Secret Lovers Kill
Makhwapheni Uyabulala, or “Secret Lovers Kill,” was Swaziland’s first national media campaign to focus on the HIV risk of multiple and concurrent sexual partnerships (MCP). The campaign promoted HIV prevention in the country with the world’s highest HIV prevalence by broadcasting a powerful message that resonated with the public and encouraged behavior change. The Makhwapheni Campaign launched a widespread public exchange about multiple sexual partnerships and the spread of HIV, a topic rarely discussed in Swazi society.
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Secret Lovers Kill
A National Mass Media Campaign to Address Multiple and Concurrent Partnerships
By Aldo Spina
The text message on the young woman's mobile phone reads, "He's workin' late, cum work on me." It's for her makhwapheni ("secret lover" in SiSwati). But next to the image of the phone appears another message that dramatically changes the mood: "Why kill your family," followed by the tagline, "Secret lovers kill."
In July 2006, this blunt ad—simultaneously suggestive and terrifying—first appeared in newspapers and billboards and on the radio in Swaziland. It was issued by the Makhwapheni Campaign, the country's first national media effort to focus on the HIV risk of multiple and concurrent sexual partnerships (MCP). The campaign sought to promote HIV prevention throughout Swaziland, which has the world's highest HIV prevalence.
As with all HIV prevention campaigns, the goal was to broadcast a powerful message that would resonate with the public and encourage behavior change. But the strength of the response took all by surprise. That message struck a nerve, sparking a passionate national debate in the media and in communities.
On call-in radio shows, in the newspapers, and between friends, Swazi openly discussed the formerly unmentionable practice of makhwapheni and the attitudes of fellow citizens toward multiple sexual partnerships. The Times of Swaziland invited readers to send text messages on their thoughts of the campaign, which were then printed in the newspaper, fueling further discussion.
The debate soon spilled into the streets. People living with HIV (PLWH) felt that the campaign branded all people with HIV as makhwapheni, responsible for the epidemic. They protested outside the offices of the government's National Emergency Response Council on HIV/AIDS (NERCHA), which had launched the campaign, and petitioned the Prime Minister to withdraw the ad. After two weeks, NERCHA changed the ad's tagline to something less controversial: "Hha, i-HIV ibhokile" (Hey, HIV is everywhere).
But in the few weeks the original campaign message ran, it achieved close to universal recognition among the population. Even more important, survey data suggest that the number of men reporting two or more partners dropped by 50 percent immediately after the campaign began (CIET Trust 2006).
Thanks to the furor the ad created, the Makhwapheni Campaign launched a widespread public exchange about multiple sexual partnerships and the spread of HIV, a topic rarely discussed in Swazi society. And its controversial messaging approach has also helped reopen global debate about whether, when, and where negative and fear-based advertising—long avoided by public health programmers—has a place in HIV prevention programming.
Disclaimer: The author's views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.
Multiple and Concurrent Partnerships
Reducing MCP is challenging in Swaziland, where polygamy has long been an accepted cultural practice and where MCP appear widely accepted. Many Swazi men who are married or have a regular girlfriend have sex with other women. When respondents to the Makhwapheni Campaign baseline and evaluation survey were asked how common it was for people "around here" to have another regular partner in addition to a spouse, 59 percent of respondents in 2005 and 53 percent of respondents in 2006 said it was common or very common.
While Swazi society generally accepts MCP for men, women are expected to remain faithful to their partners. Yet some Swazi women—both married and unmarried—also engage in sexual networking, often for financial support. Intergenerational sexual partnerships are seen as commonplace in Swaziland, with girls and young women engaging in sex with much older men. Despite these growing HIV risks, deeply rooted gender inequity makes it difficult for most women, especially married women, to negotiate the use of condoms. Another factor is an increase over time in the number of sexual relationships taking place outside of marriage (The Government of the Kingdom of Swaziland 2006).
