Renewing media and public attention to the AIDS pandemic in sub-Saharan Africa in the post-2015 development agenda : A reflective perspective

Since the emergence of the deadly HIV pandemic over 30 years ago, advocates and stakeholders in sub-Saharan Africa (SSA) have implemented diverse tactics to generate unprecedented media, public and political attention to the crisis (UNAIDS, 2011a). This paper examines some of the advocacy strategies undertaken to position HIV/AIDS in sub-Saharan African and concludes that the pandemic has reached the peak of its attention as a public health and development agenda on the continent. The post-2015 development agenda, which does not include a specific goal on HIV/AIDS, also raises concerns that public attention to the pandemic might diminish. However, the paper argues that AIDS is still an ‘unfinished agenda’ of the Millennium Development Goals (MDGs) and to sustain public attention in the future, advocates need to develop a new narrative for its rebranding and vigorously pursue an integrated and innovative social mobilization agenda.


INTRODUCTION
Sub-Saharan Africa is the epicenter of HIV/AIDS, and has experienced the worst cases of infection in the world (Gahaku, 2010;Robinson, 2011).According to Bärnighausen et al. (2012), the HIV/AIDS epidemic has had its most profound impact in sub-Saharan Africa, with 70 percent of new worldwide infections and 70 percent of HIV-related deaths; 1.8 million new infections in children each year, and 14 million AIDS orphans.UNAIDS (2015, p. 59) captures the staggering effect of AIDS with the following details: " In 2014, 25.8 million [24.0 -28.7 million] people in sub-Saharan Africa were living with HIV, accounting for almost 70% of people living with HIV worldwide.…Across the region, 13.8 million [12.8-16.0 million] women, 9.7 million [9.0 million-11.3

million] men and 2.3 million [2.2 million-2.5 million] children were living with HIV."
Although there were significant controversies on its origin and twisted arguments on its scale (Okigbo et al., 2014;Pisani, 2010), the pandemic has been positioned in the sub-region as a political, development and health issue.However, emerging evidence points to media, donor and public fatigue.The post-2015 development framework approved by the United Nations General Assembly (United Nations, 2015) which does not include a specific goal on the disease, as was the case with the MDGs, reinforces concerns that attention to AIDS is likely to plummet (UNAIDS, 2014).Against that backdrop, this paper analyzes some of the advocacy and mobilization strategies adopted to position HIV/AIDS in the media and public discourse in sub-Saharan Africa.It also reflects on the dimensions of the emerging fatigue to the pandemic.The paper argues that, to sustain attention on AIDS in the post-2015 development landscape, activists need to capitalize on the momentum already generated in the last 30 years and rebrand it through more innovative communication, cross-movement networking, and the elimination of insular issue positioning.

