Risk and sex in an HIV epidemic: Challenges for HIV prevention communication

Risk and sex in an HIV epidemic: Challenges for HIV prevention communication Warren Parker, PhDPEPFAR Partner’s Prevention Meeting, Johannesburg, 16 July 2007Co-researchers: Cathy Connolly, Pumla Ntlabati, Benjamin Makhubelewww.cadre.org.za

HIV/AIDS Communication Survey 06/07 • Quantitative: A national cross-sectional household survey with a sample size of 7006, respondents aged 15-65 stratified by province, race and locality type • Probability of household selection proportional to 2001 census. Additional sampling procedures and weighting of data were used to achieve representivity. • Fieldwork conducted in first six months of 2006. • Quantitative study partners included JHHESA, Health Development Africa/Khomanani/DOH and Soul City, with funding from DOH/Khomanani for the quantiative study and USAID/PEPFAR for both quantitative and qualitative studies • Summary quantitative weighted data is presented here, focusing mainly on 18-30 age group • Main focus of presentation is parallel qualitative data gathered amongst unmarried 18-30 year old males and females during 2006/2007

Demographic characteristics: 18-30 (I) • Vast majority are either unemployed or students, with nearly two thirds of females unemployed • Around half of both males and females have completed grade twelve of schooling, with 8.1% of males and 8.7% of females having a tertiary qualification

Demographic characteristics: 18-30 (I) • Vast majority are unmarried • Half of all females are caring for at least one child in the household, with nearly one in five caring for two or more. • Around 15% live in dire poverty

Relation to HIV/AIDS, and HIV testing and 18-30 unmarried / 15+ all • High exposure to HIV disclosure in past year (around 1 in 4) • Around half personally knew someone who died of AIDS in the past year • Around 40% have attended one or more AIDS funerals and/or worn a red ribbon in the past year • HIV testing is high - around a quarter of males and nearly half of females ever tested, with around half testing in past year

Unprompted and prompted prevention knowledge: 18-30, unmarried • Low unprompted awareness of HIV prevention being linked to avoiding concurrency and limiting sex partners • Only around half of respondents said it was true that having fewer partners reduced the risk of HIV acquisition • There were low levels of agreement with the attitudinal question that it was acceptable to have more than one girlfriend

Age at first sex, sexual partners in past year and past month: 18-30, unmarried • Around half (46.3%) and nearly a third of females (29.3%) have sex at 16 or younger • Around a third of males, and more than 11.1% of females have 2+ partners in past year, and over a third of this group report 2+ partners in past month

HIV prevalence declines linked to changes in PRIMARY relationship practices • Malawi:Urban ANC HIV prevalence, 15-24, 27.0% (1996), 16.9% (2003)- sex with 2+ partners per year, 15-24, 1996/2000 males – 28.2%/12.0%; females – 3.0%/0.6% • Uganda:Nsambya and St Mary’s Hospitals, ANC HIV prevalence, 15-19- 28.0% Nsambya, 1991; 21.5% St Mary’s, 1993- 4.9% Nsambya, 2002; 5.9% St Mary’s, 2002- 20-24, St Mary’s, 31.8%, 1993; 10.0%, 2002- Median age at first sex, F, 15-24, 16.7% (1995); 17.3% (2000)- Never had sex, 15-19, rural, F, 38.0% (1995); 48.0% (2000)- Sex by age 15, 20-24, M, 20.0% (1995); 9.0% (2000)- 2+ partners in last year, F, 11.0% (1995); 6.0% (2000) • Zimbabwe:- ANC prevalence, 15-19, 24.9% (2000), 13.7% (2004)- Sex before 15, M, 8.8% 2001/2, 4.6%, 2003- 2+ non-regular partners/year, F, 17.2% (2001), 8.2% (2003) • www.stijournal.com, 2006, 82 (Suppl 1)

Qualitative survey: Key questions • What are the perceptions and practices of unmarried sexually active people aged 18-30 in relation to having high overall numbers of sexual partners and having concurrent sexual partners? • How does this interrelate with the context of a severe HIV epidemic? • What is the interplay between sexual partnerships and gender, economic and other contextual factors? • What is the relationship between sexual practices and perceptions of risk? • What prevention strategies are being adopted? • What are the opportunities for intervention, particularly in relation to HIV prevention communication?

