Disease Prevention Seminar: Danielle Tougas and Rachel Mackay

Investigation and Application of Disease Prevention: A Case Study of HIV in Rural Tanzania
Learning objectives:
The seminar will focus on addressing three key learning objectives:
1) To be able to demonstrate an understanding of disease prevention, including a definition,
levels of prevention and key principles
2) To demonstrate knowledge of disease prevention strategies and integrate prior knowledge in a
case study
3) To compare and contrast global population health and community health programs for disease
prevention
Agenda:
Introduction (10 min): Introduce activity; discuss twitter question; discuss principles of
disease prevention with reference to assigned reading and AFMC Primer (Donovan, McDowell,
& Hunter, 2009) Learning objectives targeted: 1 (by defining disease prevention, levels of
prevention and key principles); 3 (by introducing differences between global and community
health programs)
Media piece (10 min): YouTube video from Ralf Jurgens discussing laws as barriers to
HIV prevention and care. Learning objectives targeted: 1 (identifying key principles of disease
prevention expressed in his talk); 3 (understanding the merits and issues of a rights-based
approach, as advocated by Jurgens; understanding that the approach he advocates is mostly
global (primarily using legislation as a tool) and discussing how this is different from a
community approach or how a community approach could be used here)
Case consultation (20 min): Provide participants with written materials detailing case
information and their respective roles on the consultations team (see Appendix); allow time for
participants to discuss the case and their prevention strategies to address it Learning objective

targeted: 2 (demonstrate knowledge of disease prevention strategies and integrate prior

knowledge in a case study)
Case presentations (15 min): Each group will be given 5 minutes to present their case and
there will be brief discussion of differences between the approaches Learning objective targeted:
3 (comparing and contrasting global disease prevention and community-based disease
prevention)
Take home messages (5 min): Disease prevention is complex and multi-leveled. It is not
an independent entity, but relies on many disciplines and practices, including surveillance, health
promotion and health needs assessment. Review learning objectives Learning objectives
targeted: 1, 2 and 3

Summary:
Everyone will be welcomed and thanked for gathering to address the high incidence of HIV in a
rural community in Tanzania. The class is intended to represent two trans-disciplinary research
teams that have been brought together to formulate an intervention strategy to prevent future
cases of HIV in this area. Class will be reminded that they have been chosen to address this issue
because they did such a positive job when discussing the issue of malaria (reference to the
assigned readings). The learning objectives for the seminar will then be showcased. In order to
present some background information on disease prevention, the presenters will acknowledge
that everyone here is an expert but that we want to be sure that everyone is on the same page in
regards to types of disease, disease prevention and the levels of prevention. This will provide the
presenters an opportunity to present a definition of disease prevention and provide further
explanation. This information will be presented through prezi and while presented in a primarily
didactic manner, will also employ a catechetical technique (e.g., getting students to identify

prevention strategies from the assigned readings). Thus, students will be given an opportunity to
discuss and evaluate the required readings. Additionally, key ideas from the weekly twitter
discussion will be integrated. The class will then receive a paper copy of the case and have 20
minutes to work on the case with their group and 5 minutes to present their prevention strategies.
This will be followed by a brief discussion of the prevention strategies and a recap of learning
objectives and take-home messages.

Script:
Rachel/Danielle: Welcome to the UNAIDS session regarding HIV transmission in rural
Tanzania. You have been invited as experts in disease prevention to work on a transdisciplinary
team to develop strategies to prevent HIV/AIDS in rural Tanzania. Disease prevention has both
local and global elements, so you have been divided into two groups accordingly. We know you
have recently had some success preventing malaria and we encourage you to draw on your
previous experience as you address this case.
Rachel/Danielle: Although we know that you are all experts, we will quickly review some
principles of disease prevention:
(The following points will be addressed in the Prezi and will include both didactic and
catechetical (question and answer teaching) elements. (Rachel/Danielles responses are in red)
Different modes of transmission and implications for prevention (chronic, infectious,
transmissible)
Primary, secondary, tertiary and primordial prevention (AFMC Public Health Primer; ask
students to identify where each of the readings falls on this continuum)
Article One (Montgomery, 2006): This article focuses on tertiary prevention because it discusses
reasons why mothers may not bring their children to a clinic despite knowing that the child may