THEORETICAL FRAMEWORK
The challenge of getting social problems into public arenas has been addressed from diverse analytical standpoints and contexts.A comprehensive interrogation of the nuances of the vast intellectual discussion in this research area will not be possible within the scope of this review.However, two interrelated theories that underpin this paper are issue attention cycle and agenda setting.
In a seminal ork on issue-attention cycle, Downs (1972, p. 54) suggests that issues go through a five-stage attention cycle namely: pre-problem stage, alarmed discovery, euphoric enthusiasm, gradual decline and post problem stage.Although Downs does not propose that all issues go through a definitive linear progression of five stages, he agrees that issues may recapture public interest once they have reached national prominence.Two additional factors identified by Downs as imperative to the process of moving issues through the attention cycle include the size of the population affected by a problem and the intrinsic qualities of the issue.Other policy theorists (Sabatier and Weible, 2007;Schindlmayr, 2001;Zahariadis, 2007) have also underscored the importance of linking the issue-attention cycle to essential policy elements, such as policy subsystem, political processes, activism by advocacy coalitions, and public opinion.
Insights from agenda setting are also fundamental in understanding how issues get on the agenda in any society.First, it is important to note, as Dearing and Rogers (1996) observe, that agenda setting is an ongoing competition among issue proponents to gain the attention of media professionals, the public and the policy elites.Their study establishes the intrinsic connection among the different agendas in the society, primarily media agenda, public agenda and policy agenda.It is also generally argued that the mass media are fundamental in the formation of public opinion and public agenda building; however the relationship between the media and other elements of the policy change process is largely unclear.Kingdon (1995) expounds agenda setting from a policy domain to explain how issues get on the agenda of policy process.The theory identifies three main streams in the policy making process, namely; problem, politics and policy streams.Conceptually, the streams operate independently as political events flow on their own dynamics and their own rules.According to the author, the likelihood that an issue will be given attention within the political space is when two or all the streams connect, based on what is called a "policy window".In other words, the coupling of streams is what helps to attract attention to an issue (Zahariadis, 2007, p. 71).This approach also examines the role of policy entrepreneurs which helps to build momentum for issues.From this perspective, it is clear that the process of influencing political decision making and public agenda does not take a linear stimulus-response relationship.Invariably, getting issues on the policy agenda is a complex process involving the collective action by different stakeholders.It is also subject to what the author calls political manipulation of different political influencers and other contextual variables.
From a predominantly media angle, McCombs and Shaw (1972) examine the correlation between media agenda and the public"s agenda from where they developed the agenda setting hypothesis.In principle, the agenda setting hypothesis posits that the media are fundamental to shaping public debates and keeping issues on the public agenda (Kim et al., 2002;Pan and Kosicki, 1993;Scheufele and Tewksbury, 2007).However it is necessary to link media agenda setting function and issue-attention cycle to policy processes such as policy subsystem and public opinion.It is therefore argued that issue portrayal is fundamental and salience from the media on issues is important to issue attention.
Also relevant to issue-attention and agenda setting is the role of the digital media in our contemporary public sphere and development context.Clearly, the emergence of the digital media has affected how issues are positioned in society.Wilson and Murby (2010, p. 33) argue that the merger of social media and communication into a new media is changing the vital part of life, creating a new world of possibilities.Thus, with so many people "blogging, tweeting, uploading, downloading, crowdsourcing, wiki-ing, linking in, geo-referencing, i-chatting, skyping, flipping, videotaping and many more," they conclude that the possibilities for new media in social enterprise could lead to a new social eco-system.The new media also has great promise for advocacy and activism on social issues across the world.Brodock et al. (2009) found that increased digital activism is associated with access to multiple social media platforms.The authors note that with increased access to various new media formats, more people are becoming digital activists and mobilising public opinion for diverse social actions and issues.This has led to suggestions on the erosion of the traditional agenda-setting and gatekeeping function of the mainstream media and the emergence of new patterns of issue attention dynamics.
From this review, a number of lessons can be learned by advocates interested in positioning social issues in public discourse.First, public attention is a finite commodity.However, in a digital age, the nature of public attention has become more fragmented and democratized.Social issues compete for attention, thus to enhance the likelihood of attention, advocates need to understand the complexity of issue attention in our contemporary context.Second, without effective framing, it would be difficult for advocates to effectively position social issues in media and public discourse.Third, the mass media alone cannot guarantee that issues will receive public or policy attention in a contemporary world.Fourth, evidence from public policy making suggests that the "coupling of streams" (problem, policy and politics) by policy entrepreneurs plays a major role in influencing policy agenda.Finally, we argue that the "what" (the issue to be communicated) and the "how" (the way in which issues are portrayed) are important in achieving strategic positioning of social issues in society.In the following section, we shall present some of the communication approaches deployed in positioning HIV in SSA.

Cycles of campaigns
From the beginning of the HIV pandemic, advocates have adopted the "campaigns mentality" as a major element of social mobilization and public information.In most African countries, impassioned campaigns have been implemented to address (1) the drivers of the epidemic, such as ignorance and denial of HIV, gender inequality, peer pressure, sexual coercion, fatalism; and (2) HIV prevention strategies such as stigma and discrimination reduction, male circumcision, concurrent partnerships, the use of condoms and many other topics (UNAIDS, 2011b).Field experience shows that the AIDS fraternity moves from campaign-to-campaign, to continuously keep HIV in the media and public focus.The current campaign on "Getting to Zero" is focused on "zero new HIV infection, zero discrimination and zero AIDS-related deaths" (UNAIDS, 2011, p. 24).The campaign also incorporates mobilization of national leaders for political support and institutionalization of a positive environment for progressive national and regional AIDS programmes, policies and strategies.Without a doubt, the various campaigns have been a source of momentum to attract attention to the pandemic; however the unintended consequences of such campaigns deserve further investigation.Health activist and former international model.In 2015, the group was expanded to include the following: Kgalema Motlanthe (former President of the Republic of South Africa); Joyce Banda (former President of Malawi); Olusegun Obasanjo (former President of Nigeria) and Alpha Konaré (former President of Mali).This group of distinguished persons has been conducting dialogues with national and regional leaders on specific HIV issues, and has also carried out regional advocacy during international conferences.The group uses mass media channels for awareness creation and regularly produces communication materials, such as booklets, blogs, fliers, newsletters, editorials, and reports on thematic HIV issues.An impact assessment of the role of the network is yet to be undertaken, but it is argued that the social capital of the group has great potential of enhancing the public and media attention to HIV and AIDS in the region.