Reducing the number of sexual partnerships could potentially help reduce HIV transmission. Uganda's "zero grazing" campaign of the 1980s, which focused on partner reduction and faithfulness, led to a decline in multiple sexual partnerships. Along with other factors, including condom use, these reductions contributed to a sharp drop in Uganda's HIV prevalence in the 1990s (Green et al. 2006).
Swaziland's national HIV strategy seeks to address MCP as an important component of a comprehensive prevention program. While earlier prevention campaigns in Swaziland had addressed the issue of multiple partnerships, the Makhwapheni Campaign broke new ground by concentrating on MCP and using advertising to confront the public with the dangers it poses.
Evolving Prevention Messages
The Makhwapheni Campaign was the most recent in a series of three HIV prevention campaigns that NERCHA developed between 2001 and 2006. Shortly after its formation by an act of parliament in 2001, NERCHA implemented the I AIDS indzaba yetfu sonkhe (HIV Is Everybody's Business) campaign. The campaign, which followed King Mswati III's 1999 declaration of AIDS as a national disaster, aimed to mobilize the Swazi public by building community ownership.
In 2005, NERCHA launched its second campaign, Likusasa ngelami (The Future Is Mine), to counter a growing sense of fatalism about HIV. The tone was upbeat, with a focus on delaying sexual debut. Targeting young people, the messages emphasized living for the future: "I'm definitely in control. Sex can wait because ... the future is mine" and "My education comes first. Sex can wait ... the future is mine." Some ads addressed the importance of having only one sexual partner, such as this one created for young male professionals: "I choose to have only one sex partner because ... the future is mine."
The Makhwapheni Campaign, launched in July 2006, aimed to deepen public discussion of MCP. NERCHA staff recognized that, despite a high level of HIV awareness among Swazis, corresponding behavior change had not occurred. Government strategy documents described a lack of seriousness in confronting the epidemic, characterizing the response as "business as usual." This was articulated in the country's second national HIV Strategy:
So far national efforts to address this challenge [HIV epidemic] have only yielded heightened awareness of the problem but have failed to stimulate levels of sexual behaviour change that are necessary for turning the epidemic around [The Government of the Kingdom of Swaziland, 2006: iv].
To promote behavior change, NERCHA sought to stimulate public discussion of MCP. The goal was to transform public perception and ultimately change cultural norms that accept such practices.
Development and Implementation
Several steps led to the development and implementation of the Makhwapheni Campaign.
Concept: Before developing the creative brief (which outlines the task for the creative agency), NERCHA staff discussed the concept of makhwapheni as a way to encapsulate the issues surrounding MCP. Soon, the term makhwapheni became the hook around which the entire campaign grew. Makhwapheni, which can be translated as "my secrets," implies "my secret lover" when used within the context of the campaign. It was seen as an effective way of referring to relationships "on the side" that are not entirely acceptable. The term was seen to have more cultural poignancy than a straightforward tagline promoting the practice of having only one sex partner. Before the campaign, the term was not in daily use, although it had been heard in a South African pop song.
Objectives: The campaign's overall goal was to provoke public debate about MCP and ultimately change public perception of such relationships as acceptable by:
- Encouraging positive and responsible sexual behavior
- Discouraging MCP
- Influencing public debate on the issue of MCP
- Encouraging sexually active persons to reduce the number of sexual partners
- Encouraging faithfulness among partners
Planning: At the outset, NERCHA produced a concept paper outlining the rationale, objectives, and strategies of the campaign. The paper outlined how the campaign would build upon previous campaign efforts. Implementation was planned for six months, from June to December 2006, in two phases.
Phase I aimed to draw attention to the campaign through advertising, using multiple mass media channels such as radio, newspapers, billboards, television, and promotional materials. The goal of Phase II was to interactively engage the audience by providing opportunities for more in-depth information sharing and knowledge building. Plans included a range of interpersonal communication strategies, including drama, concerts, men-only and women-only dialogues, debates, and other community-based activities.