Qualitative survey: Methods • 30 interviews and 6 focus groups with people aged 18-30 in five provinces: three cities located in Eastern Cape, Gauteng and Northern Cape; one informal settlement in the Western Cape; and a rural area in Mpumalanga. • Participants recruited through organisations and personal contacts, sexually active, unemployed, employed and students • Focus groups included two with males, one with females and three with males and females (mixed) • Interviews and discussions conducted in English, Xhosa, Sesotho, Xitsonga, Setswana and Sepulana (dialect) • All interviews and focus groups tape recorded, translated into English and transcribed (>860 pages of data) • Data read by all three researchers, coded in Atlas.ti/HyperResearch and analysed

Interpreting the data • Interviews and focus groups provide deep insights into perspectives and intimacies of peoples’ lives, and we recognise the contributions of those who shared their stories with us. • Diversity of perspectives, practices, sexual strategies, inconsistencies, contradictions and emotions are presented openly and honestly. In the overall, what is said is not unique to sex as it occurs in South Africa, but are representative of the journey that relates to sex and relationship development in most parts of the world. • It is important to avoid approaching the data judgmentally or to attempt to summarise findings into stereotypes. Rather, we are attempting to draw on our open discussions to inform intervention and risk reduction in the context of a severe epidemic. • This presentation is only a small subset of the data.

‘Main’ and ‘other’ partners (1) • Both sexes were ‘matter of fact’ about having ‘main’ and ‘other’ partners: We as men are not faithful. There are about two or three that I have had sexual relations with during that period [past two years]. The thing is that as I knew that there was someone more important than them, someone whom I wanted to protect, so I used condoms with them. Interviewer: Can you explain what you mean by the important person? Interviewee: The important person is the one whom you have chosen as the one you are going to spend your life with. Interviewer: What do you call the others? Interviewee: The others are also important, but the thing is that we do not have them in our lifetime plans. With them it is a matter of lust, like seeing someone and feeling lust for them and lust is a short term experience, it is not long lasting - it is easily satisfied (Male, 28, Mpumalanga).

‘Main’ and ‘other’ partners (2) And also you find that I have my main boyfriend whom I have sex with because he is my boyfriend. And you meet someone else and become close to that person, you are going have sex with him for a different reason. That is not because he is your boyfriend, but just maybe that you have grown close to him. (FGD, Female, 20-30, Gauteng) I guess people have spare boyfriends because I mean most people are afraid to be, like, alone, like they are afraid. It’s their fear to be alone, to think hey, if the boyfriend decides that he doesn’t want to have sex she can go and cry on the other boyfriend’s shoulder. So it’s always that case. (Female, 18, Gauteng)

‘Main’ and ‘other’ partners (3) • There was little sense of love, intimacy or respect in relation to ‘other’ partners: I can have others in the same area, but they have to know there is someone in my life. If they can’t accept that, then we part ways immediately. I mean, I don’t lack for anything, it was more a favour I was doing for her anyway. (FGD, Male, Western Cape) Interviewer: She has a 30-something boyfriend? And the fact that she has someone else, what does the issue of sex say to you? Male interviewee: The thing is, I had to follow procedures set in starting the relationship. I agreed to be understanding to that fact that she has a boyfriend. (Male, 27, Eastern Cape)

Casual sexual partnerships (1) • For some, casual partnerships did not include having ‘main’ partners, but rather a series of overlapping sexual relationships: Interviewer: Can you tell me how this happened, that you got involved with up to three women?Interviewer: I thought it was the right thing for me at the time... Interviewer: Did you have one regular partner or was it just the three, no distinction? Interviewee: No, I was involved equally with all of them. Interviewer: And were you serious about these relationship or was it all just for fun? Interviewee: I think it was just something to suit the moment, I wasn’t really serious at the time. I didn’t have a serious partner and I could tell that they were also not serious about me.(Male, 27, Eastern Cape)

Casual sexual partnerships (2) • Casual partnerships had to be actively managed: Amongst the three that I had told you about, one was a one-night stand. The other one that I saw for a month or two came into the picture while I was having my current girlfriend. So I would have sex with one this week and have sex with the other the following week. I avoided a situation where I had sex with one today and have sex with the other the following day because it is not nice to do that. What I would do was go and see one and not do anything sexual with her and then pass by the other one and pick her up for the night. (Male, 23, Mpumalanga) Let us say there is Sipho and Themba and whoever else. Sipho will arrive at seven, Lucky will arrive at ten. [These women] manage, but I do not know how. Sometimes you find that maybe Themba lives in Finetown, Sipho lives here and others live in other different places, so that they do not meet. (Female, 22, Gauteng)

