Until recently, there has not been much good news about HIV prevalence or incidence. And although prevalence and incidence rates are finally declining in many African countries [
2], there still remains much work to be done in identifying the factors associated with successful responses to the epidemic, particularly in the realm of prevention. Using a case study approach, much of the existing research identifies political will and the capacity of African governments as predictive of HIV outcomes [
3‐
8]. But some weak countries, like Uganda, have enacted positive change, while some of the richest countries, with the most capable governments, like Botswana and South Africa, have experienced persistently high prevalence rates.
The case study methodology thus fails to achieve the generalizations made possible by statistical analysis of more observations. Previously used methodological approaches therefore produce insufficient evidence for use in designing health-related interventions. To circumvent these issues, I rely on between-country variation in organizational and structural factors, particularly those associated with population interventions, in order to try to explain variation in HIV outcomes. Specifically, I analyze data on all sub-Saharan African countries to test for a statistically significant association between the organizational and political structures resulting from efforts to address population growth in the 1980s and 1990s, and HIV outcomes in the 2000s.
The hypothesis that there exists a relationship between population-related interventions and later HIV outcomes rests on the assumption that many of the obstacles faced when implementing family planning programmes are similar to those experienced when implementing HIV prevention programmes. These include, and are not limited to, the challenges associated with talking about sex, particularly with young people, as well as concerns over altering sources of authority for sexual decision making. Simply put, preventing pregnancy and preventing HIV in sub-Saharan Africa both require that people change the way(s) they have sex. In both instances, governments, organizations and international actors with large sums of money have involved themselves, leading to a continuity of issues, actors and outcomes across interventions. For these reasons, we should see a relationship between earlier population interventions and later HIV outcomes.
This research adds to a small but growing body of literature addressing the links between population and HIV interventions. Stillwaggon [
10] criticizes HIV interventions for paralleling population interventions and failing to address larger issues driving population growth and HIV transmission, specifically poverty. Richey [
11,
12] points to the continued narrow focus of population interventions, even in the era of reproductive health, on family planning, which comes at the expense of an integrated approach that includes HIV/AIDS. And Cleland and Watkins [
9,
13], while noting important differences between the two issues, state, “The ambitions, assumptions and implementation of both [population and AIDS] movements are strikingly similar and the social processes by which the AIDS crisis is ultimately resolved are likely to be similar to the processes that earlier led to the widespread adoption of fertility control” ([
13], see page 208). This existing research, combined with the analysis in this article, supports the importance of analyzing the history of sex-related interventions in order to develop better policies and programmes, and ultimately improve human wellbeing.
The following section provides background on population interventions in Africa and the known determinants of successful HIV outcomes. I then discuss the examples of Senegal and Malawi, which illustrate the connections between the organizations and political structures associated with population interventions and later HIV outcomes, as a precursor to the statistical analysis that forms the core of the paper.
Population interventions in Africa
Between the early 1960s, when most African countries gained independence, and the late 1970s, pregnancy prevention was not a primary concern of most African governments, organizations or individuals. A combination of economic and social motivations promoted high fertility norms at the individual level, and these were reflected at the national level by positive views towards population growth, which many African governments saw as a means to increase the size of their economies and to achieve scale efficiencies in production. During the 1960s and 1970s, private, non-governmental family planning organizations began to crop up in a number of countries, meeting the burgeoning demand for contraceptive services of primarily a well-to-do urban clientele, and by 1980, approximately half of African countries had such an organization [
14]. By the 1980s, as recession loomed globally and donors promoted structural adjustment programmes and population reduction locally, some African governments began to view 2% to 3% annual population growth rates as a burden that challenged their promises to educate and employ citizens, as well as keep them healthy.
