Picturing AIDS: Using Colour Pictures to Raise Global Awareness

Raising awareness on any Public Health issue can be a major challenge, especially where ‘sexually transmitted infections’ and ‘death’ are part of the discussions. These are still two major ‘taboos’ that are rarely or reluctantly talked about. This article is, firstly, about a strategy that was used in Zambia and Botswana to raise awareness around sexually transmitted infections (STIs), with a focus on HIV infections and AIDS. The strategy involved showing clinical colour pictures and story-telling in HIV/AIDS empowerment (AIDucation) in the villages. Secondly, to demonstrate the role of faith community leaders in AIDucation; and thirdly to show that an African village solution or public health HIV/AIDS intervention strategy could be replicated in Europe or the West in addressing the spread and the control of HIV infections and AIDS.


Introduction
Raising awareness on any Public Health issue can be a major challenge, especially where 'sexually transmitted infections' and 'death' are part of the discussions. These are still two major 'taboos' that are rarely or reluctantly talked about. This article is, firstly, about a strategy that was used in Zambia and Botswana to raise awareness around sexually transmitted infections (STIs), with a focus on HIV infections and AIDS. The strategy involved showing clinical colour pictures and story-telling in HIV/AIDS empowerment (AIDucation) in the villages. Secondly, to demonstrate the role of faith community leaders in AIDucation; and thirdly to show that an African village solution or public health HIV/AIDS intervention strategy could be replicated in Europe or the West in addressing the spread and the control of HIV infections and AIDS.

AIDucation in Livingstone, Zambia and Lobatse, Botswana
Zambia and Botswana are two countries in Southern Africa that have been grossly affected by HIV infections and AIDS [1], Table 1, with obvious visible and invisible socio-economic impacts, in the local communities. Reaching out to educate local communities on an 'invisible disease' was a major challenge in the late 1980s and early 1990s. The public health messages had to reach the communities in line with 'prevention is better than cure, ' especially as there was no cure or treatment for AIDS at the time…and at present.
There was a national crisis and emergency that had to be addressed in the two Southern African countries to prevent thousands of preventable infections, ' AIDS-related diseases, cancers…' and deaths. Diseases such as tuberculosis (TB), hepatitis, herpes zoster, other sexually transmitted infections especially with genital sores or open wounds; chronic fungal infections; cancers such as Kaposis sarcoma, cervical cancer, lymphomas and anal cancer that can be indicators of undiagnosed and an underlining HIV infection(s) must be high-lighted and taught to the public for prevention of new infections and better access to care.

Colour Pictures in Public Health and AIDS Education (AIDucation)
Raising awareness through the use of colour, clinical & social, pictures with story-telling or use of traditional 'oral history' was born in Livingstone, Zambia, in 1990. Village folks wanted to '…see AIDS so as to believe, ' that there was such a '…sexually transmitted infection that made you so thin…had no treatment…and ultimately caused death. ' AIDS was claiming a lot of lives in the African countries. No one could 'see' AIDS! Many folks did not heed 'the AIDS' Story. ' If anything it was believed amongst young people that AIDS was an 'American (or Adults) Ideology for Discouraging Sex. ' "Scare tactics (AIDS)" of addressing teenage pregnancies and sexually transmitted infections. Denial was very strong.

District Medical Doctor, Dr. Edwin Mapara, embarks on Local AIDucation
A local Zambian medical doctor working at Livingstone General Hospital in Zambia came up with a novel initiative of 'picturing AIDS' to the general public, who doubted the existence of AIDS or "the radio disease…the thinning disease…disease of the blankets, " as locals would say in the vernacular languages.
Medical doctors and nurses knew of AIDS. Healthcare personnel are trained with "Medical Illustrations" or "Clinical colour pictures" during their training at medical schools or nursing schools respectively. Medical conditions were 'pictured' before actually seen on the wards, in the clinics or hospitals.
Why not extend the medical and nursing schools' teaching with 'colour pictures' (awareness training tool) to the lay, grassroots community members or villagers? The village folks were in serious denial despite nursing some of the discharged patients in home-based care. The public and home-based care volunteers had to be equally protected from possible infections.

