Behavioural Surveillance Surveys - The Wisdom of Whores

How are these indicators selected?
Essentially, for prevention efforts to make a
difference to the course of the HIV epidemic,
three things have to happen :
1. The intervention has to be delivered as
planned
2. It has to reach the people for whom it was
intended
3. Those people have to adopt behaviors that
reduce the risk of HIV transmission
Indicators can be defined for each of these
levels, but BSS concentrates on measuring the
third level : the behaviors which directly
influence the HIV epidemic. These are the
behaviors that determine :
• The likelihood that an uninfected person
will come into contact with an infected
person. This is determined by number and
type of sexual partners, or by patterns of
needle exchange.
• The likelihood that transmission of HIV
will occur if that contact comes about.
With regard to sexual behavior, this is
determined principally by levels of condom
use, but also by other factors such as the
presence of another STI (influenced in turn
by treatment-seeking behavior). In drug
injecting it is determined by equipment
sharing practices.
So indicators need to be selected that
measure these aspects of risk behavior.
But they have to share other qualities too.
Indicators should above all be relevant to
program effort. It bears repeating : there is
no point trying to measure changes in behavior
if you are not doing (or planning to do)
anything to bring about the change. Indicators
need to be capable of measuring trends over
time (so yes/no type measures such as
“the existence of a law requiring the regular
screening and treatment of sex workers for STIs”
would not be considered a useful indicator).
Indicators need to be easy to interpret. This
has proven a stumbling point for indicators of
attitudes, in particular, since many attitudinal
questions invite an element of “it depends”
in the response, so that it is hard to be sure
what exactly is being measured. The precise
wording of questions determines to a large
extent how easy behavioral indicators are
to interpret. Recommendations for ensuring
the clarity of a questionnaire are made in
Chapter 5. Finally, indicators need to be
feasible to collect.
While most of the suggested indicators
focus on sexual and drug-taking behaviors
themselves, BSS surveys may want also to
investigate factors likely to promote high-risk
sexual behavior (such as alcohol and drug use)
or to reduce it (such as knowing someone with
AIDS, having been exposed to a prevention
program, or knowing one’s own HIV status).
Accordingly a small number of indicators are
defined in these areas. The questionnaires
also provide information on all sorts of other
aspects of risk behavior and exposure to risk,
which may be very helpful in program planning,
and in helping to interpret changes over time
in key indicators. This includes socio-demographic
information that can be used to
compare samples over time, for example
the country of origin of sex workers, or the
educational level of men who have sex with
men and are sampled in cruising areas.
These are not included as indicators in their
own right, since they are not generally things
that prevention programs are directly trying to
influence. They do not therefore meet the first
criterion of indicator selection, which is that an
indicator should be relevant to program effort.
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C H A PTER 9 B EHAV I OR A L S U R V EI L L A NC E S U R V EY S