NERCHA convened and sought input from a technical working group consisting of individuals with expertise in behavior change communication. The group included individuals from United Nations agencies, the Swaziland National Network of People Living with HIV and AIDS, Population Services International, the Ministry of Health, the Family Life Association of Swaziland, Women in Law in Southern Africa, and the Resource and Information Centre. Their role was to provide technical advice rather than to act as a representative body of key stakeholders.
Choosing a creative agency: After the development of the concept paper, NERCHA staff sent a creative brief to several creative agencies and invited them to pitch their ideas. Part of the process involved providing thorough verbal briefings to agencies to ensure they understood NERCHA's objectives.
Agencies that pitched ideas received numerical grades on a range of criteria, including understanding of the brief, how effectively the pitch addressed requirements, and each agency's capacity to deliver an innovative campaign. The agency with the highest score—S'buko Sesive, a Swazi-owned and -run agency—won the contract.
"Secret Lovers Kill"
Creative aproach: The increasing popularity of mobile phones in Swaziland (with approximately 400,000 mobile phone subscribers) prompted the agency to use them to realistically portray how men and women organize makhwapheni encounters. This approach also emphasized the secretive nature of these encounters, since mobile phone text messages are perceived as private forms of communication.
Print advertisements featured graphics of a mobile phone displaying text messages intended for a secret lover. In contrast to the messages of earlier campaigns, these were intended to be both explicit and confrontational (although the language was tempered somewhat to ensure that it was appropriate for public display). Appearing next to each of the text messages was a warning, including "Why kill your family" or "You have put yourself in trouble." Beneath each message appeared the campaign tagline, "Secret lovers kill." Advertisements often appeared in both SiSwati and English.
Launch: A few days before the ads appeared, several HIV agencies and groups previewed the campaign and provided feedback. At this point, PLWH stakeholders raised concerns about the campaign messages. They later reported that they felt these issues were not addressed before the ads began to appear.
The media: In July 2006, the advertisements appeared on radio—Swaziland's most widely consumed media—and in print, as well as on some outdoor billboards. Ads appeared in both daily newspapers, the Times of Swaziland and the Swazi Observer. (Both papers are in English,which may limit their readership.) Despite the more limited consumption of local television, TV ads were planned but did not appear during the initial campaign; they had not been finalized by the time radio and print advertisements began, although they did appear during the modified campaign.
Radio and print newspapers actively engaged their readers and listeners in a debate about the issues. One example is the Times of Swaziland, which solicited text messages from readers about the campaign and then printed them. Radio listeners often phoned in to discuss the campaign and the issues it raised.
As a result of media interest in the campaign, NERCHA began to brief key media. This provided an opportunity to explain to editors and journalists why the campaign was addressing MCP, as well as some of the thinking behind the campaign's creative approach.
Market testing: After advertisements began to appear, market testing of the campaign material assessed the audience's initial response. Five discussion groups of 37 participants total were held in rural and urban settings. In addition, 10 key informant interviews were conducted with traditional leaders, religious leaders, HIV decision makers and program staff, and PLWH.
The testing revealed that the campaign was successful in achieving its overall aim of opening up public debate on MCP. It recommended that the campaign continue to use a range of media (print, radio, television) because of their effectiveness in communicating with the target audience. The report noted that the term makhwapheni was confusing and should be replaced, a recommendation that informed the development of the modified version of the campaign.
"Hey, HIV is everywhere"
Modified campaign: Only a few weeks after the initial advertisements first appeared, NERCHA suspended the campaign in response to the controversy that had been generated. It agreed to review the campaign, in consultation with PLHIV, to consider how to address some of the concerns that had been raised (these issues are outlined in detail below).
In August 2006, the modified advertisements appeared. Gone was the "Makhwapheni uyabulala" (Secret lovers kill) tagline, replaced by the more general message, "Hha, i-HIV ibhokile" (Hey, HIV is everywhere).
The modified campaign used the same suggestive mobile phone text messages. But this time, the accompanying messages focused on rejecting the sexual invitation rather than on the potential consequences, with such responses as "Sorry, I'm over that" and "I'm no longer available 4 this."