Population policies designed to limit population growth through reduced fertility were one result of this shift in perspective. Although Kenya and Ghana announced policies in 1967 and 1969, respectively [
15,
16], following these early declarations, there was an almost 20-year lag before a glut of policy announcements started in 1986 when Kenya announced a revised policy, and continued in 1988 when Nigeria, Senegal and Liberia adopted policies [
17,
18]. This trend continued through 1999, with 27 additional countries adopting new policies, and Ghana adopting a revised policy. Since then, no country out of the 15 remaining countries without policies has announced one, although some countries have revised their policies [
19]. Generally speaking, these policies focus on reducing population growth as a means to achieve improved standards of living.
In addition to representing government willingness to address issues related to sex, population policies matter for a number of reasons. First, countries that adopted population policies received, on average, more funding from the United States Agency for International Development [
20]. Second, countries with population policies experienced statistically greater fertility declines between 1987 and 2002 than those without such policies: 21% compared with 14% (author’s calculations from the World Bank [
21]). Third, countries with population policies have a greater potential to improve gender and human rights because the policies motivate discussion of sex, generation and power, and provide language to groups promoting such rights [
22].
Determinants of successful HIV/AIDS outcomes
The key mechanisms through which reductions in HIV/ AIDS have been, and can be, realized are decreases in the number of overall and concurrent sexual partners, increases in condom use, increases in the age at first sex, and prevalence of male circumcision [
23‐
32]. Existing scholarship has identified two main factors that operate through these mechanisms to determine country-level success in addressing HIV/AIDS: (1) political leadership and commitment; and (2) government coordination with NGOs and other civil society organizations.
Political commitment and leadership should help reduce HIV prevalence because they galvanize action around HIV/AIDS, organize those efforts, and provide legitimacy to messages promoting behaviour change [
3‐
7,
33‐
36]. There remains, however, no convincing cross-national study that shows that political commitment leads to reductions in prevalence of HIV, although factors such as lack of ethnic fragmentation [
37] and press freedom, income equality and high HIV prevalence [
38] lead to high levels of political commitment, and countries with “good” leadership provide better care to their HIV-positive citizens [
39].
The second prominent factor associated with successful reductions in HIV prevalence is government interaction with civil society, broadly understood to include NGOs, community-based organizations, religious organizations, labour unions and other social groups [
3,
5‐
7,
33‐
36]. Coordination with such groups provides the conduits through which messages about prevention are spread, as well as increases the perceived legitimacy of messages that cover sensitive issues relating to sex, morality and religion.
The most-frequently studied AIDS success stories in Africa are Uganda and Senegal. In Uganda, HIV prevalence declined from approximately 20% to 10% in the 1990s [
30]. The mechanisms for Uganda’s decline were a decrease in number of sexual partners and an increase in condom usage [
30,
40]. The drivers for these changes included political leadership on the part of the country’s charismatic president, Yoweri Museveni, a decentralized government that allowed for local experimentation and personalization of responses to HIV/AIDS, and active incorporation of different social groups in prevention efforts [
6,
23,
40‐
43].
In Senegal, HIV prevalence has remained at approximately 1% since the 1980s [
23]. The mechanisms for this lack of increase in prevalence include low numbers of multiple concurrent sexual partners, a less virulent form of the virus (HIV-2), an increase in the age at marriage and first sex, and almost universal male circumcision [
7,
8]. These outcomes resulted from early government acknowledgement of HIV, effective management of sexually transmitted infections among sex workers, and active incorporation of social groups, particularly religiously oriented ones, in distributing HIV-prevention messages [
8,
23,
34,
42,
44‐
47].
The emphasis of the literature on political commitment, and on the cases of Senegal and Uganda, poses three challenges to determining the causes of variation in country-level success addressing HIV/AIDS. First, political commitment is a difficult variable to measure [
7,
34,
35,
48] and may not actually translate into action once countries have learned that displays of political commitment are necessary to garner and maintain international support [
42,
46]. Second, the cases of Senegal and Uganda do not generalize well. In Uganda, the timing of the decline in HIV prevalence indicates that behaviour change most likely occurred
prior to intervention by Museveni and international donors, and so is probably not the result of policy [
1,
30,
49]. In Senegal, there is no way to know whether the epidemic would have actually grown out of control in the absence of the government actions taken [
50], particularly given the relative protection provided to the population by near-universal male circumcision and other factors.