"A Picture is Worth a Thousand Words"
The English say, 'Seeing is believing…a picture is worth a thousand words. ' The Africans in the same vein say, "Seeing (eyes) is very different from being told (mouth) … you remember more of what you see (eyes) than what you hear (ears) or are told (mouth). " This is the foundation of AIDucation, picturing or using visual aids to empower the community. TALC is a non-governmental organisation, (http://www.talcuk. org/), born in 1964 that supplies cheap (not expensive) teaching aids and books to raise standards of healthcare and improve the quality of life of disadvantaged individuals and communities. TALC has traditionally focused on developing countries. It has now become global and distributes materials to more than 200 countries.

AIDUCATION: Picturing AIDS in Europe's Universities and Colleges
In 2002, after twelve fruitful years of 'picturing' AIDS in Botswana, Dr Edwin Mapara re-located to London, to study at the prestigious London School of Hygiene and Tropical Medicine (LSHTM), University of London. The Zambian trained medical doctor had no inclination whatsoever that as from 2005 to date, July 2016, the local African born "AIDucation" programme would become international and part of the university courses.

AIDUCATION: Picturing AIDS in Europe's Black & Minority Ethnic Communities
In 2005, the black and minority ethnic (BAME) groups in London benefitted from Zambia's AIDucation programme that was born in 1989. Community Health Action Trust (CHAT), an African-led charity based in Willesden, in the borough of Brent, soon became a household name. CHAT implemented a successful AIDucation Course for the BAME communities that ran for five years. AIDucation was the talk of Brent! More than 8,000 community members were enlightened and empowered between 2005 and 2010. AIDucation led to the birth of a 'best practice' project, a community-based voluntary counselling and testing (VCT) centre at CHAT [3]. The HIV awareness campaign in Brent led to more than 750 people going for a finger-prick HIV test between 2007 and 2009 at CHAT.

AIDUCATION Gives Birth to Voluntary Counselling Centres (VCT) in London
The CHAT VCT Project was a documented a 'best practice' -"Model 2 VCT in community based centres," by The London VCT Project Report (August 2007). Soon London followed CHAT's initiative, as community-based VCTs mushroomed across London that has a population of close to 10 million people. AIDucation's rallying call was, "Better to know, than not to know," voluntary testing for HIV infection, diabetes, hypertension and chlamydia.

AIDUCATION Library of 120 Colour Pictures from TALC is Foundation
AIDucation lectures, workshops and conferences were built on five (5) sets of TALC colour slides (pictures), 120 pictures. Each teaching set has 24 colour pictures with a script. The pictures are mostly of Africans or Asian people, so as to move away from the initial belief that, "AIDS is a white man's disease…in gay communities and injecting drug addicts. " The TALC sets used in 'picturing' AIDS to raise awareness and initiate HIV prevention are:

Feedback on Raising HIV/AIDS Awareness with Colour Pictures -Local (London)
CHAT ran a three (3) years Community Integrated Sexual Health Initiative Course (CISHI) sponsored by the Kings Fund, that targeted Pastors and Imams in the BAME communities. The 'CISHI AIDucation Course' began in 2007 and concluded in 2010. There were a total of 15 courses that lasted 3 days each [4].
Total number of participants were two-hundred and fifty (250), who went on to sensitise hundreds more people, Table 2 4. "Very, very interesting and meaningful…If somebody tells you, you think it is rubbish until you see those pictures…HIV is real. " 5. "The visuals are offensive to pastors with inabilities to talk openly and freely on HIV/AIDS…blocked by culture of where we are coming from. " 6. "Motives behind the pictures are important…if the motive is to educate people, I do not see anything wrong with that. If the motive is pornography, then there is something wrong. " 7. "Pictures send home the message…what you see has a way of impacting on you…what you see sticks in your heart…recorded in your heart…you remembered forever. " 8. "In our culture pictures may be embarrassing, but once you get the message behind the pictures, they are not embarrassing. They leave a lasting impression. " 4. "We never had any AIDS discussions in our church. " 5. "I never carried out any activities…I was not bold enough.
Secondly the culture did not allow me to talk about sex. You dare not discuss it at all…either in the church, community or group…it is a taboo subject. " 6. "Very useful course…before CISHI I never talked HIV infections to my congregation. " 7. "Before CISHI I was involved in some HIV/AIDS activities, but not as much as now…my knowledge did not permeate to the church…nothing much will change…ours is a spiritual approach. " 8. "Activities before CISHI, we never had…I did some health activities but not focussed on HIV problem only…it was broad health like smoking, blood pressure and obesity. " 9. "Many people believe AIDS is for homosexuals…not for the church to address. "

"No activities at all…AIDS was for doctors and nurses to teach
and not pastors. " Knowledge on HIV infections and aids before cishi course    People need love…unconditional love…like Christ did for us. " 5. "People were trying not to talk about HIV infection initially (Denial). We had to AIDucate the church and it has paid off… People are empowered. People did not even know the meaning of wearing a red ribbon…people wrongly assumed that wearing the red ribbon showed that somebody had AIDS!" 6. "Stigmatisation is still rife in Church…that is why the people do not want to test for HIV. Discrimination is there…encourage the people to have HOPE…pray with them…I will not announce it in church…confidentiality is kept…I do not even explain it to my assistant pastors…I lead the person to the hospital…trust is very important. " 3. "Chances are limited, the law does not give a free hand…you are not allowed to ask somebody to go for HIV testing…the law does not allow you to be counselling because it is for specialists trained in counselling. " 4. "We do not preach condoms…the law does not allow you to talk freely…there is God…there is healing…there is divine health…To avoid the law, churches keep away from HIV/ AIDS…we leave it to the doctors and nurses. "

"
The law is not friendly at all here … but you can walk into any hospital in Africa and the people want you to pray for them. The others (patients) will also call you to pray for them, not here…here there is political correctness to fear!" 6. "In Africa you have the liberty to preach without the government interfering, but here there are too many laws…one has to be careful with the language used…sensitive. " 7. "There are so many hurdles…blockades…legislature… government policies…legal barriers…one has to be careful how he speaks to patients… mentioning God, Christ, or bringing your faith into places is a very sensitive issue…you can be in trouble. " 8. "Hope and belief is given by the African church, but here if the church is quiet and not involved, how does it give that hope and belief to somebody with AIDS? It is difficult. " not know (Subject of AIDS)…that is why discriminating behaviour. " 4. "The Bible says my people perish because of lack of knowledge… AIDS is a good example where we lacked knowledge…people died and will continue to die. " 5. "Knowledge is power. We lacked knowledge…As the Bible says, we are saved to save others…The knowledge is given to me (as a pastor), so as to impart it to other people. I plan to organise some programmes…church gatherings…family gatherings…where my duty is to introduce the knowledge to them (congregation members) and then work with a doctor to teach the rest…to reduce stigma and welcome all…All made in God's image. " 6. "We lacked knowledge, wisdom and understanding…Ours is to help look after people with HIV/AIDS and to give them hope, just like Jesus gave hope. Some pastors do not know or understand that this includes looking after people with HIV / AIDS. Christ came more for the sick and oppressed…the church must care for its flock…even with AIDS. " Denial, stigmatisation and discrimination in faith communities 1. "There is stigma and discrimination in the church…I was in that group of people who spread stigma and discrimination before October 2008…I used to condemn those people with AIDS…I could not live with them, shake their hands or even imagine eating with them…After the CISHI course I can eat with them, use the same plate and I can sit with them…I do not put them as second class citizens anymore…They are (human beings) just as I am. "

