicts some of the major behavioral mediators. For example, a sense of optimism, a sense of perceived happiness is a predictor of the age of sexual debut of young people. And you can see it. Young people who have a sense of the future have the sense of a life in ten years’ time tend to protect themselves. Where those young people who feel that they’re in a spiral of pessimism and poverty that put themselves at risk. We’re not surprised by that statistical finding. Coercion in relationships, girls particularly feeling compelled to have sex is a major predictor of the age of sexual debut. And we’re able to demonstrate that open communication with parents is a protective factor. So these are – this is really getting behind those behavioral mediators that I described. This is what is driving young people to the high-risk sexual behavior. LoveLife is a new lifestyle brand for young South Africans. Lifestyle because of the factors that I’ve described. Brand driven because that’s young people’s headspace in South Africa. High media coverage, sophisticated marketing environment. Young people who very brand loyal, very brand aware. And so LoveLife competing for their attention with the Nikes the Soviets the Guess, the Diesel for the attention of young people. That is the terrain in which we are operating. And like any brand, we need to have both the advertising but we have to have the product and the service delivery. Got to have a real experience for young people. And so we combine on the one hand a high-powered media campaign using a range of media with a nationwide drive to develop adolescence – appropriate adolescent health services outreach and service programs. The integration of the two is absolutely critical. The media strategy needs to be backed-up by a way in which young people can interact with the media. And that’s where the sexual help lines – the free sexual help lines is very important.

The LoveLife Y-centres that really serve as regional hubs for a lot of our other services – multi-purpose youth service – multi-purpose youth centres situated around the country mobilizing the angio-sector through the LoveLife franchise program. Mobilizing young people themselves. Some of the young people you’ve seen today who are LoveLife Groundbreakers participating in a year-long program of personal development coupled with task-specific training enabling them to run most of the LoveLife programs. There’re currently 350 young people full time in that program and we hope to be at 600 by the end of next year.

At the heart of our work is working with the public sector health facilities, clinics, trying to make them more friendly, more able to respond to the great demand of young people for appropriate services. Those are the institutional platforms that we use backed up and supported by outreach where we don’t have an institutional base. The LoveLife Games which is the largest interschool sports development program in South Africa that we’ve combined leadership development, debating, arts, culture, drama into festivals of lifestyle that are enabling young people from the most rural areas of the country who’ve never ever been on a tarred road before to participate in a festival that is really about the future, the choices that they need to make and be able to fulfill their aspirations. And then we used to have a quite unique outreach vehicles to other broadcast units that link-up with mainstream radio but now broadcast from deep rural areas of the country run by Groundbreakers and the same set of thing with the loveTrain, a big, purple train with a radio studio run entirely by Groundbreakers who use the train as the base. It’s a tremendous draw card for young people but then get into a lot of schools.

At the moment – well this was at the end of two years. In November 2001, 62% of all young South Africans 12 to 17 had been exposed to LoveLife. This is national probability sample survey of 2,200 young people household based, with a sampling error of about 2%. Notes that there is – while we have very good rural urban spread, we’re out across the country – 62%, 61%, we still have a challenge getting to the poorest households – 58% of poorer households saying that they’ve been exposed to LoveLife versus 67% of those that are wealthy. And so for us, given the fact that income is a predictor of sexual behavior, we have to have even more of an all-out strategy to get to those poorer households that are located in both urban and rural areas. Most young people say that they identify strongly with LoveLife. Three quarters saying that it made them think about safer choices, that it was different, innovative, that it reflects the aspirations in lifestyle. The challenge of communicating with young people is probably manifested in 24% who say that it was boring and they weren’t interested. And we really see this as a challenge despite the fact that it’s a huge percentage of young people find this incredible attractive, there is a group of young people that is still challenging for us. A bit of a – I guess it’s a bit of a “up yours” syndrome that we’ve got to deal with.

Behind the design of LoveLife are a few points that I’d like to highlight. And this is really sharing with you some of the major insights that we have learned over the past two years. The first is that even in a comprehensive national prevention campaign you need to target. You can’t have a single communication strategy aimed at a 13-year old and a 25-year old. And so homing in, designing a strategy that is going to be most attractive to specific segments of the population is really critical.

Secondly, tap into their aspirations and not their fears, are described motivation, a sense of optimism as being one of the factors predicting sexual behavior. And so while there’s obviously a place for making it clear that HIV leads to AIDS and leads to death, it’s very, very important that young people do have a sense of aspiration, the sense of the future. The importance of encouraging South Africa to talk about it. Open early frank discussion of sexuality, being the starting point, not enough, but the starting point to addressing the epidemic.

Moving away from the didactic, “you must do this – abstain or burn in hell” type of approach to one that is around understanding what is shaping young people’s behavior and providing them with the options and explaining the risks associated with that and then allowing young people to engage with themselves and with each other about the messaging.

And then finally, as I’ve said, behavior change needs to be a total lifestyle experience. We’re talking about a fundamental change in the norms of young South Africans. And it cannot be simply a case of services of simply media. We have to have a comprehensive national strategy targeting young people. I’ve described that. The fact that in South Africa brand awareness coupled with high media penetration is such a feature. You can see that young South Africans, almost 90% of them, say that they are very happy or somewhat happy with their lives. Forty-five percent of young South Africans saying that the opportunities are limitless. Twenty-six percent saying that there are limited opportunities. But there’s a significant proportion. Twenty-nine percent of young South Africans who say they’re opportunities are very limited. Similarly, 13% of young South Africans who very unhappy. And we know that there’s a very strong correlation or there’s a strong correlation between young people’s sense of happiness and their sexual behavior.

What or probably is the most predominant action that young people take as a result of LoveLife is talking about it – talking to their friends, talking to family and others, looking for more information on sex and sexuality. And among the 60% who report of having heard of LoveLife, nearly three out of five say that it has prompt them to talk to their family and to others. And parents as well. This was at the end of two years. It was just before we ratcheted up a big parents campaign. There was only a 40% knowledge of LoveLife amongst parents. But look at that. Eighty-two percent of parents in view of LoveLife say that it provided them with an opportunity to talk to their children about HIV-AIDS. Seventy-one percent say that they have provided them an opportunity to talk about sex.

Roughly half percent of (MS?) or roughly 50% of all South African young people or 75% of those who know of LoveLife say that they have taken some action as a result of LoveLife. And just to really re-emphasize the importance of multiply reinforcing strategies aimed at young people. You can see here that 60% of young people who know of LoveLife have been exposed to more than four of LoveLife’s products. And this for us is critically important to create the sense of – when you switch on your television, there’s tons of Groundbreakers. When you read the newspaper, there’s (MS?) to prints. (MS?) means to talk about it. When you turn on your radio, it’s (MS?) twenty. When you interact in the LoveLife Games, there are Groundbreakers participating. And that’s what we mean by this multiply reinforcing brand presence for young South Africans.