have malaria. Thus the focus is on reducing the impact of a disease that is already symptomatic,
which is tertiary prevention.
Article Two (Snow and Marsh, 2010): This article mentions several levels of prevention as
means to reduce malaria burden in Africa. Primary prevention, which would require prevention
of Plasmodium falciparum transmission, was mentioned when discussing the use of treated bed
nets and indoor residential spraying for example. Tertiary prevention is included through the
mention of ACT. There is also inclusion of primordial prevention, as the article discusses
objectives for reducing levels of malaria via population level interventions that are aimed at
improving health of communities.
Article Three (Mushi et al. 2003): This article also discusses examples of primary prevention
(use of treated nets) and primordial prevention (providing vouchers to make treated nets more
affordable).
Community-based vs global disease prevention (both are important but play different roles and
can accomplish different things)
Prevention at the global level can involve more resources. It can also involve developing
standards from large evidence bases. There is potential for bigger or more upstream, impacts
such as changing laws or funding structures. An example of a global approach to disease
prevention can be found in the Snow and Marsh (2010) article. The article describes primary
(insecticide-treated nets, residual house spraying), secondary (improved diagnostic capabilities)
and tertiary (artemisinin-based combination therapy, preventing adverse consequences for
maternal and neonatal health) prevention strategies. The article also describes the amount of
funding that is available on a global scale - $5.3 billion from the Global Fund in the article ($8.8
billion is the current estimate on the Global Fund website). The Snow and Marsh article further

describes that this approach has had mixed success, with dramatic reductions in malaria in some
areas, while other areas are unaffected. It concludes that on the scale of the African continent,
few if any gains have been made, suggesting that global approaches can face some limitations in
their application to certain populations.
Prevention at the community level can be more responsive to individual community needs but
may be limited in its ability to affect the social determinants of health. For example, the
Montgomery et al. (2006) article focuses on expanding malaria education to fathers, recognizing
the role of gender in their study area. This shows a flexibility of approach based on local
circumstances but does not change the gender inequalities that prevent women from taking their
children to the clinic or reduce drivers of malaria (early treatment is tertiary prevention, not
primary or primordial). Similarly, although the Mushi et al. (2003) article targets primary
prevention through increasing awareness and accessibility of insecticide treated bednets, the
approach here is also limited by social determinants of health, including income and gender. By
focusing on the community approach, the authors were also not able to address problems of net
supply. However, the community-based approach gave the authors the ability to learn more about
their target population and to adapt their approach based on their research about barriers and
facilitators of net use.
Prevention techniques and strategies (ask students to identify from readings, Twitter or previous
experience; examples also provided in AFMC Public Health Primer and UOttawa Prevention
portal)
As discussed earlier, there are several levels of disease prevention that go beyond merely
preventing the transmission of a disease.
We will incorporate examples from Twitter here

 We will also introduce prevention techniques and strategies common to HIV

e.g., promoting condom use, monogamy, safe injection sites, prophylactic medication (preexposure and post-exposure), blood bank screening, regulations on blood donations, providing
free/low-cost HIV tests, maternal-child transmission education and medication, etc.
How is disease prevention linked to concepts we have already covered in this course?
Disease prevention is not an isolated entity. Instead, the concept is intrinsically linked with
concepts that have been covered thus far in the course. For example, health promotion is a
disease prevention strategy and surveillance allows us to identify which diseases need to be
prevented. Health promotion typically addresses the primary level of prevention.

Media Piece (10 min):

Rachel/Danielle: Now that everyone is on the same page regarding disease prevention as a
concept (seen through malaria lens), we would like to show a brief YouTube video discussing
some of the concerns surrounding HIV/AIDS prevention. Interventions aimed at preventing
disease can be well intentioned, but it is vital to evaluate them critically to avoid any potential
harms. https://www.youtube.com/watch?v=Rc3TNmAz6ac. Questions will be asked following
the video.
1) What are your initial thoughts after watching this video?
This video showcases the complexity of disease prevention. In the video, Jurgens typically
focuses on a rights-based approach to HIV prevention and approaches the topic from a global
perspective, using legislation as a tool. Moreover, by presenting some of the negative
consequences of disease prevention legislation, the need for critical assessment of interventions
is apparent.