NERCHA, with support from the U.S. Agency for International Development, commissioned the South Africa-based nonprofit organization CIET Trust to survey the audience. The survey examined the impact of the Makhwapheni Campaign before the modified advertisements appeared.
Overall, the results showed that people heard and understood the key campaign message. The survey found that 86 percent of respondents had heard of the campaign. Given that the media advertisements in their original form ran for only two weeks, many people first heard of the campaign because of the controversy and subsequent media coverage, even if they had not directly seen or heard the advertisements (the survey did not untangle this).
Of those who had heard of the campaign, approximately 87 percent agreed with the messages. Qualitative focus group discussions also found that most participants who had heard of the campaign agreed with what it said and thought the overall message was necessary, although many had comments about the choice of words and the negative tone. Respondents who disagreed with the messages were more likely to have multiple partners or multiple spouses or to not have used a condom the last time they had sex with their regular partners.
Comparison of the survey to 2005 baseline data revealed some positive changes in behavior among men. The numbers who reported having two or more partners in the preceding four weeks dropped by nearly half. Approximately 16.7 percent of men reported having two or more partners in the last four weeks, compared to 30.6 percent in 2005. There was a similar trend in multiple sexual partners in the preceding six months, with men in 2006 significantly less likely to say they had multiple partners over that period.
There were also promising improvements in several responses to questions about intentions and understanding. Among men, there was a small but significant reduction in the proportion saying they intended to have multiple partners in the future. In the 2006 survey, those who had heard of the Makhwapheni Campaign were more likely to know that people can reduce HIV risk by having just one partner who is not infected and who has no other partners.
But some attitudes did not improve. Compared to 2005, an increasing proportion of male and female respondents said in 2006 that the number of sexual partners an individual has was a personal matter. People who had heard the messages of the Makhwapheni Campaign were also significantly less likely to discuss multiple partners with anyone and more likely to consider casual sex okay, compared to those who had heard the messages of the earlier Likusasa ngelami campaign.
What Worked Well
One of the striking achievements of the Makhwapheni Campaign was that it achieved fairly close to universal recognition in a very short time frame. Four key elements most likely contributed to the campaign's achievement of a high level of interest.
Evidence-informed: The campaign was built upon research that identified MCP as a key driver of the HIV epidemic in Southern Africa. Further impetus to address this issue was provided when a 2006 study found that high levels of men and women reported having two or more partners in the past three months, suggesting that a large proportion of the Swaziland population was engaging in concurrent partnerships (James and Matikanyam 2006).
"How Is the Situation There, Come Let Us..."
"You Have Put Yourself in Trouble"
"Secret Lovers Kill"
Research examining whether fear arousal in HIV campaigns can contribute to a decline in HIV prevalence also informed the development of the campaign (Green and Witte 2006). The research found that fear campaigns, paired with the message that people can do something to avert infection, created optimal conditions for behavior change. This research influenced the tone of the campaign, which focused on the negative and potentially fatal consequences of having secret lovers.
Apart from being informed by research, NERCHA and the creative agency understood the culture within which they worked and cultural norms and attitudes about MCP. This "insider knowledge" helped them develop a campaign with cultural resonance.
Clarity of purpose: While HIV prevention programs may use multiple or nuanced messages, effective mass media advertisements tend to focus on a single well-communicated message. Thus it is important that the producers of HIV mass media campaigns be clear about what they are trying to say.
After reviewing the research and considering cultural practices, NERCHA had a clear idea of the key issues to be addressed and of their goals for the campaign. They were thus able to brief the agency, which in turn could translate the campaign objectives into effective ads. This approach recognizes that while creative agencies are competent in developing advertising, their success depends on how well the client briefs them on HIV prevention issues.