I’ve presented to you some of the intermediary indicators that we’re using to track changes over the next five years. Obviously it’s only going to be, in five years’ time, that we can look back and say that the incidence of HIV has declined sharply. But we have to track, in the meantime. And so by using a combination of this market indicators that I’ve described together with tracking changes in the behavioral mediators that I’ve described, the predictors of sexual behavior. We hope that we’ll be able to demonstrate trends that at least indicate to us that we are on the right track. All that I’ve suggested to you today is that at least there is a very strong and growing sense of positive association with the positive lifestyle message that LoveLife is trying to put across. Young people are beginning to relate HIV-AIDS with positive, safe sexual behavior. It is self-reported. There is undoubtedly over attribution to LoveLife and we want to be the first to acknowledge that. But I think that if these findings are correct or at least half as correct, it does point to substantial changes in the course of epidemic over the next five to ten years, provided that we can sustain that effort.

We’ve done a little bit of modeling based on internationally precedence in South African base lines to get an inkling of what sort of impact we’ll be able to attain. And I want to comment from two angles. One is tracking changes incrementally over the next five years for one cohort of 15-year olds. We couldn’t develop a model that was comprehensive or dynamic enough to demonstrate the interactive effect of changes of all young people. But we’ve simply taken one cohort of 15-year olds and tracked the – and projected the number of infections averted based on where we are at the moment with respect to a number of behavioral mediators. And the behavioral mediators are – and here I’ve just shown you the five-year outcomes. Obviously our modeling is done from year to year and showing incremental change from year to year but the indicators that we used was the percentage of young people who say that they always used condoms in the last sexual encounter and in the last year. The percentage of young people who report multiple partners. Secondly, abstinence. Those who say that they have stopped having sex even though they previously were sexually active. And the percentage who are not sexually active. And we’re having a look at the number of infections in that cohort from year to year. The dotted line reflects the situation if there were no intervention. Obviously the highest number of infections starting early one amongst girls 15 to 20 with a decline amongst 20- to 30-year olds. The intervention demonstrating that the impacts if LoveLife were to be able to attain the changes in the behavioral mediators that I’ve described. And the black dotted line indicating the number of infections averted. This is for girls. You can see the impact is most marked amongst 15 to 20-year olds. A different sort of graph for boys where consistent with the HIV incidence curve, you can see that the impact would be most marked in an old age group. And I would like to come back to that.

What these graphs do show is that – I just want to go back – what these graphs do show is that for that single cohort and assuming no interaction between that cohort and other groups, there will be an 18% reduction in the number of infections – 18% to 20% reduction for that cohort, I’m told over a 30-year period.

We did central cost analysis based on what LoveLife is spending at the moment. We believe that we need about five or six dollars per young person per year in our target group, should be most effective. And, obviously, even for this very, very conservative estimate of benefit/costs, we find that the benefit/cost ratio is about two to one. This is all piecemeal and partial and I’m not trying to make a huge thing of it except to say that we’re beginning to demonstrate, based on the experience of Uganda, other countries, and based on out tentative evidence of change that there is the potential for a significant decline in the numbers of infection. And if we can beat the deadlines, if we can achieve even greater impact than that incremental decline in the two to three years, that’s going to have an even more compounded effect because what’s your doing is taking a significant number of young people out of the high-risk pool immediately and putting them into a low-risk pool. And so what I’m trying to demonstrate here, and this may not be as highly realistic, but the importance is of getting a national campaign up to scale effective as rapidly as possible. If we wait from year to year, we are going to result in a huge number of unnecessary infections occurring. That is the mindset of LoveLife to try and achieve the scale and scope that is needed as rapidly, as quickly.

Finally, some of the evidence suggests that there is the potential for significant change by 2007. Three quarters of young people exposed to LoveLife say that LoveLife has caused them to be more aware of the risk of unprotected sex. Sixty-five, two-thirds say that it has caused them to delay or abstain from sex. And the effect is even more marked amongst sexually experienced youth where four-fifths of young people who’s sexually active exposed to LoveLife say they’re now more consistently use a condom when having sex or they have reduced the number of sexual partners.

There’s a significant difference between young people exposed to LoveLife and those not exposed to LoveLife in terms of they’re reporting that they have changed their sexual behavior as a result of LoveLife. Our goal is to try and hold the rate of new infection of HIV and significantly reduce sexually transmitted infection and pregnancy in 15 to 20-year olds within five years. I think the evidence that we presented to you tend to though it is suggests that we are at least achieving a high level of affinity between young people and LoveLife. And if we can sustain that association, and if these reported findings are true, we are on track to affect the target declines that I’ve demonstrated. Thank you very much.

DR. ROBERT FULOVE (MS?): Good afternoon, everyone. I’m Dr. Robert Fulove from Columbian University in New York City. Those of you who have a copy of this program see that what we’re about to begin now is a panel discussion that has as its title “HIV Prevention Among Young People Resurrecting Behavior Change.” David’s presentation was intended to be a case study. It was an effort to demonstrate what it’s possible to do in the area of targeting projects directed at behavior change for young folk in a country that is facing some of the worst damage imaginable from the HIV epidemic. For this afternoon, for the rest of our session which will go until 4:00, we would like to think about this problem globally. Not just in South Africa, but all over the world, where young people, as has been stated on a number of occasions, are an increasing risk for this – for being exposed to the virus. What we would like to do is have two speakers make very brief presentations. And then because our intention is to talk with you, not just at you, we’d like to open the floor for comments, for questions and for observations so that we have a true exchange, if you will, about next steps to take in resurrecting behavior change. The two folk I’m going to ask to speak are Dr. Judith Araback (MS?) who’s from the National Institutes of Health in the United States and Dr. Bernard (MS?) Schwartzlanden (MS?) who is from World Health Organization. Dr. Araback.

DR. JUDITH AUERBACH: Okay. I have to begin with a cap here as people like me often do. And that is to say that today I’m actually going to speak as a sociologist almost as myself for a change. And the comments I have to make should not be construed as representing those opinions as the Federal government of the United States or my particular agency, the National Institute of Health. At least not necessarily. What I’m going to do is go from the specifics we’ve made and presented back out to the much more general and take on this issue of resurrecting behavior (MS?). And I’m going to do this from two angles that are relevant to the kind of work that I do. The first – and that I think its of interest to those of you who come more from the science community here. The first is the issue of behavioral science in the context of the (MS?) or the dominant of biomedical models. And the second is this question of individual behavior change in the context relative to macro-social – a much larger social reality.