2) Ralf Jurgens mentions a few examples of barriers to prevention rooted in law (inmates, drug
addicts, violation of human rights) can anyone suggest ways in which this could be rectified and
avoided in the future?
Awareness of the fact that barriers to prevention can be created or exacerbated from
legislation is a critical first step. Just being aware of possible barriers can make us more vigilant
to protect against them, and to take necessary action to reduce any harm such barriers may cause.
Follow up assessment of an intervention is needed in order to not only evaluate the efficacy of
the intervention, but also to ensure there are no damaging consequences. Moreover, a strong
partnership with the community can help enable earlier detection of barriers as well as identify
specific needs. Regarding HIV legislation, laws that help promote access and availability are key.
Rachel/Danielle: We have also found a public service announcement from Tanzania. This will
give you an idea of the approach to prevention that is currently being used in the country. Pay
attention to the messages the video sends about prevention, sexuality and who is responsible for
HIV. https://www.youtube.com/watch?v=_K_-72NXmv0 How will you consider this message in
your strategy? How will you change it?
The problem with this PSA is it doesnt provide a very comprehensive explanation of HIV.
Instead, it implies that having few partners is how you protect yourself from HIV, yet no mention
is made regarding safe-sexual practices. There is consensus that sexual behaviour is strongly
related to HIV transmission and overall sexual health (Johnson et al., 2001). However, this is
only one aspect of HIV risk and transmission. One can still have HIV despite having few sexual
partners, yet this message is not transmitted in the video or PSA series. This may result in an
educational gap in the population, which could put the population at greater risk. Additionally,
one of the topics on Twitter this week was public health ethics. By emphasizing monogamy as an

HIV prevention strategy, this ad could stigmatize people with HIV as promiscuous and
encourage a blame the victim approach among viewers.
Rachel/Danielle: Now, the case at hand. You have been asked to develop disease prevention
strategies for a rural Tanzanian community affected by HIV. You will all receive a delegate
package with specific details about the case, including HIV prevalence, current strategies in
place and major drivers of infection. Those of you on the local team will focus on local
strategies. Those of you on the global team will focus on strategies on a global level but will
show how the effects of these strategies are relevant on a local level.
Each team must:
Develop a disease prevention plan making use of at least two levels of disease prevention
Describe how you would decide which strategies to implement (hint: think of previously covered
topics for the course)
Justify your choice of strategy using an applicable combination of knowledge from your
concentration or other coursework, knowledge from this course (including your tweets for the
week), and grey or academic literature
Your briefings include some questions to guide your prevention plan development. You may
incorporate them as much or as little as you like into the final project, but we will come around
and discuss them with you. You have 20 minutes to cover the case and 15 minutes to present.
Your time starts now.
Take-home Messages (2 min):
Rachel/Danielle: A thank-you to each team for presenting your disease prevention strategies. We
would like to close this UNAIDS session by reviewing some of the key points from today's
discussion as well as revisiting our session objectives. As a concept, disease prevention is
complex and multi-leveled (objective 1). It is not an independent entity but instead, relies on the

many disciplines and practices such as surveillance, health needs assessment and health
promotion. As such, there are a variety of different disease prevention approaches and strategies
that can be employed (objective 2). Additionally, through discussion of the required readings,
differences between global population health and community health prevention programs were
able to be ascertained (objective 3). A global approach to disease prevention tends to be more
general but can mobilize more resources for the cause, whereas community health programs can
be tailored to adhere to the specific needs of a community.