Deployment of advocacy coalitions
Influential African musicians have played a critical role in attracting media and public attention to HIV.In many countries, songs have been used to explain the impact of HIV, motivate action against stigma and promote community support towards the elimination of discrimination against people affected by HIV (Gahaku, 2010).An example of such celebrity advocacy for HIV is afro beat Nigerian musician, Femi Anikulapo Kuti, appointed a UNICEF Goodwill Ambassador following his father"s death from AIDS.Through music festivals and performances, he has drawn attention to the impact of HIV and challenges public ignorance (UNICEF, 2000).The various spokespersons and celebrities engaged for AIDS advocacy have played a considerable role in raising awareness and mobilizing public attention.However, to sustain the movement in an era of boredom with the pandemic, novelty and repackaging would be necessary (Gahaku, 2010;UNAIDS, 2014).

Use of special events
Special events serve as platforms for national and transnational advocacy to position issues at various levels.The World AIDS Day is the epic event in the AIDS calendar for public advocacy and mass mobilization.This annual campaign commemorated on 01 December every year, integrates multimedia activities and public outreaches, including songs, symbols, speeches, dances, reports, demonstration, candle-light vigils, orature, storytelling, and other social influence tactics.Major national and regional events such as sports festivals have also been used to draw attention to the pandemic.Special events have been useful in attracting attention, but their sporadic nature vitiates their long-term effectiveness.As Robins (2014) argues, the ritualized expression during special events is largely inadequate when AIDS is a ferocious and daily reality in many parts of the continent.This calls to question the long-term impact of such events.

Regional and national media partnerships
Media partners have played a major role in attracting attention and interest in HIV and AIDS.The South Africa HIV and AIDS Information Dissemination Service (SafAIDS) established in 1994 has contributed to information collection, production, dissemination, networking and building partnership on cutting-edge issues around HIV and AIDS.Media networks such as the Forum for Southern Africa Editors on AIDS, the Media Institute of Southern Africa (MISA) and Journalists against AIDSs (JAIDS) have also been established.In many African countries, journalist networks on AIDS have increased the level of attention to HIV issues (Komolafe-Opadeji, 2008).In the early 2000s, the co-sponsors of UNAIDS established collaborative engagements with influential media institutions such as PANOS and Inter Press Service (IPS) to publish informed and wellresearched stories on the pandemic.The African Broadcast Media Partnership against HIV/AIDS (ABMP) is another creative initiative which promotes the HIV-free generation campaign.The collaboration with broadcast media partners from over 70 broadcasting networks on the continent resulted in the allocation of 5% of airtime to HIV issues (ABMP, 2010).
Overall, the establishment of regional and national media network plays a significant role in promoting media and public debate on HIV.Furthermore, to build media capacity in understanding HIV and AIDS issues, development agencies have sponsored thematic media consultations.Following the conclusion of the randomized controlled trials on male circumcision (MC), UNAIDS and its co-sponsors organized a series of media sensitization from 2008-2010 with representatives of the Media Institute of Southern Africa.The objective was to educate them on the science of male circumcision and to mobilize their support for effective reporting.UN agencies and other development agencies also facilitated thematic consultations and orientation on the orphan crisis in the region, HIV treatment, prevention of mother-to-child transmission of HIV and a host of HIV issues.Clearly, media consultations, orientations and training workshops play a significant role in strengthening the capacity of media professionals in raising awareness and shaping the HIV agenda in sub-Saharan Africa.Nevertheless, many of these sessions were sporadic, uncoordinated and unsustainable, resulting in wavering portrayal in the region.

Multimedia production and publications media
As already noted, the domain of HIV is very complex; its science is progressively unfolding.The provision of updated information and education materials is essential for the media and public"s understanding of the issues.This has led to the development and dissemination of diverse information materials for public education.A multitude of studies, reports, and analyses have been produced and circulated to the mass media.A clearing house was established in the 1990s to facilitate prompt information dissemination to media institutions and professionals.UNAIDS and its co-sponsors have also launched and distributed regional and global reports, the Global Plan Progress report, and World AIDS Day reports for public and media information.Targeted exhibitions, photo essays and other forms of visual communication have also been organized to stimulate public attention to specific HIV issues (UNAIDS, 2014).Other tactics include information packages such as good or best practice, case studies, investment cases, briefing notes, policy briefs, score cards, progress reports, infographics, and trend analyses have been produced and disseminated.