After 20 and more years of the HIV/AIDS epidemic, we now have a robust scientific literature establishing the ethicacy of psychosocial, behavioral and social change interventions for reducing sexual risk of HIV transmission among youth and among other folks and infection by affecting one or more of the following sayings. Any many of the things I’m going to say will resonate with what David had said more specifically. We’ve had interventions that reduce sexual risk by affecting one or more of the following things: delaying the onset of sexual intercourse, the sexual debut; reducing the number of sex partners; increasing condom use, of sexually correct and consistent condom use; and developing supportive policies and programs. Those interventions have taken a number of approaches. You should be familiar to most of you. Individual and small group counseling about protective strategies, educational workshops, like say sex workshops, popular opinion leaders, peer based and network interventions to change social norms about risk behaviors and social marketing to name the most common approaches. And these interventions, approaches themselves are based on basic and theoretical work in the behavioral and social sciences that emphasize a number of things. Knowledge about specific HIV and AIDS transmissions risks, motivation to protect oneself and one’s partners, outcome expectancies if I do this, then this will follow, skills required for engaging in protective behaviors, the ability to maintain protective behaviors over time, social support for protective action, social movements and collective or community action. And some of the models you hear named are health belief, reason to action, information motivation, phases of change, the fusion of innovation. You rarely hear about social movement and collective action so I’m going to say that twice. And given that these models and approaches are about behavior and social classifies, it does, in fact, make scientific sense that the outcome measures for these interventions that derive from them are also behavioral and social indicators such as those mentioned earlier by David. For example, age at first intercourse, increased or decreased in sex partners, increase or decrease in condom use. However, given that the ultimate goal that these interventions that are HIV preventative interventions is in fact to prevent HIV infection by a logic outcome, behavioral outcomes are easily rendered intermediate mediators and often insufficient at least as a matter of scientific evidence in the work of HIV prevention.

Moreover, the methodologies that are employed in those interventions rely on self-report. You heard David be a little apologetic about that as most people often are. And there’s much skepticism, as we all know, about the veracity, the truthfulness of such self-reports, especially amongst the biomedical science community. And this is really the crux of the issue, the fact that HIV prevention research, for the most part, takes place in a biomedical context and it’s funded by biomedical institutions such as the one for which I work. Thus the rules of scientific evidence that are applied to behavior and social science based interventions are really not their own rules but rather those imposed by a biomedical paradigm that valorizes and celebrates a particular methodology specifically to randomize control trial which maybe quite – is quite appropriate for biological and clinical research, but it’s celebrated as the gold standard for all health research. And it’s the standard to which all health research is expected to aspire.

So the question raised by David’s analysis in this first set of comments is under what circumstances can we arrest HIV prevention back from the controls, the biomedical model, and return it to its rightful behavioral and social science origin? Is it when we have a generalized epidemic and we don’t have the luxury of time or resources to conduct randomized control trials? So sort of a default (MS?)? If behavioral interventions and behavioral outcomes are combined with modeling and forecasting data, the kind of analysis that David was talking about, is that sufficient evidence for action? Action being further implementation and scaling up.

So this brings me to the second point I wanted to make or the second angle, which is about individual behavior change and larger social change. Over time, more and more people have come to recognize that HIV transmission is essentially and almost always a relational phenomenon. That is, it involves two people in behavioral interaction. And that interaction, of course, takes place within larger social and cultural context. Some people and groups are indeed at greater risk of infection due to a number and usually a constellation, a factor that operates at the macro level, such as poverty, gender inequity, social dislocation, structural violence, ethnic discrimination. And these macro social conditions are, in fact, likely of what underlies the specific determinates of predictors of risk behavior and risks that David mentioned earlier. For example, one has to ask the question, why is there coercive sex? Why do people have more sex partners under certain circumstances than others? Why does a young girl engage in sex earlier than she might otherwise? Some would further more argue that absent major social transformations that would change these kinds of larger social factors efforts that focus only on HIV prevention are futile. And, of course, this is an age-old dilemma that people have been dealing with for – in many arenas in the world of economic development programs, in reproductive health programs, family planning programs, and so on. And usually we resolve to keep at the work on a relatively micro level, even as we participate in struggles for greater social change. Else we do nothing meanwhile, and the problems get worse.

Now, in the case of an infectious disease transmitted from one human being to another, chiefly through behavioral interactions, we can never give up on addressing behavioral change at the individual, couple, network and community levels. The LoveLife program that we just heard a lot about seems to me to be one that attempts the micro/macro dilemma by helping to create a positive and supportive environment and culture for youth in South Africa in particular. While at the same time focusing on a specific behavior that are most relevant for HIV risk and protection and employing the strategies that are very well documented in scientific literature from the behavior and social sciences. On this issue, the question is, can individual behavioral change outcome combined with the kinds of social and marketing indicators that David mentioned, provide sufficient evidence for action, again absent brand in mind control trials or in conjunction with some brand in mind control trials. Ultimately on both issues of behavioral change in the context of biomedical paradigms and behavioral change of individuals in the macro social context, in my mind, the real question is – the real question about what constitutes sufficient evidence for HIV prevention is who gets to decide? (MS?)

DR. ROBERT FULOVE: Thank you. Bernard.

DR. BERNARD SCHWARTZLANDER: Thank you. (MS?)

DR. ROBERT FULOVE: (MS?)

DR. BERNARD SCHWARTZLANDER: This one.

DR. ROBERT FULOVE: (MS?)

DR. BERNARD SCHWARTZLANDER: Okay. I feel a little intimidated sitting here with so many friends sitting in the room watching the front line fighting this battle, especially with young people. And I feel especially intimidated having a quite of outstanding young people sitting on the other side of this table and I would like to switch because I think I would like to learn, to hear from you, what you’re doing and how successful you are in your fight and what your struggles are. I hope that in the discussions we can actually reverse as in a little and also involve those that are at the front line to participate reactively and let us know what works, what doesn’t work and what makes a difference.

I’m going to be very, very brief in my statements and actually want to say only a few very broad things. One and I think that has come out already, young people are the future of out societies. It’s actually no question that if we can’t get a good and healthy start in adult life hood for the younger generations that this will be – we will see a burden of the epidemic which we could not imagine or cannot imagine yet. We have first indications, of course, when the countries that are hardest hit but big, big [several inaudible words] with the high infection rates that we’re already seeing but clearly none of this is inevitable and we can change this around.

The other statement that I would like to make is young people are the biggest challenge with this disease. And what is much more important, they’re the greatest hope in the fight of this disease. The challenge because they are by far the most vulnerable. Let me just give a few more examples to those that have been given already by the very impressive presentation and true that we saw. To give examples around the world which underscore, underline what has been said here. Studies show – study that has been undertaken (MS?) that more than one third of all sex workers are teenagers – they’re less than 20 years of age. If you go to Russia and look into injecting drug users with HIV, it was just a handful in 1995. This number has risen to more than 10,000 by now in young people – again less than 20 years of age. These are children still going to school basically in these societies. Similarly, study has shown – a study undertaken in Latin America looking into when actually drug injectors start to shoot drugs. Seventy percent started shooting drugs before by the age 18. And 20% by the age 16. So this is an issue of young people. In Africa we have seen some of the data. Young girls coming to (MS?) clinics to give birth to a child. Again less than 20 years of age. Up to 30%, 40% in some communities carry the virus which certainly is not a good start in adult life.