References:
Donovan, D., McDowell, I., & Hunter, D. (Eds.). (2009). Association of Faculties of Medicine
of Canada (AFMC) Primer on Population Health. Retrieved from http://phprimer.afmc.ca/Part1TheoryThinkingAboutHealth.
Dunkle, K. L., Jewkes, R. K., Brown, H. C., Gray, G. E., McIntryre, J. A., & Harlow, S. D.
(2004). Gender-based violence, relationship power, and risk of HIV infection in women
attending antenatal clinics in South Africa. The lancet,363(9419), 1415-1421.
Gmez, C. A., & Marin, B. V. (1996). Gender, culture, and power: Barriers to HIVprevention
strategies for women. Journal of Sex Research, 33(4), 355-362.
Johnson, Anne M., Mercer, Catherine H., Erens, Bob, Copas, Andrew J., McManus, Sally,
Wellings, Kaye, . . . Nanchahal, Kiran. (2001). Sexual behaviour in Britain: partnerships,
practices, and HIV risk behaviours. The Lancet, 358(9296), 1835-1842
UNAIDS (2014, March 31). The United Republic of Tanzania Global Aids Response Country
Progress Report. Retrieved from
http://www.unaids.org/sites/default/files/country/documents/TZA_narrative_report_2014.pdf

UNAIDS (2013). The United Republic of Tanzania Epidemiological Fact Sheet on HIV and
AIDS. Retrieved from http://www.unaids.org/sites/default/files/epidocuments/TZA.pdf
Unicef (2013, December 31). United Republic of Tanzania Statistics. Retrieved from
http://www.unicef.org/infobycountry/tanzania_statistics.html
Rose, G. (2001). Sick individuals and sick populations. International journal of epidemiology,
30(3), 427-432.
Stokols, D., Hall, K. L., Taylor, B. K., & Moser, R. P. (2008). The science of team science:
overview of the field and introduction to the supplement. American journal of preventive
medicine, 35(2), S77-S89.

Appendix: Delegate Package

Welcome delegate! This package contains everything required to participate in the UNAIDS
session on HIV prevention in rural Tanzania. All information regarding the media discussion,
case description and background information on HIV in Tanzania can be found below.
Media Discussion:
Ralf Jurgens on Harms of Public Health Interventions:
1) What are your initial thoughts after watching this video?

2) Ralf Jurgens mentions a few examples of barriers to prevention rooted in law (inmates, drug
addicts, violation of human rights) can anyone suggest ways in which this could be rectified and
avoided in the future?

Tanzanian HIV Public Service Announcement (PSA):

1) What type of messages does this PSA send about HIV prevention, sexuality and who is
responsible for HIV?

2) How efficacious do you think this PSA is in preventing the transmission of HIV?

Case Briefing:
You have been asked to develop disease prevention strategies for a rural Tanzanian community
affected by HIV. As mentioned, this delegate package contains specific details about the case,
including HIV prevalence, current strategies in place and major drivers of infection, but you are
encouraged to search out more information to ensure that your strategies are evidence-based.
Those of you on the local team will focus on local strategies (ex. education programs, support
groups for people living with HIV/AIDS, condom distribution, access to local clinics for
treatment). Those of you on the global team will focus on strategies on a global level but will
show how the effects of these strategies are relevant on a local level (ex. negotiating with drug
companies for generic patents so antiretrovirals can be produced in LMICs, strengthening rural
communities to reduce poverty and urban migration, funding global campaigns to reduce
maternal to child transmission of HIV as part of maternal-child health campaigns). Note that
many issues can and should be addressed from both local and global perspectives: for example,
increasing access to medication can be done by negotiating generic patents to reduce cost of
medication at a global or national level, while extending clinic hours, training more staff or doing
outreach to rural communities can accomplish the same goal at a local or community level.
These two goals are complementary and each will enable the success of the other.
Each team must:

Develop a disease prevention plan making use of at least two levels of disease prevention

Describe how you would decide which strategies to implement (hint: think of previously
covered topics for the course)

Justify your choice of strategy using an applicable combination of knowledge from your
concentration or other coursework, knowledge from this course (including your tweets
for the week), and grey or academic literature

Your briefings include some questions to guide your prevention plan development. You may
incorporate them as much or as little as you like into the final project, but we will come around
and discuss them with you. You have 20 minutes to cover the case.