Media engagement: Generating free media coverage is a powerful way to raise the visibility of HIV campaigns, although most HIV programmers struggle to attract media attention. Even though NERCHA and the creative agency had not intended to provoke controversy, undoubtedly the negative response from PLHIV contributed to media interest, which further fueled the public's interest. The level of discussion within various media indicates that the campaign did prompt a public debate about MCP. However, controversial ads can potentially obscure their own key messages. If the audience is unable to get beyond what may have offended or shocked them, then the campaign messages will be lost. This may have occurred for some segments of the audience, such as PLWH.
Audience engagement: A comprehensive multimedia strategy can help HIV messages reach the intended audience, but this does not necessarily mean the audience engages with the messages. As in many other countries with hyper-epidemics, Swazis have been subjected to a range of mass media advertisements and HIV prevention programs. The resulting high levels of awareness and knowledge of HIV have not necessarily translated into sufficient behavior change to reduce HIV incidence. In such an environment, the population can become indifferent to HIV messages.
The Makhwapheni Campaign appears to have effectively engaged the attention of the audience. Because the campaign's evaluation focused on assessing its impact rather than exploring audience engagement, it is difficult to identify which components of the campaign resonated most with the audience. One factor that most likely worked in its favor was that its approach and tone were unexpected. Unlike previous HIV campaigns, it was not nice, gentle, or upbeat. It focused on the negative consequences, rather than the positive rewards, of behavior change. The Makhwapheni Campaign may have also resonated because it directly tackled sexual practices that were not openly discussed within the community. The Makhwapheni Campaign may have also resonated because it directly tackled sexual practices that were not openly discussed within the community.
"One factor that most likely worked in its favor was that its approach and tone were unexpected. Unlike previous HIV campaigns, it was not nice, gentle, or upbeat. It focused on the negative consequences, rather than the positive rewards, of behavior change."
Undoubtedly, given the controversy, the word makhwapheni was an important component of what engaged the audience. Given that talk about sex in Swaziland tends to be indirect and euphemistic, it was a culturally powerful way of talking about MCP, even if it was disliked by some who interpreted its meaning differently. On an emotional level, the term may have resonated because it brought sexual "secrets" and their impact on Swazi families and society out into the open.
The campaign aroused intense passions. Varying interpretations of the key messages, as well as differences in opinion of how to effectively use mass media advertising to promote HIV prevention messages, were behind much of the controversy.
Audience interpretation: One of the key points of contention hinged on the interpretation of the term makhwapheni. NERCHA felt the term was gender neutral and could refer to either male or female secret lovers, whereas the Swaziland National Network of People Living with HIV and AIDS (SWANNEPHA) claimed in its petition to the Prime Minister that "makhwapheni in our society refers to women's secret lover." They argued that within Swazi society only women have secret lovers because it is culturally acceptable for men to have multiple, concurrent relationships. SWANNEPHA's interpretation of how it was used within the campaign was based on reviewing an advertisement that showed a woman initiating contact with her male secret lover; however, it should be noted that there were an equal number of advertisements showing men and women contacting their secret lovers. While the campaign tried to focus on risky behavior rather than blaming individuals for the spread of HIV, SWANNEPHA, based on their interpretation of the term makhwapheni, argued that the campaign was blaming women for bringing HIV into the home.
Stigmatization of people with HIV and orphans: PLWH believed the campaign could be interpreted to imply that all people with HIV are makhwapheni and therefore promiscuous. Another concern was that the campaign would discourage people who did not know their HIV status from getting tested out of fear of being labeled makhwapheni. Some pointed out the potential of the campaign to stigmatize orphans who had lost parents to HIV. One of the ads included the message "wait elubishinin," which can be translated as "and more orphans were left behind." The petition to the Prime Minister further criticized the campaign for failing to acknowledge the many ways one can be infected with HIV, such as "the presence of serodiscordant couples in our society" and the "many children who are living with HIV or AIDS [who] got the virus from their parents."