Civil society activism
One of the hallmarks of AIDS positioning is targeted activism by civil society organisations.The example from South Africa is a good reflection of civil society activism that has been pivotal to promoting attention, public and policy attention to HIV (Robins, 2006).South Africa has a strong tradition of political activism which has been transferred to the health and development arena.Various civil society organisations, including the National Association of People Living with AIDS (NAPWA), AIDS Law project (now Section 27); AIDS Consortium, COSATU and many others, were involved in the fight to attract attention to HIV and promote appropriate government response.The Treatment Action Committee (TAC) became the most-vociferous in mobilizing support against HIV.
Critical social influence activities include media engagement, supporters" mobilization and public outreaches (TAC, 2010).The TAC established district branches and trained their members in various aspects of HIV and empowered them to demand their rights.The TAC members also undertook community outreaches, one-one-one discussions, thematic workshops and advocacy with key influencers at the local level.A coordinated set of protest marches (popularly called "ToyiToyi) was organized to generate public attention.The TAC organized public protests at the Constitutional Court in 2002 and in 2010 for universal access to treatment (TAC, 2010).A powerful technique in the advocacy efforts of TAC to influence government actions was litigation.The TAC instituted legal actions against government and such cases served as opportunities for attracting public and media attention to HIV concerns.Government"s refusal to roll-out ART for infected people was challenged in the courts.
Overall, AIDS has been positioned at the regional and national spheres and has been made a media, public and political issue.HIV has become a story about arts, culture, taboo, sexuality, religion, celebrity business and politics.Political commitment has been mobilized with African leaders committing national and regional political support for a robust response (AU Summit 2015).Vibrant advocacy coalitions have been established, continually advocating for different aspects of the HIV narrative (UNAIDS, 2011a).Regional and national business coalitions have been formed, providing a private sector insight to the response (The World Bank, 2004).International gatherings of experts, advocates and intellectuals (such as International Conference on AIDS and STIs in Africa, ICASA) have been institutionalized to keep the public debate going.Nevertheless, after 30 years of the pandemic, evidence indicates a plummeting of public and media attention.

The emergence of 'fatigue'
As Shiffman (2006) opines, HIV has reached its pinnacle as a global health agenda, while to Schneider and Garrett, (2009), the AIDS pandemic does not grab the kind of attention it did in the past because the development landscape has been crowded by many issues competing for attention.The challenge of donor fatigue to HIV is also well documented.For example, Buse and Martin (2012) opine that international financing for HIV has not increased since 2008.Also in a special report to commemorate the 30-year anniversary of the pandemic entitled, "AIDS at 30: Nations at the crossroads", the UN Secretary General, Mr. Ban ki-moon observes: "International resources needed to sustain this progress have declined for the first time in 10 years, despite tremendous unmet needs" (UNAIDS, 2011a, p. 7).Dwindling resources allocation to AIDS is definitely a sign of fatigue.
Media attention to HIV stories is shrinking.Reviews undertaken by Esipisu (2013Esipisu ( , 2014) ) confirm that HIV is a "tired" story because it has been told over-and-over again, resulting in media fatigue and a general unwillingness among editors to approve another HIV story.In another study, (Chalk, 2014) found that HIV is no longer a story which engages journalists or the public.Boredom with HIV also manifests in different population groups.In an article "Does anybody remember AIDS?" focusing on the situation in South Africa, (Heywood, 2014) writes: "AIDS is sinking ashamedly back into the shadows, where many think it should always have been, like Tuberculosis….AIDS points fingers at academics who romanticized and theorized "social movements" when they were on the rise, but deserted them when they began the difficult days of staying alive.AIDS rebukes media houses who brought AIDS to (the) light and now help to put it back into the shadows; journalists who found convenient heroes but now ignore the real ones because they are poorer or darker.AIDS reviles editors who make (it) something into the past when it"s still in the present." From the foregoing, emerging evidence suggests that public and media attention to AIDS may be declining, which is a natural phase in issue-attention dynamics (Downs, 1972;Jones and Baumgartner, 2005).It is therefore argued that in the post-2015 development agenda, AIDS will need to compete with broader development issues such as planet, people, prosperity and peace (United Nations, 2015) which may further reduce the attention it gets.Thus, rekindling public attention to HIV/AIDS would be essential in the post-2015 development agenda.