And when we come to the more important part of this message – yes they are vulnerable, and we know that. But I truly believe and I would like to sort of build up on their case that Drew has given to use. They are the opportunity for change. And I think it’s really important, to not only realize, and some of the (MS?) data that Drew has presented to us may actually be misunderstood as the young people are the burden of the epidemic because most infections happen in young people. This, of course, should not be the case. Young people have a chance. They are infected because they don’t have the knowledge. They don’t have the means. And they don’t have the environment in which they can change behavior. But we have evidence from one study – from one country to another – from one society and other, that if we actually empower young people to change behavior, they are the ones to change behaviors first much more than the older generations. They’re much more willing, much more able to change their behaviors and therefore, contribute to really turning this epidemic around and I have (MS?) in all countries that we have seen this success. I would like to stop with that.

DR. ROBERT FULOVE: Thank you. Well, as promised, we have approximately an hour to have what I hoped would be a fruitful exchange between those of you in the audience and members of the panels, whose names are given on the programs and who I’m about to introduce about your thoughts, your feelings, your projections, your notions of what we need to do to get started with the business of resurrecting behavior change. So, if I may, I’d like to open the floor for comments, questions. Over here.

AUDIENCE #1: [several inaudible words]

DR. ROBERT FULOVE: We need to get to a microphone.

AUDIENCE #1: [several inaudible words] I would like to know how maybe in some of the young people, how far you think these sort of approaches could be replicated across the region and those other countries where similarly success and from the panel and if you should decide question, who does decide. You mentioned a figure of five to six dollars that may be a third of some of the public health sector budgets in some of the countries. If there are limited choices, what do you do?

(MS?)

DR. ROBERT FULOVE: What we’ll do is take a group of questions first and we’ll try and get a mass response. So, with the mike?

AUDIENCE #2: Yes. Thank you very much. I come from a (MS?) one of the countries that’s been most affected, and as part of my (MS?) I’m [inaudible doing (MS?) study on HIV/AIDS intervention. What we do to off-set the perceptions of inmates and the challenges of a safe. And the LoveLife program is a very good intervention and I’d just like to find out from – if (MS?) interventions that home to intervent for youth in specials (MS?) because truly they are there because of how much (MS?) and it is often my finding that they are totally (MS?) and they are not aware of [several inaudible words] safe issues of coercions and sex. So it is very complicated but I’m just wanting to ask how can you reach [several inaudible words].

IAN (MS?): Yes. Hello. Ian (MS?) Johns Hopkins Centre for Communication Programs. I’d like to commend David Harrison and the whole LoveLife group and Kaiser Foundation. I think you’re really pushing the envelope and I love the concept LoveLife and I think you’re really doing a great job. But I wanted to point out one area. There’s been quite a lot of criticism of the mass media – various components of mass media aspects of LoveLife in the third world. I wanted to know how you react to some of that stuff and what kind of processes of pre-testing do you go through to make sure that people are understanding those aspects of the campaign? Thank you.

(MS?)

FRED: Yes. Good afternoon. My name is Fred [several inaudible words] is related to policies and long-term [several inaudible words]?

AUDIENCE #3: This is (MS?) from UNSPA. I have two; one comment and one question. My comment is related to the fact of (MS?) addressing the needs of young people in setting their HIV prevalence is still low and that’s where the maximum impact in the working epidemic could be. How do we start? How do we create the environment with all – setting up such a program. So I would like to listen more from LoveLife or from others. What kind of social change that you effort to – of enabling environment support can be created so that the cultural context is fully engaged and in accessed because that could be one of the major challenges starting off other than, of course, maintaining itself. My question is related to the dual protection role of condoms. If there is one group where dual protection makes more – most sense, it is for young people. And I would just like to ask LoveLife because I did not see any indicator though you mentioned it as a goal on pregnancy prevention as an indicator coming out of the intervention package. Thank you.

DR. ROBERT FULOVE: We have a person over here and someone – and a couple in the back.

AUDIENCE #4: Yes. My name is [several inaudible words]. I’ve a question on the very beautiful and effective program LoveLife. To what extent teachers in schools you’ve heard in the programs? Thank you.

AUDIENCE #5: Hello. I’m (MS?) from the United States. My questions has to do with – I run a fetal base program which is behavioral based called Nexstar (MS?) in New York City. Now, we’ve been doing this work for 15 years (MS?) and we’re trying to assess the behavioral interventions using theoretical basis (MS?) as it were, social modeling. And the trouble I have in the United States, in New York City, is collecting data that is necessary because of the school restrictions in the school-base program. And I could use some help, support on how are we going to overcome this in order to resurrect because I’ve been trying to resurrect or at least do it for many, many years and I’m having a lot of difficulty in a country in which we’ve known about behavioral interventions for 15 years.

DR. ROBERT FULOVE: One more and then I think we’ll try and answer the many questions (MS?). In the back. Okay. Sorry. Go ahead. Go ahead. Please.

SELMA BEARTY (MS?): I’m Selma Bearty, medical director of the Taliative (MS?) Medicine Institute in South Africa. But first of all I would like to say how excited we were. We started in 1998 to find out what LoveLife is doing. And what I’d like to ask is in the comprehensive approach, are you linking the prevention with care and support in any way because in the work we’ve been doing, we’ve been training home-based care as well as doctors and nurses. And in the home-based care field, we found that the prevention is most effective when you link it with care and support because it is integrated much more. If we very much like to be associated with LoveLife within the home-base care program. The other project we’ve realized that we need to go much further than the classical definition of terminative care, which we no longer believe is just for dying at all but we have discovered in our work in the community that the parents in the sort of general townships and sectors and so on are actually very ignorant about HIV/AIDS or causes of it. They reject their children and throw them out of the houses. They isolate them in the houses. They’re scared, dead scared of contagiousness and so we started an organization called Parents Concerned with HIV/AIDS and we are using as our strategy the same studies that we’ve used in the Apartheid struggle of street communities making parents (MS?), training them in workshops so that they will train others within their streets. We have three pilot projects. We’re hoping very much that we can work together with this very excellent media program that LoveLife are doing with well-known personalities in the media. And so we are street people and therefore, we think that it could be a very complimentary activity. Thank you.

DR. ROBERT FULOVE: Helen. This - I wonder if I could ask you to respond to that last comment as the person who is sort of responsible for doing some of the evaluation activities (MS?) LoveLife. I’m wondering whether or not you’re collecting data about the activity, the involvement of parents in the work that LoveLife is doing with young people. Is there evidence that that kind of connection is being made?

