Skinning the goat and pulling the load: HIV risk and violence among youth in Tanzania

1. Skinning the goat and pulling the load: HIV risk and violence among youth in Tanzania Suzanne Maman Health Behavior and Health Education

2. The associations between HIV and violence • Violence as a risk factor for HIV infection • Women in violent relationships less able to enforce HIV preventive behaviors. • Women who have experienced physical and sexual abuse engage in more HIV risk behaviors. • Biological trauma from forced sex may facilitate HIV transmission. • Violence as an outcome of HIV status disclosure (4) Violence is a major barrier to disclosure for HIV+ women.

3. Growing evidence of the overlapping epidemics of HIV and violence • In South Africa, women with violent partners have a more than 50% increased risk of acquiring HIV. (Dunkle et al., 2004) • In Tanzania, the odds of reporting violence are 10 times higher for young, HIV-positive women as compared to young, HIV-negative women. (Maman et al., 2002).

4. Rationale for working with young men • Men are generally perpetrators of gender-based violence • Men control the terms & conditions of sexual relationships • Very little is understood about the attitudes and behaviors of young men in this context • Young men lack access to information and services • Adolescence is a time when lifelong patterns are formed

5. Tuelemishane ProjectDar es Salaam, Tanzania An intervention to reduce HIV risk and reported use of violence among young men using a combination of peer support and community theatre

6. Tanzania Population: 33 million Pop in Dar: ~ 3million Per capita GNP: $246 Life expectancy: 45 years HIV prevalence: 8.8%

7. Intervention Design The intervention consists of two major components: • Community Theatre • Trained theatre group perform interactive skits • Performances in venues frequented by young men • 3 different skits performed 12 times • Peer support • Young men enrolled in groups of 10-12 • Groups meet monthly for 12-months • Facilitated by trained peer group leaders

8. Research Design • Formative Phase • IDI • 14 FGD Evaluation Design Intervention 475 men, 16-24 yrs Interviewed baseline Participate in intervention Interviewed 2 month Post-intervention Control 475 men, 16-24 yrs Interviewed baseline Interviewed 2-month Post intervention IDIs with the female partners of 40 men

9. Formative and Baseline Findings

10. Relationships revolve around sexual activity • To love a partner means one must be willing to have sex • “How can she be my partner without making love? To know that she loves you and she’s your partner you must make love, that’s why I convinced her. “ (male, 24 years, not married) • There were few examples of partnerships between young men and women that did not involve sex.

11. Mistrust of sexual partners due to concerns of infidelity • Youth described little emotional/romantic love • Mistrust stemmed from concerns about infidelity and financial motives • Infidelity openly acknowledged by men and some women • Infidelity the most common trigger for violence mentioned by women

12. Mistrust also related to the transactional nature of relationships • Expectations of money/ gifts from male partners • Money/gifts used as yardstick to measure the degree of men’s love. • Some women engaged in sexual relationships out of need • “When girls need assistance they must have sex to get that assistance.” (male, FGD participant) • Concerns over the financial motivations of women was the primary trigger for violence mentioned by men.

13. The language that youth use to describe their relationships reflect the mistrust • Pulling the load (Anavuta mzigo) • Men describe taking on new girlfriends as pulling the load • Skinning the goat (Kuchuna buzi) • Women describe strategies to extract money from their partners as skinning the goat

14. Conservative attitudes regarding gender norms and expectations • 69% of men agreed that men should have final say in all family matters • 48% felt women should tolerate being beaten to keep family together • 44% felt if women want to leave abusive partner they must leave children behind

15. Experiences with violence in childhood were common • 11% reported unwanted sexual touching or intercourse under the age of 12 years • 43% reported experiencing serious physical violence as a child • 28% reported witnessing their father physically assault their mother

16. Young men describe substantial HIV risk • 70% of men were sexually active and the mean age of first sex was 16 years (SD 2.90 years) • The mean number of lifetime partners was 3.96 (SD 5.55) • 47% reported having had sex without a condom in the past 6 months

17. Use of physical violence against female partners was high • Among sexually active men, 30% reported at least one episode of physical violence with a partner • 9% reported using physical violence to force a partner to have sex • 5% reported reacting violently when a partner refused to have sex

18. Factors associated with the use of physical violence • Number of sexual partners • Men with 4-10 lifetime partners had 5 X greater odds of reporting violence (95% CI: 2.6-10.4) • Men with 2 or more partners in the past 6-months had 2 X greater odds of reporting violence (95% CI: 1.19-4.56) • Pressure from peers to have sex • The odds of reporting violence was 2.5 X higher among men who report moderate pressure from peers to have sex (95% CI: 1.30-4.99) • Childhood physical abuse • The odds of reporting violence was 2 X greater for men who experienced physical violence in childhood (95% CI: 1.42-3.33)

19. Conclusions

20. Despite being two decades into epidemic, youth are still at risk • 8.8% of Tanzanians are HIV infected nationally • 60% new infections occur among 16-24 yr olds • Multiple partnerships were common • Unprotected sexual intercourse was common

21. Men control the sexual decision making in relationships • Men describe conservative attitudes related to sexual norms and expectations • Women have limited agency in the process of initiating and maintaining partnerships

22. The socioeconomic context plays a role in the formation and dynamics of sexual relationships • Women engage in sexual relationships to achieve financial support • The transactional nature of relationships leave women vulnerable to both HIV risk and violence

23. There were clear associations between HIV and violence • Men with more sexual partners report using violence more often • Infidelity was the trigger for violence mentioned most often by women

24. Tuelemishane Project • Moves us out of the clinic into the community, and shifts the focus from women to men • Designed to give men space to talk about norms surrounding sexual behavior and conflict. • Through a 1-year intervention we hope to see some changes in attitudes and norms—and optimistically behaviors.

25. Where do we go from here? • One approach is not sufficient • Multi-level interventions are needed • The challenge is to reach men where they spend time & to keep them engaged • Venue-based interventions • Younger men need to be the focus of our interventions

26. Acknowledgements Funding: The intervention is funded through a grant from USAID, Interagency Gender working group. The research is funded by The Population Council Horizons Project. Co-Investigators J. Mbwambo, (Muhimbili); M. Sweat, H.Lary (JHU), M. Roche (UNC); F. Kouyoumdjian (Toronto) Research Staff: R. Kaballa, A. Mwampashi, L. Sabuni, E. Kakwezi, U. Peter, L. Ezekiel, E. Chezi, H. Marijani and J. Donath.