Reducing sexual partners as an HIV prevention message: Reducing the proportion of sexually active persons who have sex with more than one sexual partner is a key prevention objective in the national HIV strategy. Yet not all stakeholders found this appropriate or acceptable. The petition to the Prime Minister stated:
At the core of the campaign we should be reduction [sic] of transmission rates through practicing safer sex. If we concern ourselves with multiplicity and legitimacy of sexual partners, we shall be lost in a maze and in the process transmission rates will be continuing unabated.
In fact, the point of the campaign was to delve into the very issues that the petitioners argued should be left alone. Research that informed the campaign highlighted the importance of questioning the "multiplicity" of sexual relations. One HIV activist was quoted in The Washington Post as saying:
Don't tell me how many people to have sex with... you can't dictate that to me. I go to bed with someone. That's my choice. Rather, tell me how to be safer (Timberg 2006).
While the campaign did not explicitly tell people to reduce their number of sexual partners, it did unambiguously state that having secret lovers was a risk factor for HIV. In a culture where MCP are widespread, some may not have received the campaign favorably because of its emphasis on partner reduction, which they saw as inappropriate moralizing. Perhaps its message was less palatable than condom promotion messages because it requires more fundamental behavior change. Nonetheless, an overwhelming majority (87 percent) of respondents in the evaluation of the campaign agreed with the campaign messages.
Negative or fear-based advertising: The Makhwapheni Campaign focused on the negative consequences of sexual behavior ("You have put yourself in trouble") and on fear ("Secret lovers kill") to promote behavior change. Some who believe negative or fear-based advertisements do not work disliked the campaign's messages. The petition to the Prime Minister said "using fear does not work in the response to HIV and AIDS," and that such approaches "did not work 20 years ago" and will not work today.
"In a country where the response to HIV has been described as 'business as usual,' it may be appropriate for a campaign to confront complacency by focusing on the negative consequences of risky sexual behavior."
The use of negative or fear-based advertisements for promoting and sustaining behavior change has long been a point of debate. Some of the research that informed the development of the campaign questions the orthodoxy that fear campaigns in HIV prevention do not work (Green and Witte 2006). It argued that arousing fear in public campaigns can successfully promote behavior change when combined with messages that empower people to actively protect themselves.
Unfortunately, too little data exist on whether or when to use such approaches since, as the researchers have pointed out, there have been relatively few recent campaigns of this kind to study.
In a country where the response to HIV has been described as “business as usual,” it may be appropriate for a campaign to confront complacency by focusing on the negative consequences of risky sexual behavior. Unfortunately, too little data exist on whether or when to use such approaches since, as the researchers have pointed out, there have been relatively few recent campaigns of this kind to study.
It is not unusual for the public to have high expectations for mass media advertisements. Many believe that advertising can address myriad issues or delve into the complexity of an issue—but they cannot. The best advertisements aim to communicate one key message. To broaden the discussion, HIV mass media advertisements are often supported by multilevel communication activities, including community-level intervention and interpersonal communication, where issues can be explored in depth.
"Avoiding stigmatization of PLWH does not mean HIV prevention campaigns should shy away from hard issues. HIV prevention campaigns need to learn how to balance elements that promote behavior change with one segment of the audience without stigmatizing, offending, or providing an unintended message to another segment."
It is not clear whether the campaign may have contributed to the stigmatization of people with HIV. While NERCHA did not intend to stigmatize PLWH, all HIV prevention campaigns need to anticipate potential unintended consequences. But avoiding stigmatization of PLWH does not mean HIV prevention campaigns should shy away from hard issues. HIV prevention campaigns need to learn how to balance elements that promote behavior change with one segment of the audience without stigmatizing, offending, or providing an unintended message to another segment. At the same time, it is important to remember that negative or fear-based messages will not necessarily lead to more stigmatization of PLWH.
Implementation of interpersonal communication activities: A planned Phase II set of interpersonal communication activities for the campaign did not proceed. Unfortunately, after the first set of ads appeared, NERCHA did not have the time or energy to implement Phase II because it had to respond to the controversy and modify the campaign. As a result, the Makhwapheni Campaign relied solely on mass media to promote its message.