HELEN: I think that one of the obligations that we’ve taken very seriously since we’ve started the whole LoveLife program is, in fact, to monitor this because it is an enormous leap of faith that we’re taking based on evidence and based on common sense and based on morality but a leap of faith. So, again with that background we are, in fact, collecting all the routines actually can about how many people are contacted, how many people phoned help lines, how many children attend the LoveLife Games, how many go to the trains, and so on. We also then try and break that down further where we’ve got the capacity to do it so that we can start to, for example, identify the kinds of questions that we get into the help lines. So with respect to the parents question, there is a parents’ help line and we’re going to be able to break the data down and get the kinds of questions that parents are asking, the kinds of regions from the country where those questions have been generated from. And what we’re trying to do all the time is to tailor the intervention continuously to respond in some way to that kind of messaging. Similarly, we have also monitored the media but I think David will answer that with respect to your question about the media. And I think that’s also important. But I think definitely the parents are extremely important and I think – I suspect we probably underestimated when we started how important parents were but it’s come out more and more – the role of parents and adults as being critical. And I think that is something that, as you say, we already campaigning around and we will – as we go along perhaps emphasizing more.

DR. ROBERT FULOVE: I’d like to ask some of the young people who are involved with LoveLife, if you could tell us something about your involvement with parents. I know and have seen directly with what you’ve done with young people. But what about your interactions with the parents and committee? What do they have to say? What do they think of what you’re doing?

FEMALE SPEAKER #2: Well, at first, most of the parents didn’t really understand what LoveLife was. At first most parents didn’t really understand what LoveLife was all about. They had their own perceptions which we took us to work even more harder in explaining what LoveLife is all about what it does for our people. And when we start realizing that this (MS?) making to their own children actually they become very much interested and especially with the teachers at school to go to the – their programs that having school (MS?) LoveLife. We’ve got (MS?) program [several inaudible words] program and also [several inaudible words] advent directly exclude. So we are so interested in the hear what programs would bring to (MS?) school from the teachers (MS?) and that’s where they (MS?) understanding what the concepts of LoveLife and they become very much interested. And with (MS?) said “what about us?” “We also want to become confident with our children. We also want to have debating programs. We also want to be part of the (MS?) programs” [several inaudible words]. So they didn’t understand but now, because we have enough information we go them informed. Now they’re very much interested in the program. Thank you.

(MS?)

DR. JUDITH AUERBACH: I think because this is part of an answer to the woman question about in low prevalence areas where do begin and one of the things you can take from this lesson is perhaps begin with parents as well – they’re adults and developing skills [several inaudible words] such and they can transmit and communicate with their kids.

DR. ROBERT FULOVE: William, would you like to comment? I’m sure you – please.

WILLIAM: I think I want to maybe touch on the issue of the messages.

DR. ROBERT FULOVE: Please.

WILLIAM: But I think LoveLife uses one of the billboard. I think this, in some way or another, represented (MS?) but it was between the older generation and the younger people because I think if you spoke to younger people, they think to comprehend them much better than (MS?) and then I think that it was quite appropriate because the whole thing is driven by them and their message, their culture and they understand it. But it was (MS?) that it be useful, I think as part of their message to be coordinated to begin to bring icons of famous into the messages. We now have, for example, from [several inaudible words] about on television. He appears on the media. We also have had the Minister of Health on some of the media on LoveLife. I’ve seen the debate president except that he was questioned on our sex in parliament and he couldn’t answer that. I think what is [several inaudible words] of sexual behavior and of human beings in our society that we live, I think, in a culture where we are divided in our perceptions, in our dreams and aspirations in what we can transmit to our children and sometimes we see what our children can transmit to us. And the idea, I think of refocusing and bringing, I think, all the generations into the messaging and the media is beginning to address also, I think, the fact that both the adults and the children are going to be involved in this program. It is not either/or. It’s both. And I think it brings me to three comments I want to make and I’ll make no more comments after this.

DR. ROBERT FULOVE: Are you sure?

WILLIAM: (MS?) in every one of us male – that is a female biologically and socially. We don’t realize this. We tend to think that because we are really male. Biologically they’re female and as both behaviorally and biologically. I think in the human beings are both complex and yet simple and there will be no single message that will be adequate to achieve what appears to be a simple (MS?) objective because some of (MS?) by seeing a friend. Another person will listen to a teacher. Somebody else will listen to a friend. Another one will listen to a traditional healer. The comprehensiveness and coherentness of this whole program illustrates, I think, both the simplicity and the complexity that we really need taken together. Not either/or. They just – you just need to discovery who learned what from what? And use that to bring that effective change in behavior. They’re not going to prescribe a single message. Thank you.

DR. ROBERT FULOVE: Thank you. David, somebody had asked the question, “What’s the role of the national government?”

DR. DAVID HARRISON: Hello?

DR. ROBERT FULOVE: Yeah.

DR. DAVID HARRISON: Okay. Alright. South African government is very supportive of LoveLife and I think to some extent the controversy around HIV/AIDS in South Africa has provided a lot of political space for us to operate. There has been a desire on the part of government to the public in general to respond to the HIV/AIDS epidemic. And so certainly we’ve been able to run a far more frank campaign than we’d have otherwise be possible. We’re able – we had a press conference this morning and some people were looking at some of our public service announcements on – in on young people talking to their parents about condom use. We certainly have a huge amount of space to run a campaign that we feel is most appropriate and it (MS?) young people most directly. The government is now in form of partnership of their (MS?) Foundation in support of LoveLife. It provides funding about two and half million dollars a year to LoveLife. But probably more importantly, is five percent government departments are active collaborators in elements of LoveLife. The LoveLife Games is a partnership with Sports and Recreation South Africa. That’s the national department. The national (MS?) funding clinic initiative is (MS?) full partnership with the Department of Health. And the groundbreaker (MS?) is implemented (MS?) with the Department of Social Development and if I could just briefly answer Selma’s question about some of the links that are starting between prevention and parents’ support is that social development is locating Groundbreakers in their care and support programs. The Department of Finance, (MS?) the Department of Education is involved. And so there is active collaboration and then at (MS?) political leadership (MS?) from the President’s and Deputy President’s office there is a lot of support. Thank you.

DR. ROBERT FULOVE: David, so why I interrupted you before, but there was a question that was posed about the degree to which some of these approaches can be translated into other parts of the world, other parts of Africa. Since Uganda has been acknowledged as a world leader, having realizing quite dramatic shifts, turn-arounds, if you will, in its infection rates. I wonder if you would be interested in commenting on that?