The third challenge to determining the causes of variation in country-level success addressing HIV/AIDS is that although the literature has identified government engagement with civil society as key to fighting HIV/AIDS, no systematic research has incorporated measurements of the strength of civil society. The analysis that follows addresses all three challenges to the existing literature by testing a new hypothesis about the legacy of population interventions, employing a multi-country analysis, and incorporating information on the historical depth of NGOs. These contextual factors are highly likely to impact HIV-related outcomes.
The examples of Senegal and Malawi
Population and HIV interventions in both Senegal and Malawi provide support for the hypothesis that experience with country-level population interventions impacted later success in addressing HIV/AIDS. In Senegal, there is evidence that some of the factors associated with its successful response to HIV mirror previous experience gained in response to population issues, including the development of NGOs, government support of sex-related health issues, and government and NGO interaction with religious leaders. In Malawi, there is evidence that negative experiences with population interventions may have spilled over onto early HIV efforts. I provide these cases to illustrate the potential causal pathways through which the variables representing population interventions included in the statistical analysis that follows (early family planning NGOs and the existence of a population policy) may have influenced HIV outcomes.
As mentioned, Senegal was a vanguard population policy adopter in 1988. While the policy resulted from an intersection of national and donor goals, practically it represented the willingness of the government to address issues related to sex. In addition, through the 1980s and mid-1990s, Senegal ranked in the top third of African countries based on the degree of effort put towards providing family planning services and supplies [
51]. These government efforts were rewarded by donors, as Senegal was a popular recipient of international aid for population activities [
52].
In addition to positive government efforts towards family planning, Senegal’s strong civil society encompassed a number of reproductive health NGOs. In 1985, prior to the emergence of HIV/AIDS, there were 31 local NGOs doing some work in the area of reproductive health in Senegal [
19], and this figure grew to 57 by 1989. One of the most important NGOs involved in family planning and sexual health in Senegal, the
Association Sénégalaise pour le Bien-être Familial, or ASBEF, was founded in 1975 and affiliated with the International Planned Parenthood Federation in 1981. It provides sexual and reproductive health services, particularly contraception, to youths as well as to women through clinics in the majority of Senegal’s regions.
NGOs helped facilitate dialogue on population issues with religious leaders, civil society and the government. A national seminar entitled “Islam et Population” was held in 1984, with the assistance of ASBEF [
53]. ASBEF also hosted a roundtable on Islam and family planning in 1989. Then, following the 1994 United Nations conference on population and development held in Cairo, Egypt, a set of networks related to religion and contraception were formed. One was the
Réseau des Parlementaires Sénégalais pour la Population et le Développement (Senegalese Network of Parliamentarians on Population and Development), making Senegal the first country to have a network of parliamentarians working on population issues.
The existence of ties between the government and religious leaders, and between NGOs and religious leaders, also proved to be beneficial in response to HIV. Specifically, outreach to civil society organizations, particularly religious ones, began with efforts to promote family planning, and most likely spilled over into HIV prevention efforts. Senegalese government coordination with religious leaders on HIV dates from at least 1989, and in 1994, the primary US-funded AIDS programme in Senegal, AIDSCAP, and the Senegalese government surveyed religious and political leaders regarding their attitudes towards AIDS [
54]. One of the recommendations from the analysis of this data was a national colloquium on religion and HIV, as religious leaders had indicated that they wanted to be involved in the response to AIDS [
54], and this role was institutionalized with a major conference in 1995 between Muslim and Christian leaders [
55].