CONCLUSION AND RECOMMENDATIONS
This paper sought to examine some of the approaches adopted by HIV/AIDS advocates to position HIV/AIDS in the media and the public discourse in sub-Saharan Africa.Our examination has demonstrated the diversity of strategies executed to attract attention to HIV such as information politics, multimedia packaging, strategic engagement with various media and political gatekeepers and opinion leaders.However, like most social issues, after reaching prominence, HIV is now affected by public and media fatigue.The consensus from the literature is that HIV/AIDS may be on the cusp of attention decline (Shiffman, 2006).Going forward, we argue for a repositioning or a rebranding strategy which will involve two fundamental shifts: (1) a macro-framing of programme direction, and (2) a strategic shift in AIDS communication"s philosophy.
First, a new macro-framing of the future direction of AIDS messaging is pivotal to keeping the issue on the various agendas.Different studies have affirmed the role of effective framing in issue positioning (Kahneman et al., 2011;Scheufele and Tewksbury, 2007;Weaver, 2007).A reframing of AIDS will therefore be critical for its future prospects.The current top-line message of "ending AIDS by 2030" has become the master narrative for the next 15 years (UNAIDS, 2015).Its main targets are: "reducing new adult HIV infections and eliminating new infections among children; reducing stigma and discrimination faced by people living with HIV and key populations; and reducing AIDS-related deaths" (WHO, 2014, p. 9) Clearly, the science of HIV is emerging and a trajectory of the epidemiology is relatively well-established now.However, we argue that the overall messaging should promote integration and linkages with relevant health areas, such as sexual and reproductive health.This implies that the AIDS fraternity would need to avoid the insularity or exceptionalism of the past (Shiffman, 2006;Smith and Whiteside, 2010).Second, communicating HIV after reaching the peak as a public health agenda in Africa will require a different philosophy.Evidently, the traditional hype and buttonpushing images of "AIDS kills" of yesteryears or the arcane slogan: "Africans are dying of AIDS" of the past will not work in an age of innovative treatment strategies and in the post-2015 framework.In search for the new philosophy of HIV communication, Chasi (2014, p. 75) recommends an "Ubuntu" informed communication approach in South Africa, which may be applied to other African countries.According to the author, "If HIV/AIDS communication is guided by the ethics of Ubuntu, it is possible to imagine democratic ways of living in which individuals feel valued, loved, trusted and hopeful in ways that make development and health the norm."Within the new philosophy, the role of the media will not just lie in reporting stories but in promoting dialogue on HIV (Pirio, 2012).This will also involve a new level of investigative journalism to tell the "untold stories" of the pandemic and moving the HIV narrative beyond the slogans and sound bites of development agencies which have dominated the traditional communication of HIV and AIDS.This will also involve systematic empowerment of multiple communicators (including health workers) with adequate information and knowledge of HIV issues to keep the dialogue going behind the media headlines.To be clear, HIV communication needs to move from just messaging, to voice; and to the interactive engagement of people who are the center of development (PANOS, 2003).
Third, the strategic use of evidence for appropriate framing has played a fundamental role in inspiring individual action and social influence (Sidibé et al., 2010).However, new evidence and arguments will still be critical in the rebranding process.Compelling narratives based on evidence, medical research and innovative programming will continue to be needed in keeping various segments of society informed.Nevertheless, advocates should be cautious of "playing with the numbers" to attract attention (McNeil Jr., 2007;Timberg, 2006;Kresge, 2007).
Fourth, effective use of social and digital media will be essential to sustaining public interest in HIV.Advancements in digital media and communications technology have generated considerable optimism on the role of social media in achieving developmental and public health outcomes globally.Developments in mobile telephony have made the sharing of health messages more interactive, more "mobile" and almost a 24/7 phenomenon.The extensive availability of mobile phones has accelerated the delivery of health messages and made health education more social and more interactive; a far-cry from the traditional information, education and communication (IEC) approaches of yesteryears.Social media power needs to be optimized.As the UNAIDS Executive Director opines: "The potential of social media and mobile technology to re-energize the AIDS movement is clear.We need nothing less than an HIV prevention revolution, with social media and mobile technology at its core" (UNAIDS, 2011c, p. 1).However, a robust combination of various media platforms for effective dialogue with different populations will be critical.
The post-2015 development framework calls for new arguments and approaches for communicating AIDS to tired media and a bored public.AIDS advocates need to rethink their philosophy of mobilization to sustain attention to the pandemic in the new development context.
Champions for HIV-free Generation was formed in 2008 to champion HIV response on the continent.Members include: Festus Mogae, former President of the Republic of Botswana; Dr. Kenneth D Kaunda, First President of the Republic of Zambia; Joaquim A Chissano, former President of the Republic of Mozambique; Benjamin William Mkapa, former President of the United Republic of Tanzania; SpeciosaWandra, former Vice President of Uganda; Desmond Tutu, Archbishop Emeritus South Africa and Noble Laureate; Justice Edwin Cameron, South African Supreme Court of Appeal Judge; Professor Miriam Were, former Chairperson of the Kenya National Aids Commission; and Liya Kedebe, Maternal and Child