WILLIAM: Right. Also while I’ve had the privilege of actually looking at LoveLife in South Africa, in coming from Uganda where we would like to think we have done little (MS?) HIV I was truly impressed by the various combination of activity, i.e. the communication of the mass media combined. This is very important combine with the provision of health services. Basically, they do have adverse and friendly clinics where they can funnel young people (MS?). There’s a lot of talk in – and if one of the problems is that many young people in many developing countries have difficulties accessing health facilities that in which they could have an environment. And you get where health facilities find this young – big woman and [several inaudible words] and you have an STD and, you know, he says “What?!” So that – the services the use for in the services that young life does have is truly have to be seen to be believed. It’s really very outstanding.

Along with that, they do have what they call Youth and (MS?) whereby, if you’ve got a lot of time, many of the sexually activities of these young people tend to happen because of redundancy – hanging around, nothing to do. But they do have youth centres where they are trained to do, either in sports or computer surfing computer and this tends to engage the youth especially those who may be out of school who may not otherwise be having anything to do. I think the uniqueness of the program is (MS?) coordinated (MS?) activities that compliment each other. To the extent – the question is to what extent could you be able to if we had these in other parts of the world – of (MS?) developing countries. One other thing that I actually saw of LoveLife is it’s sort of (MS?) fair at very well communication infrastructure, in both media prints and radio. That already was in place. If I look at myself in a country like Uganda, the extent to which that without being (MS?) to try to disseminating information would have been somewhat (MS?) compared to what (MS?) South Africa. Some of these Y-Centres the youth have their own radio frequency at which sometimes they actually talk to the other youth and say the music that they like to listen. I think that is fairly very unique. But I think the generation of youth (MS?) services for sexually transmitted diseases is truly unique. And I’m not seeing it in any other part of Africa and that would be a very good point to kind of emulate it actually they use already existing health clinics and just provides a kind of flow that would be contusive for youth (MS?). I think that’s as easily typical (MS?) in many other countries and they are also starting (MS?) counseling for young people. You see many, many, many countries [several inaudible words] testing and counseling with the specifically for young people for the same reason that STDs are not clinic [several inaudible words] if you have world services that are for young people, I think that would be extremely commendable. These interventions are not cheap, I must say. I think many people think that prevention is cheap but it’s not. I mean if you really have to scale-up ideally to be able to make. I think with the right resources available, the some – for instances, some others components to be duplicated. You have to have the funds. There’s no doubt about that. The funds have to be there to be able to do it. And I think throughout the theme of this conference we shall see that if you want to scale-up and make (MS?) in prevention you really have to commit the funds. And I must point out it has to be sustained. You see, what our opinion is that many of these behavior can be shown of the youth (MS?) the area the sexual – about sexual encounter is there sexual behavior but it has to be sustained so it has to be (MS?) in the norm in the community. We are not in for putting in a little fund and sustaining it a longer period of time. I think we know that (MS?) are very common and it probably won’t be able to make it on any part of the public health level.

HELEN: Well, I think just to add on to that, interesting, as we said to the (MS?) mind shift perhaps at this conference and that is we tend to (MS?) “Well this is an adolescent program and that’s a condom program and there’s the STI program.” The point about this if you look at it is it’s an integration and if in those clinics as David said we’ve got everything going on in those clinics that we know has a contribution to make towards prevention and towards treatment for people who are infected. So we try to strengthen that. All it is is a quality improvement program. And it’s actually giving particular providers tools often in a situation where they’re feeling pretty hurt and desperate and they know the young people aren’t coming. The other thing is that it quite honestly, if you look at all the models we’ve learned about over the last 12 years or so about primary health care, this is an extraordinary (MS?) primary health care because it goes out into the community. It partners the community. It partners intervention. It tries to bring the community and whole services together. But I think that though the bottom line, however, having said all of that is that we do need to have more money do to this. And I think that we do need to look at things like the Global Fund and that the bigger macro economic problem that are facing many of the developing countries because definitely that adolescent funding clinic is one aspect but you really do need to top it out with a whole lot of other exciting things to start the young people’s attention so that they actually want to utilize services.

DR. ROBERT FULOVE: I think, if we could, we can take more questions and comments from the audience. Let’s begin here.

AUDIENCE #6: Sorry about up-front here. You know I’ve spread some (MS?) whole lot of money on a drug prevention program called DARE which ended (MS?) work because I’m torn from (MS?) youth lounge (MS?). I guess as I listen I appreciate media campaigns but it seems to me that health behavior change is a very, very complex do take social fabric, to take social skills, it takes people connected to other people, it takes the establishment of an adult protective shield as well as shaping minds. Now, I was wondering what’s the consideration for not having a DARE like we had in Chicago and in the United States and what’s the safety net? And what are the other efforts to connect this media campaign and some of those other health behavior change strategies?

DR. ROBERT FULOVE: Over here.

AUDIENCE #7: [several inaudible words] just a comment and a couple quick questions. I think it’s very appropriate that LoveLife focuses on youth. And the one thing that I might leave out in that regard that is in Uganda as you’ve mentioned we’ve overseen a tremendous success 75% prevalence to the problem that arguably Uganda’s gone from the most highly affected country in the world to a two-thirds reduction prevalence from the last ten years. And I think that it’s excellent that you’re looking at Uganda for some lessons. [several inaudible words] Uganda were actually interacting – conducting a study right now [several inaudible words] a, b, c study. We’re trying to understand as best we can what’s happening in Uganda. It’s difficult to ascertain, in fact, what brought about those reduction problems but so far some things are a bit (MS?). And others [several inaudible words] 1991 and 1992 there probably isn’t [several inaudible words] late 1980s. And we know that there are [several inaudible words]. [inaudible section – three minutes]

DR. ROBERT FULOVE: Because that was like nine questions (MS?).

WILLIAM: Can I make one comment?

DR. ROBERT FULOVE: Please.

WILLIAM#: I think we’re here to try and maximize understanding and [several inaudible words].

DR. ROBERT FULOVE: David? David? We had a David – was that the question? We had a David Harrison question.

(MS?)

MALE SPEAKER #3: (MS?) raises a lot of questions. (MS?) How to start. His concept by making a lot of comments about what problem I have (MS?) in Uganda (MS?) reduction HIV, particularly among youth. And he points out the issue about (MS?) and the fact that we probably had an extensive health education problem. But I think it must be pointed out also Uganda was very initially – was one of those countries that initially had (MS?) comprehensive health education system. In order words, it was fairly easy [several inaudible words] to actually (MS?) sex education into the primary school curriculum throughout the country. And I think that was also very helpful. It’s very (MS?) to know what component really did make a tremendous impact onto what. I think the way a combination of factors, all of which one will make some suggestions allowing to solely making a before and after effect. Health education (MS?) school. To some extent, actually I would say who – people talking about the issue. I think in Uganda (MS?) road and [several inaudible words]. There was main concern both from government [several inaudible words] person on the street. Even the cab driver could talk about issues of HIV and this person to person. When you ask people where the main source of information you will find that some (MS?) they are saying (MS?) very, very strongly. I think to some extent, that also [several inaudible words] which I’m sure (MS?) among the youth. Who talked about circumcision? I know they’re one of the countries that (MS?) circumcision trial is Uganda which [several inaudible words]. [several inaudible words] if circumcision was found to be [several inaudible words]. We would hope in Uganda that this is something that would be really initiate if at all (MS?) any particular benefit other than (MS?) circumcision.