The lessons of the Makhwapheni Campaign suggest several recommendations for others exploring messaging approaches on MCP.
Ensure high-quality market research early in the process: This case study highlights the importance of market research for HIV campaign development. Market research can occur at a number of points, from concept development to pre-market testing of creative materials to tracking research during campaign implementation. The quality of the market research will help determine the quality of the campaign. Briefings from HIV technical experts can help researchers conduct well-focused market research.
The varying interpretations of the term makhwapheni highlights the importance of comprehensive pre-market testing early in the creative development phase to help producers understand how the audience might respond to the materials and whether they interpret messages as intended. This often leads to further refinement of the campaign material. While the Makhwapheni Campaign advertisements were market tested, this did not occur until after the campaign began, so the findings could not be used to fine-tune the final product before release. This meant that the campaign—which assumed the audience was HIV-negative—was not prepared for how PLWH interpreted the messages.
Involve key stakeholders: Involving stakeholders ensures greater community buy-in and therefore greater public support for campaign messages. Early involvement allows stakeholders to plan activities that support campaign messages. Input from stakeholders throughout campaign development and implementation can be valuable because stakeholders represent particular constituents and will bring their own set of perspectives to the process.
"Involving stakeholders does not necessarily mean that it will always be possible to reach consensus on the best approaches."
Inclusion of stakeholders needs to be balanced within a process that is manageable and timely, and where everyone understands their role and the decision-making process. Involving stakeholders does not necessarily mean that it will always be possible to reach consensus on the best approaches. This is one of the reasons why stakeholder involvement is not a substitute for comprehensive market research with the target audience. Stakeholder involvement and market research are both important to the campaign development process. This is one of the reasons why stakeholder involvement is not a substitute for comprehensive market research with the target audience. Stakeholder involvement and market research are both important to the campaign development process.
Among stakeholders consulted during the development of this case study, most said it would have been appropriate if they had been more involved in the development stages of the Makhwapheni Campaign. While some individuals were involved in development as members of the technical working group, they acted as expert advisors rather than as representatives of key stakeholder groups.
Use multilevel communication programs to achieve cultural change: The ultimate aim of the Makhwapheni Campaign was to change cultural norms that accept MCP. Achieving cultural change is challenging for any single mass media campaign because of the range of social and environmental factors that play a role. The South African Development Community Regional Consultation on Social Change Communication identified a number of contextual factors that must be addressed to facilitate behavior change, including gender, culture, socioeconomic status, spirituality, and the political environment (South African Development Community 2006).
Achieving behavior change requires reinforcing mass media campaign messages with multifaceted HIV prevention activities. Participants at a recent technical consultation on MCP sponsored by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) found that to achieve behavior change, "Programs will need to employ multiple communication channels, from mass media to community-level interventions and interpersonal communication to achieve scale-up" (Stash and Roseman 2008).
As an example, research examining the success of Uganda's HIV prevention efforts found that although mass media campaigns played an important role in raising awareness and fostering changes in behavioral norms, Uganda's approach to behavior change relied primarily on community mobilization and face-to-face communication (Green et al. 2006).
Involve and strengthen the capacity of PLWH to participate: In 2001, United Nations member countries endorsed the Greater Involvement of People Living with HIV principle. Swaziland's national HIV strategy also recognizes the importance of community mobilization and the need to improve the capacity of PLHIV to participate meaningfully in the national response to HIV. Giving PLHIV a seat at the table during campaign planning and implementation means their issues can be raised and considered, not that PLHIV organizations have to agree with all aspects of HIV prevention campaigns.
The PLWH organization SWANNEPHA felt that the campaign had not tried hard enough to meaningfully involve PLWH. Including PLWH throughout the planning process might have ensured comprehensive pre-test marketing to assess how campaign messages affected people living with HIV.