Things to Consider When Developing Your Prevention Strategy:

How does power and gender inequality influence HIV preventative (Think back to first required
reading)?
Risk of HIV is elevated in regions of gender inequality (Dunkle et al., 2004). For example,
women with a violent male partner are more likely to engage in risky sexual behaviours and
contract HIV (Dunkle et al., 2004). Women face distinct challenges in regards to HIV prevention
such as lack of power, self-efficacy and violence (Gomez and Marin, 1996). These factors must
be considered when formulating prevention strategies.
In what ways could you ensure cultural competency in your prevention strategy?
Partnerships with the local community to ensure a top-down approach isnt taken. Instead,
the community helps itself and improves from within.
Is there a risk of creating unintended harms with your prevention? What could those risks be?
Risks will vary depending on the type of prevention strategy being implemented. However,
potential risks could include exclusion of certain marginalized groups (inequity) and

infringement on social rights. Efforts can be undertaken to attempt to reduce these unintended
harms through partnership with the community and collaboration across disciplines.
What type of approach should your prevention strategy take? Population versus high-risk health
approach?
Population health approach makes more sense for implementing change to impact the general
population, while high-risk approach targets specific at risk populations (Rose, 2001). Depending
on where you want to implement your prevention strategy will influence the approach taken.
High-risk approach may be more beneficial in high-income countries (ex. Canada) where HIV is
more isolated to certain groups. Whereas in Africa, population approach may be more beneficial
as HIV is more generally distributed throughout the population.
How does having a transdisciplinary team influence the efficacy of the prevention strategy?
Given the extreme complexity of HIV and its associated problems, a holistic approach to
prevention is essential (Stokols, 2008). As such, collaboration across disciplines via
transdisciplinary research fields is vital to ensure comprehensiveness (Stokols, 2008).
Are there any other professions or roles that you believe should have been included on your
transdisciplinary team?
We would have included local people who are respected in the community, but did not feel that
anyone in this course could adopt this perspective, since to our knowledge none of the students
are from Tanzania
Background Information:
Statistics on HIV/AIDS in Tanzania (UNICEF, 2014)

Retrieved from: http://www.unicef.org/infobycountry/tanzania_statistics.html

Global health literacy tie-in: How does Tanzania compare to similar nations? Are its rates
of HIV higher or lower than expected? What about education? Condom use? (Check out
other countries on UNICEF for answers)

Trends in HIV infection (UNAIDS, 2013)

http://www.unaids.org/sites/default/files/epidocuments/TZA.pdf

Retrieved from:
http://data.unaids.org/pub/Manual/2007/20070306_Prevention_Guidelines_Towards_Universal_
Access_en.pdf
Information about Tanzanias current strategies:
Limited harm reduction campaign in Zanzibar
Education and condom use campaign aimed at reducing transmission in people aged 15-24
Strong emphasis on antiretroviral provision to prevent maternal-child transmission

Source:
http://www.unaids.org/sites/default/files/country/documents/TZA_narrative_report_2014.pdf

Potentially useful sources:

UNAIDS Practical Guidelines for Intensifying HIV Prevention:

http://data.unaids.org/pub/Manual/2007/20070306_Prevention_Guidelines_Towards_Uni
versal_Access_en.pdf (focus on pages 10-16 and page 34)

UNAIDS framework for evaluating HIV prevention programs:

http://www.unaids.org/sites/default/files/sub_landing/files/12_7_MERG_Guidance_Eval
uating%20HIV_PreventionProgrammes.pdf

AFMC Population Health Primer - pay special attention to segments on infectious

disease control and prevention: http://phprimer.afmc.ca/Part3PracticeImprovingHealth/Chapter11InfectiousDiseaseControl/Detectionandcontrolofoutb
reaks#Stage6:Planforlong-termpreventionandcontrol

Tanzania Commission for AIDS (TACAIDS): http://www.tacaids.go.tz/

Tanzania Third National Multisectoral Strategic Framework for HIV and AIDS
(2013/2014-2017/2018) (available as a PDF only; just search for the title)

Gapminder.org (examine HIV rates across time and in different regions)

UNAIDS Tanzania-specific report (focus on the overview of the AIDS epidemic in

Tanzania and current prevention strategies employed)