DR. ROBERT FULOVE: David, there was a question about [several inaudible words] program. And there was also a question about the (MS?) having to do with older men and younger women and I wonder if you would comment on those two? (MS?)

DR. DAVID HARRISON: Would it be okay if I took just two minute to answer just some of the very short questions (MS?) just to pick up those loose ends.

The response to what about incarcerated young people? No, we have not yet to deliver (MS?) directed it at young people in prison. It’s a problem. We know that a (MS?) of infection. And we have a bigger problem. Sixty-two percent know of LoveLife. Thirty-eight percent don’t yet. And so we got to get to that 38%. And so we really understand that. [several inaudible words] and the amount of money would cost, yeah, it’s a big challenge and I think David has responded. Prevention does cost money but the big point that we have to make is that the benefits outweigh the cost. And even economic benefits outweigh economic cost. Not even if you combine that with social benefits. And that’s acquired as a constant lobbying of political leadership and just more practically to try and (MS?) from other sources (MS?) spoken about the global fund. And one of the things that we are starting to be increasingly successful is leveraging funds with corporate sector in South Africa who loveTrain is pulled for free by the railways and the partnerships with the two national newspapers. We have a circulation of two million (MS?) for our lifestyle magazine programs. That’s a 50/50 cost split. And yes, I (MS?) the value of the money [several inaudible worlds] creative about ways to leverage funds even if it’s not cash upfront. The billboards – we don’t see billboards as putting across a message to young. It’s only when the really [several inaudible words] internalize risk [several inaudible words] our campaign provoking discussion (MS?) our help line and positioning the (MS?). That’s the role that they’re playing in the LoveLife initiative.

Pregnancy, yes. Teen pregnancy rates are something that we are tracking at the moment. It’s about 16, 15.5. We’re continuing to do that.

The involvement of teachers. Historically South Africa’s got a very dysfunctional educational system. We have a big problems with teachers having sex with their pupils. Our emphasis is on popular youth cultures and (MS?) the classroom as the first point of contact. That schools are very important and that really is the basis for the LoveLife Games. We have a training program of 1,800 teachers involved in the implementation of the LoveLife Games and throughout the year.

But just quickly the comments that you made about the media campaign and linking it with other initiatives for social mobilization. That’s what it’s going to be about. It’s got to be about this – we are talking about a social movement and that cannot be a media campaign divorced from anything else. And that’s multifaceted. It is Nelson Mandela to be part of our parents’ campaign, the Deputy President, the Minister of Health. It is the LoveLife franchise where 60 NGOs are involved. It is the parents’ campaign encouraging this restoration of the communication. It is through the schools, though the public clinics and through the Groundbreakers creating this new leadership call where there’s been a leadership vacuum. If we can get full (MS?) Groundbreakers around the country, we will start to break the cycle between poverty and HIV by creating this new cohort of the caliber that you’ve seen today.

Older men versus younger women, yes. We definitely seen that all the men are having sex with younger women. Part of the challenge and it’s the bigger picture of the general dynamics, the power struggle that is determining this epidemic is to empower young women to make young women assertive in the way that you’ve seen today and doing that through a combination of motivation, involvement and debating, challenging and the stereotypes. Getting young girls for the first time to be able to stand up and challenge their male colleagues. That’s an important starting point. But we also need to recognize that LoveLife is large – not the total response to the HIV epidemic in South Africa. It is targeted and unless we get the support and this we can sustain it through efforts that are aimed at 18 to 25 year olds and older and certainly that it going to undermine our success.

The question about circumcision, well we’ll have to cross that bridge when we get to it.

WILLIAM: Just before you go (MS?), which society is that a case where men have sex with women of the same age. And of all societies, I know, older men go for younger women. I know [several inaudible words] it’s something that maybe (MS?) addressed to the men rather than [several inaudible words].

AUDIENCE #8: Thank you for that. [several inaudible words] Zimbabwe. We’ve done a national (MS?) AIDS program there. Well done, David. I just think it’s amazing. We’ve been at it since 1986 and with the current anarchy in the country it’s virtually destroyed all our work and I just wanted to make that comment on political commitments. And I’ve been saying this at conferences for 15 or 13 years, is that it is so, so vital and I plead to everybody and organizations in the U.S., the U.N and (MS?) is don’t desert us at this time. The incidence of child abuse in Zimbabwe is weighing enormously. We have a 17% unemployment rate. It’s absolutely appalling. And poverty is (MS?) by the day. And what does that spell to you? Survive of the fit for the woman. It’s a desperate situation. And this was made the political and commitment [several inaudible words] and I really commend you, David, and I hope we can perhaps work together in some way to try and keep the youth at least vaguely on track [several inaudible words]. Thank you.

DR. DAVID HARRISON: Thank you.

AUDIENCE #9: [inaudible section – 30 seconds]

AUDIENCE #10: My name is [inaudible section]

AUDIENCE #11: [inaudible section]

AUDIENCE #12: I’m going to trip over the tripod. My name is (MS?). Currently I’m not affiliated with any organization but I thought it would be interesting to share some information about a youth centre I visited in Lower Republic. And I thought what (MS?). It’s one youth centre that’s only been open for a year and the Lower Republic is a no-prevalence country. And the centre offers an addition to (MS?) in adolescent clinic. It offers language training in Japanese, English, French. And we just love it very much. But most interesting they also started a youth counselor training program for youth, taking youth beyond their educating skills to actually becoming counselors and it (MS?) three or four phases so people really have to be motivated to move on to the next level. And thus their building the capacity of young counselors. And I’m going to (MS?) and learn more about what your youth centres offer.

AUDIENCE #13: [inaudible section].

AUDIENCE #14: I want to know a little bit about your youth clinic. When do you run them? Do you make provision for the fact that this youth are going to school? Because I used to run a youth clinic (MS?) It was very popular but it was only (MS?) afternoon. People could [several inaudible words]. And then the other thing I want to know that with this LoveLife program [several inaudible words] because finding this survival business – sex for survival [several inaudible words] because we do not have – we tend to set up our programs [several inaudible words].