Rationale for casual sexual partnerships • Casual partnerships had a wide range of rationales, including:- being someone who ‘loves sex’, ‘lust’, ‘greed’, ‘when you want to have sex it is like you are mad’ (males)- having sexual opportunities constantly available- fear of loneliness- being related to self-esteem and being unable to say ‘no’ Interviewer: What led to those situations where you were seeing more than one boyfriend? Interviewee: What can I say? I was losing control over myself. I was unable to control my feelings and ended up agreeing to different men’s propositions at the same time… How can I say this? Maybe I love that person while I am involved with another one. It is difficult for me to say no to the person I love, so I end up saying yes. (Female, 21, Eastern Cape)

Initiation of sexual relationships • Sexual relationships were initiated with very little delay –often occurring in a matter of days or one or two weeks after meeting. One-night stands were also common. Interviewer: And how long does it take to sleep together? Interviewee: I don’t take more than three days then I ask her to visit. We can sit and chat and I know that we will end up having sex. (Male, 25, Eastern Cape) Interviewer: So on average, how long before you have sex? Interviewee: It’s just days, like if you meet over the weekend, sometime during the week you will sleep with him. (Female, 28, Eastern Cape)

Perceptions of peer influence • Peer influence was seen as supporting promiscuity amongst both sexes: Most of my friends have many boyfriends, like three or four boyfriends. So when they see me sticking to one guy they take me as someone who thinks she is better than them, who is not in style. It is not like I do not want to do it, but I think about my life. If I can have more than one boyfriend I will not manage to satisfy them because I am one. It is better if it is one person. I cannot manage to do things for more than one boyfriend. I will not manage. (Female, 22, Gauteng) Like when you don’t have many girlfriends it is like you are a moshemane (boy). Things like that. They will say you are gay or something. They can mock you. Interviewer: And if they see you with a whole lot of different girls? Interviewee: They will say ‘haai, uyinja wena’ (you are a top dog)! You are the man. (Male, 18, Gauteng)

Influence of mobility (1) • Concurrent and overlapping sexual partnerships were readily sustained in contexts where people were mobile: It is just because of traveling around, going to different places. So when you get to those places you see other things as well. Sometimes you give your numbers to someone and she calls you, or she gives you her numbers and she calls you as well and then you feel you should give it a try. And at the end you end up having a sexual relationship even though you have a girlfriend. (Male, 26, Gauteng) The thing is I don’t break up with these people. It’s more like putting things on hold because of distance and lack of opportunity. I can see any of them, even after months of no contact and even if they have main partners I know they will see me when the need arises. We will get together and have sex and she will then leave. (Male, 25, Eastern Cape)

Influence of mobility (2) • For young women, the influence of mobility included relationships with married men that are interlinked with childbearing and economic support: I will start with the father of my child. He used to love me but after I had a child he left me. I have also learned that to be involved with a married man has its good and bad sides… He is married and on top of that got transferred, leaving me lonely. He has told me not to get involved with someone else because I am involved with him. The second thing is that he is not even promising to pay lobola for me. I have also told him that I am not prepared to be a second wife. So I have told him that I need to go on with my life, but he does not agree. I have raised concerns about the distance as well, and when he is off or over weekends he goes to his wife in [another town]. It is difficult for him to come and see me here because the little free time he has he goes to his wife. (Female, 26, Mpumalanga)

Trust, honesty, faithfulness (1) • Having frequent partner turnover and concurrent partners was seen as normative: I actually don’t know where lack of trust and faithfulness culturally came from. Everywhere – people are just cheating. I don’t know where it came from – when cheating and unfaithfulness became the norm – but I think people think they are invincible. I mean like one of my distant relatives, she fell pregnant and she was like ‘I don’t know who the father is!’. (Female, 25, Eastern Cape) I also have one partner that I’m very close to and I may spend up to six, eight months without having sex with any other person. We don’t use condoms and sometimes it occurs to me that she could maybe place my life in jeopardy by having affairs on the side. I always end up mulling this possibility over, but what can I do? (FGD, Male, 20-30, Western Cape)

Trust, honesty, faithfulness (2) • The concept of faithfulness was not understood as having an exclusive relationship. Rather it had to do with protecting one’s partner from ