- Look at the world!
- Which world?
- What do you mean, there is only one world!
- Yes, maybe in your mind...?

The Geographical Perspective


13. The Geographical Perspective


The geographical perspective puts the light on the spread of the pandemic. At the same time it should be understood as an eye-opener for local epidemics. Since there is a global spread of HIV, we can clearly say that the disease has a global geographical coverage, even if the spread is not equally distributed. Some areas of the globe are heavier affected by AIDS than others, and this can be explained through factors such as: 1) where the virus first mutated (its epicentre), 2) movement patterns of people, and 3) how countries have responded to the local epidemic.
This means the risk of getting infected varies from area to area. If you for example live/travel to an area heavily affected by AIDS, the risk of becoming infected will increase, which of course also depend on what you do, the risk behaviour, your and the surrounding population’s knowledge about the disease, how it is spread etc., and if you are able to protect yourself or not, access to condoms etc.
Therefore, there is a need for us working on HIV prevention to understand the incidence and prevalence rates in the geographical areas in which we work.

The spread of HIV differs also from area to area in most countries. In India for example, studies on HIV prevalence among tested pregnant women have shown that there are differences ranging from 0.1 percent in one district to over 3 percent in others. Also the US shows large geographical differences where areas in the southeast are more affected than those in northwest. Similar division can be seen in countries like China, Japan, Brazil and Russia, most likely connected to socio-economical factors and traditions in trade, as well as travelling and tourism.

In the Security Perspective I wrote about refugees fleeing from their homes to avoid conflicts of various kinds, in connection to the risks of contracting HIV. Here I will highlight people migrating for other reasons, such as to seek for a better life in another countries or other areas within the country, trying to get a job so they can send money back to the family. I hesitated when deciding where to write about this, and decided to connect refugees to security and migrants/guest workers to geography.
It is estimated that 125 million people live and work outside their country of citizenship, while between two and four millions migrate permanently each year. This migration can have a large impact on their health as it has been shown that migrant populations are at greater risk of developing poor health in general, and HIV infection in particular. Reasons for this are a combination of many elements such as the impact of the socio-cultural patterns of migrant health, their economic transitions, their reduced availability and accessibility of health services, and the difficulty of the host country’s health care systems to cope with the traditions and practices of migrants. Also, the
otherness of migrants is an element that can create xenophobia, isolation and hostility by the host community. In addition, as with other people living with HIV or AIDS, migrants who are HIV-positive are subject of stigmatisation and discrimination, and therefore they hide their HIV status as long as possible, thus making support services unavailable for them.

The preconceived idea that migrants have more sexually transmitted disease than locals and therefore are at greater risk of contracting HIV, has only been indicated true when single men live isolated from the new community. If they migrate and live with their family, the risk of contracting HIV is at same level as the general population. It is however not only their single status which leads to having multiple partners and commercial sex, it is also connected to their employment, often in a low-status job and their geographic mobility, which lower their chances of creating stable relationships with a partner in the host culture.
In these cases, the understanding of the causes of increased risk cannot change the situation, but it may add to the understanding of factors determining the risks and the directions of the interventions.

If we narrow the geographical areas further, we can also see differences between rural and urban areas. HIV infected people are more prevalent in cities than rural areas. However, it does not stop there. Also the city is divided and different areas within the city attract (or forces) different kinds of people for different kinds of reasons, housing, worship, working, entertainments, sex, sports, and other cultural lifestyle activities. Working on HIV prevention, we need to know who might be most at risk in these areas. So the geographical perspective involves both sub-groups, meeting places for drugs and sex, and the area should include both physical areas as well as virtual once, i.e. the Internet.
The places existing in the local settings are arenas where different cultural specific methods can be used to communicate with the target groups aimed for the activities.

As in all prevention work in other cultures than your own, there is a need in HIV prevention work for understanding the ethnicity of other cultures, their sexual orientations as well as to give recognition to specific social groups e.g. sex workers, homo- and bisexuals and drug users are needed, as well as the importance of involving both women and men in the work. Remember, we do not have to “love” who other people are or what they do, but we need to understand, involve and respect them as fellow human beings in order to be able to work effectively on prevention.

Knowledge and understanding of the population we are working for (and with) is essential for being able to provide proper services, and for organisations to develop in good and stable ways. This mindset is also linked to the choice of methods, and the selection of media to use for this. In market economy, marketing is based on trying to develop a message people will “buy”, so the companies providing the goods or services can survive and develop. If you want to reach everyone, you will reach no one. In HIV prevention we want to reach different people, so we need to develop different messages and methods to do so. It is often said that information does not change people’s behaviour. Of course it doesn't, if there is no reasonable recognition amongst those the information is designed for!

I claim that most of us who are involved in HIV prevention activities, and draw strategies and plans for different interventions have too little knowledge about marketing and its mechanisms. Too much focus is put on how to bring attention to the own organisation, or to provoke or suck-up to decision makers? Maybe it is time to brand different behaviours, and label them in similar ways as other well-recognised brands have done (e.g. Ferrari, Swatch, Levi’s, Volvo, D&G, Pepsi, IKEA, Mac, Samsung, MacDonald’s, Real Madrid…) to promote behavioural change in our messages?
I remember Philip Kotler (Principles of Marketing) when studying marketing many years ago. He presented the four “P’s” as one strategy for a Marketing Mix:
Product, Package/Promotion, Price and Place (distributive channels), Purpose was later added, for good reasons.
In HIV prevention terms, the Product is the knowledge and information that we want other people to know about. Package/Promotion is the design of brochures, posters, advertisements, TV/radio commercials etc., how we present the Product. Price is the cost of running the campaigns and prevention projects, often presented in contact-cost. Finally, the geographical perspective equals to the
Place, meaning where we can reach and come in contact with the different groups of people we need reach to make HIV prevention effective.

At last I would like to draw the attention to our own “geography” that exists within our mind-settings, which I call “the world map” in training sessions I conduct. It is an exercise based on our thoughts about other people that affect our actions, which are also connected to our feelings. If you want to know more about this exercise, please contact me. (I do not want to disclose it here, since many persons I conduct training for follow my writings, and this would spoil the “surprise moment” in this exercise.)
Maybe you expected to have a presentation in this perspective, on the HIV prevalence in different geographical areas of the world. I am sorry if I have disappointed you, but as I have stated earlier; there are many other sources for statistics and numbers, and I wanted to point out other matters that I find essential for being able to understand the complexity of AIDS.


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This concludes All the 13 Perspectives of AIDS, which I have presented in these articles. Connected to this concept, I have developed a practical tool , in the form of a checklist, on how to plan for, and implement HIV prevention programmes and projects, taking all these perspectives into consideration. Please contact me for further information if you find this useful or interested in learning more about how to use this concept for developing your work on HIV prevention.