An additional set of parallel conferences were held on religion and HIV. The first, in 1995, was entitled “AIDS and Religion: The Response of Islam” [
54], and was attended by Islamic religious leaders from all over the country. In addition to providing an important opportunity for dialogue, the key outcome from the conference was a statement that it was acceptable for serodiscordant couples to use condoms [
54]. The second, “AIDS and Religion: Responses of Christian Churches” was held in 1996, and was also attended by Islamic leaders [
54]. Although there is no explicit evidence that religious leaders’ practice of dialoguing about family planning paved the way to similar conversations about HIV, the parallel experiences are certainly suggestive.
Malawi’s response to population growth differed dramatically from that of Senegal. Hastings Kamuzu Banda, president from 1964 to 1994, exercised a form of authoritarian rule that emphasized cultural nationalism, particularly respect for hierarchy and authority [
56]. As a result, he found western “permissiveness” particularly threatening, and had a very narrow view of the role of women [
56], both of which made family planning unacceptable and led him to ban it during the 1960s [
15]. As donor interest in family planning increased in the 1980s, the Malawian government remained unwilling to fully endorse family planning, and so implemented a “child-spacing” policy in 1982 with a goal to increase the number of years between births [
15]. It was not until Malawi transitioned to democracy and Banda left office in 1994 that the government adopted a national population policy [
15].
In parallel, through the 1980s, Malawi had family planning effort scores in the bottom third of African countries, and had only moved to the middle tier by the mid-1990s [
57]. The primary family planning organization in the country,
Banja La Mtsogolo, was not founded until 1987, and the affiliate of the International Planned Parenthood Federation (IPPF) only came into existence in 1999 [
19] when the government parastatal involved in family planning, the National Family Welfare Council, was privatized ([
58], see page 18).
Malawi’s initial response to HIV/AIDS was mixed. Despite being a medical doctor, President Banda had minimal commitment towards HIV/AIDS [
43]. The Ministry of Health’s National AIDS Control Programme, started in 1987 [
34], was ultimately quite ineffective [
43]. AIDS was declared a national emergency in 1999, but this still did not provoke much local interest, and the removal of the National AIDS Control Programme from the Ministry of Health in 2001 in order to comply with World Bank guidelines, decimated the ministry and further hampered efforts to address HIV [
34]. Surface efforts to address HIV/AIDS continued: a national AIDS policy followed in 2004, and that same year, HIV became a campaign issue for the first time [
43]. It was not really until ARV therapy became widely available in 2004 [
59], however, that the intensity of the response to HIV skyrocketed in Malawi.
The fact that the government began to care about population growth at the same time as HIV/AIDS was leading to increased mortality made the government’s efforts in relationship to HIV all the more suspect [
60]. Like family planning, HIV was also viewed as something dubious that came from abroad [
61]. Family planning was seen as a western effort to take the fun out of sex, as were the condoms that health workers and NGOs insisted be used to protect against HIV. As a result, the acronym for AIDS was given an alternative interpretation: the American Invention Depriving Sex” [
61].
Amy Kaler [
60] has explained the suspicion about AIDS and condoms as the “long shadow of population control” describing how everyday Malawians’ interpretation of family planning efforts impacted their understanding of AIDS and AIDS interventions. Specifically, Malawians interpreted family planning efforts as the combined efforts of donors and the government to decimate the population of a country that was constantly begging for international aid. Given this degree of suspicion about population control, when the same actors began talking about AIDS, Malawians saw AIDS as a continuation of those population control efforts: a further concerted effort to eliminate the population. Because the same actors also proposed solutions for AIDS, particularly condoms, Malawians were understandably suspicious. As a result, condoms were viewed as dangerous, ineffective and possibly even the source of AIDS itself.
The examples of Senegal and Malawi suggest that the nexus of interventions related to population growth and family planning both practically and symbolically structured the macro context in which these same countries addressed HIV. I turn to testing this hypothesis in the following statistical analysis, which looks particularly at whether countries had an early affiliate of the IPPF (which Senegal did and Malawi did not), as well as whether countries had a population policy.