Church leadership and silence on AIDucation
2. "Pastors have been sinning by not shepherding His (Jesus) sheep…HIV is not for sinners…It is for any person…the church must not be judgmental…the church must love. " 3. "Stigma exists because of ignorance…ignorance is root of stigma…you shall know the truth and the truth shall set you free…pastors through visits and shaking hands of clients can address stigma through pastoral action. " Volume 7 • Issue 9 • 1000611 J AIDS Clin Res ISSN: 2155-6113, an open access journal 9. "Even as a hospital chaplain you have no right even to suggest prayers for a patient…even if the patient is dying…you have no right…you cannot blame pastors for not being involved (in the AIDS campaign). " 10. "The law needs to be AIDS friendly for the church to be visible in church AIDucation!" The church and the use of the condoms 1. "The condom issue is a controversial one and a naughty one.
They say it prevents AIDS…I do not preach on condoms…I preach on abstinence… my advice is something that should give a 100% protection and security. " 4. "What if an atheist might marry a Christian sister and infect the Christian sister? What happens? Meanwhile the sister has been abstaining…so they must use condoms. "

Feedback on Raising HIV/AIDS Awareness with Colour Pictures -International
Global or international comments on "Pictures: Using Images to raise HIV/AIDS awareness" narrated in 2010, from the Communication Initiative Network website -http://www.comminit. com/healthecomm/top-tens.php?showdetails=188 [5]. 8. '"A picture is worth a thousand words. ' These pictures make our work as health educators much easier, especially as a resource that we can access so readily, I believe that health educators can access them from anywhere in the world. Find more materials so that over time, the picture bank becomes bigger and bigger. Keep the spirit of sharing these invaluable resources. Best regards. " [East and Southern Africa] 9. "I strongly believe Dr. Mapara is right in using pictures to education AIDS. Having seen the pictures myself, I still have that imprinted in my memory and feel once I saw the pictures, I truly believed. There are so many myths and stories that surround AIDS and the pictures tell only one story, 'You will contract AIDS if you do not protect yourself against it. ' AIDS has been looked at as an ' African problem' but that is not the case. With the financial migration of Africans and Asians to Europe and America, political asylum seekers and refugees, this is something that the entire world should be worried about and continue to do something about. Pictures are just one way of trying to combat AIDS as there are several other ways. I congratulate Dr. Mapara  2009, that just ended, I strongly believe they (pictures) are the best way to reach even in the illiterate masses of many developing countries and also the already developed countries. I am also a believer of 'SEEING IS BELIEVEING' as the saying goes. How I wish Malawi which has been one of the hardest hit in the sub-Saharan was considered, and accorded an opportunity to benefit greatly from Dr. Mapara. How I wish he was here yesterday than the unknown tomorrow. " [East and Southern Africa] 21. "I think pictures or images talk more than we do. For me it I a good way to make people aware of the diseases. Good luck Dr. Mapara!" [West Africa] 22. "As the population in Africa is in majority illiterate the best way to spread such important information is by pictures in the sense that Africans are more visual memory. This method already in use in Ivory Coast has helped a lot to bring the population at an acceptable level of knowledge of this calamity. " [West Africa] 23. "Useful to acknowledge input from regional examples, e.g.
TAS0-Uganda. This shows the practicability of interventions in almost similar settings. TBA and PMTCT figures, Botswana have some impressive figures!! Article has a genuine applicability on a wider regional scale. " [East and Southern Africa] 24. "I have found that visual aids/pictures are the most effective way to reach young people with the effects of sexually transmitted infections. This is knowledge that I have gained from previous experience, working with young people. Although tutors have sometimes found the images offensive, young people have not, they have seen and acted by way of seeking more advice and resources to practice safe sex. As a pastor I have seen negative attitudes towards people living with HIV and a blame culture of immorality so rife coupled with ignorance as the church has closed its ears to information. I have taken it as a challenge for our organisation to work with the church in Africa to make then take on HIV as part of their agenda. The use of pictures will just be the quickest way of making them understand. As Edwin says, 'Seeing is believing. ' As a sexual health promotion specialist we have worked with Edwin during our different promotion days such as World AIDS Day and others. We have also used them (pictures) in training primary care staff. They are a very useful tool and will not hesitate to refer others to them.