Since the Makhwapheni Campaign, subsequent campaigns in Swaziland have sought to address the issue of MCP, such as the regional multi-country One Love Campaign produced by Soul City. In addition, a new NERCHA campaign has addressed the issue of intergenerational sex.
Although the Makhwapheni Campaign may not directly translate to other settings, lessons learned from the Makhwapheni Campaign should be of value to neighboring countries in Southern Africa wanting to address the issue. The campaign demonstrates the importance of engaging the attention and ongoing interest of the audience. Other key lessons include the value of conducting high-quality market research, working to involve key stakeholders, and developing interpersonal communication activities to support campaign messages.
Another important overall lesson is that, if direct and hard-hitting campaigns are deemed appropriate, attention must be given to ensuring that groups within the community are not stigmatized as a result of unintended messages. Although achieving this balance can be difficult, campaign producers should not shy away from producing mass media advertisements that provoke a response from the audience.
The Makhwapheni Campaign has reopened an old debate within public health: When, if ever, is negative or fear-based advertising effective as an HIV prevention tool? If negative or fear-based advertising is to be used, how do you ensure such campaigns do not lead to increased stigmatization against people with HIV or other groups within the community? Finally and most important, how do you ensure that any immediate impact on behavior change is sustained?
D. T. Halperin and H. Epstein. 2007. "Why is HIV Prevalence So Severe in Southern Africa? The Role of Multiple Concurrent Partnerships and Lack of Male Circumcision: Implications for AIDS Prevention." The Southern Africa Journal of HIV Medicine, 8: 19–25.
UNAIDS, et al. 2009. Expert Think Tank Meeting on HIV Prevention in High-Prevalence Countries in Southern Africa Report Maseru, Lesotho, May 10–12, 2006. (PDF, 565 KB) (accessed July 8, 2011).
CIET Trust. 2006. Evaluation of a National Campaign to Reduce Multiple Partners in Swaziland, October 2006.
Green, E. C. et al. 2006. "Uganda's HIV Prevention Success. The Role of Sexual Behaviour Change and the National Response." AIDS and Behavior, 10(4):335–346.
Green, E. C. and K. Witte. 2006. "Can Fear Arousal in Public Health Campaigns Contribute to the Decline of HIV Prevalence?" Journal of Health Communication, 11(3):245–259.
The Government of the Kingdom of Swaziland. 2006. The Second National Multisectoral HIV and AIDS Strategic Plan, 2006–2008.
James, V. and R. Matikanyam. 2006. Protective Factors: A Case Study for Ngudzeni ADP (Swaziland). World Vision Australia/Swaziland.
Stash, S. and D. Roseman. 2008. Addressing Multiple and Concurrent Sexual Partnerships in Generalized HIV Epidemics. Report on a Technical Consultation in Washington, DC, October 29–30, 2008. Convened by the PEPFAR General Population and Youth Technical Working Group and AIDSTAR-One.
South African Development Community. 2006. SADC Regional Consultation on Social Change communication, Mbabane Swaziland, October 3–4, 2006.
Timberg, C. 2006. "In Swaziland, 'Secret Lovers' Confronted in Fight Against AIDS." The Washington Post, October 29.
This case study was written by Aldo Spina with the support of AIDSTAR-One, USAID's global HIV and AIDS technical assistance program. A great debt of gratitude is owed to the staff NERCHA for their agreement and support in undertaking this case study. Special thanks go to USAID and PEPFAR in Swaziland for their assistance, advice, and helpful feedback. Thanks also go to stakeholders who spoke honestly and insightfully about their experiences and thoughts on the campaign, including the Swaziland National Network of People Living with HIV and AIDS, the International Community of Women Living with HIV/AIDS, the Times of Swaziland, the Church Forum on HIV and AIDS, and S'buko Sesive.
Spina, Aldo. 2009. Secret Lovers Kill: A National Mass Media Campaign to Address Multiple and Concurrent Sexual Partnerships. Arlington, VA. USAID AIDS Support and Technical Assistance Resources, AIDSTAR-One Task Order 1.