HELEN: The first comment on positive youth and there is nothing to add on to this and one of the problems at the moment, of course, is that many people – most young people would want to know their status because we don’t have a nationwide access to (MS?) and so and those people that [several inaudible words] that they will be in the older age groups. And for those (MS?) formal provision made in the services, however, what one would encourage would be the sort of self-help (MS?). Where there are young people who want to get together and talk. That indeed that they can do that. And that has happened in some of the LoveLife affiliated public sector clinics and the Y-Centres. It comes on to the question – your question about voluntary counseling and testing. It’s very (MS?) we think that this works and it improves all sorts of aspects of behavior intervention in adults. Therefore (MS?) young people but the risk of – that you might be getting 15-year old in the whole of your village is going to be positive. And that you haven’t thought through what that means to that young person and what the support system is. Indeed you may not be doing that young person service. So although we are investigating this and some of the public sector services – three of them are government designated VCG services. But in fact, when we’ve looked at them, they tend to be older young people, above 20 who tend to be using that facility, not the younger teenagers. In fact, I think of this as an interesting challenge that you’ve (MS?) and it’s one that we are now planning to do some (MS?) that we’re actually trying to actually do devise a study that will look at some of the social implications and the structural implications if you’re going to start testing these much younger young people.

And the last point – the question of evidenced-based. I think, as I mentioned earlier – I think we all totally agree with you that this is critical because as you say, this is a massive national (MS?). It’s an absolutely leap of faith based on the evidence they’ve got now. But if they [several inaudible words] government in an extraordinary scale that hasn’t been done before. I think it’s doing what (MS?) we need to do at this time, which is to scale-up some of these lessons. Let’s not – stop messing around. Let’s start the pilots. Let’s get them out there. We might do (MS?) 70% (MS?) [several inaudible words] country the 90% brilliantly in little pilot sites. I think that’s the philosophy.

Now having said that, pure evidenced-based question is critical. We have a team at the moment which consists of my organization which is parts of the university that (MS?) which is one of South Africa’s foremost international universities, and together with medical research counsel (MS?) and President of and Cambridge University, my colleague’s in the audience here. Now we are putting together the evaluation but in addition to that, we are also now looking for an outside group that are going to come and do another external evaluation of our evaluation. If it’s going to be a very extensive evaluation, it’s going to look over a five-year period. We’re going to have a national youth survey that will look all over the country at HIV status and strong link it to the behavioral question. So that you’re not only seeing HIV status but you’re actually still looking at behavioral questions. We’re looking at how you can then break that down further into regions so you can start to see if like hotspots and spots that you’re seeing behavior change and HIV status change and you start to get a better understanding of the epidemic in that way.

In addition to that, we’re going to look in the areas where we have the safe sex adolescent (MS?) clinics, these Y-Centres, these multipurpose Y-Centres (MS?) sort of things that you described versus where we have nothing yet in terms of services. And we’re going to look at what actually happens in terms of outcome, in terms of pregnancy, sexually transmitted infection, HIV behavior. Again, repeating this over a five-year cycle. But I think we take the point – your point is extremely valued and (MS?) also taken seriously but in addition to the team that are doing this (MS?). We also looking for external evaluators. They’re going to come and check that what we’ve said is objective and true and we’ll be able to validate.

DR. ROBERT FULOVE: (MS?) you’ve actually worked in one of the youth centres. Would you tell us something that actually goes on there? (MS?).

MAYAN SHEETH: [inaudible section]. And from there we give all the options. How to prevent it. How to keep their body safe and everything concerning prevention of contracting HIV or AIDS. And within the centers we also have [inaudible section].

DR. ROBERT FULOVE: [several inaudible words]. There was a question asked about AIDS orphans in South Africa, I thought.

WILLIAM: No. I don’t know much about it but we have this say. We (MS?) completed a study at the medical (MS?) counsel indicating that we obviously are going to face a massive, I think, orphanage, as the epidemic matures and begins to impact, I think, with disease and mortality that we’re predicting. And what we are trying to do at the moment is to provide, I think, evidence-based information that can have the current government and the political leadership to make (MS?) intervention now rather than wait until the massive epidemic. And what we’re trying to indicate at the moment is that we need, I think, to begin, I think, a problem of (MS?) therapy in the country because what that does, not only does it impact on prevention but basically the [several inaudible words] that people carry that also by improving the quality of life and (MS?) long in life and allowing, I think, those infected parents to be able to interact with their children and give them the life skills that are necessary longer than in the (MS?) of (MS?) quality of life. And what we have been trying to indicate with that – this has been more appropriate than simply awaiting for people to die in misery, die (MS?), leave younger children who are inexperienced and are that are costly to all of us. There is already, I think, those kinds of studies and information that is available in the country.

MALE SPEAKER #3: [several inaudible words] major concern. Country like Uganda which has a general (MS?) epidemic over a year (MS?) often that are really teenagers. And they have all the risks of probably acquiring HIV. And I’ve noticed with tendency for some of these orphans to migrate into cities or (MS?), which [several inaudible words] gaining much more higher risk behavior for survival. I am really sorry to say we do not have a very comprehensive orphan program that I can share with you. I know it’s a very important issue in times of government trying to provide assistance in ways of keeping orphans into schools and public – perhaps giving them a bit of break in life but there hasn’t been any (MS?) study trying to look at these orphans. What are their behaviors and what could be done to help them best. And one can only conjecture that they [several inaudible words] for targeting risk-reduction behavior. And I can only imagine that one of the issues what we could really do is probably to give them a better chance especially school – going to school, among other things.

(MS?)

DR. BERNARD SCHWARTZLANDER: I’m just going to add to the issue of orphans. I mean this is, indeed a major issue, which I think has been underestimated so far in this – also and only at the very beginning. And there’s a new report coming out of – in out at this conference. I think it’s going to be launched (MS?). Children of the (MS?) 2002, which actually includes new analysis that shows that currently there’s an estimate of some 13,000,000 children who have lost either their mother or their father or both parents do to HIV/AIDS only. And that number is going to increase to 25,000,000 within the next eight by 2010, which is, of course, a massive number. Not only counts those who are currently at that given point in time, less than 15 years of age, (MS?) can cumulate over time that number is, of course, much, much, much bigger and I think that is an appropriate measure as well because of those children who actually had the childhood with other parents will cumulate those with disadvantages over time. Another important thing is is not only is there sort of a desperate situations that (MS?) right now that may try them into sexually explicit behavior or getting food for sex or whatever have you there. It’s also that studies after studies that have shown that orphans almost always have much less access to education and would have add years (MS?). Those are clear determinants for the risk behavior or vulnerability in the (MS?) and it certainly [several inaudible words] most important factors for development of a society if you can get education to our children, to the younger populations. Clearly, those are issues that are only the beginning and that we have to really think very constructively and creatively how we could better cope with this and certainly some of these programs are very impressive to address these issues.

DR. ROBERT FULOVE: Thank you.

MICHAEL: Well all that remains for me to (MS?) such instance copies of David’s paper will be available on your way out. But particularly our outstanding panel and Professor Fulove was so expertly moderating it. And you, for being here. I think this has been a terrific discussion. I hope in years to come you’ll come back and watch the progress that LoveLife makes.