8.3 Recommendations for USAID

⇒ The data reported here provide evidence that behavioural changes are possible, and are having a dramatic role in reducing HIV incidence in urban and semi-urban populations in Uganda (just as they are in Thailand and Western European and North American countries). This model is within the technical capacity of Uganda and other countries in the region to sustain and should be seen as one of the most important and cost-effective interventions available.

⇒ The behavioural model should now be strengthened and refined so as to be more relevant to rural populations. Bio-medical interventions, particularly STI treatment may also go on to be an important intervention, and should be seen as a part of the strategy to strengthen behaviour change programmes. Whether STI treatment programmes will have the same degree of sustainability, and or acceptability remains to be seen. Similarly their promotive role - as opposed to their treatment role - needs be assessed, especially with respect to younger populations not yet exposed to HIV and other STI risk.

⇒ The premise that HIV prevalence trends and underlying HIV incidence dynamics are poorly understood in relationship to evaluation of interventions needs re-consideration. The findings in Uganda and Zambia as compared to Blantyre call for more aggressive linking of population surveillance to evaluation of intervention.

⇒ There is a need to build a greater technical capacity to undertake and interpret population surveillance in the region. Capacity building in public health surveillance should not be restricted to HIV but should cut across other public health issues and problems.

⇒ Major research should be undertaken in the role of population movement as a vector of disease, and social change, and its relationship to public health in Sub-Saharan Africa.

⇒ Considerations for future research should include the following:

⇒ Long-term cost benefit analyses of bio-medical and behavioural interventions with respect to HIV.

⇒ Studies of spatial diffusion of innovations with respect to HIV prevention and barriers to behaviour change (urban vs. rural). This should include social network research and how it relates to personalization of AIDS risk in urban and rural sectors.

⇒ Improved understanding of apparent barriers to condom use in rural areas perhaps through social marketing surveys.

⇒ Comparative analysis of Uganda, Zambia, and Malawi KABP and DHS surveys. Standardised interviews and strengthened analytical strategies. Support to a population based KABPs in Malawi.

⇒ Comparative analyses of HIV prevalence trends and behavioural data in Uganda, Malawi, and Zambia.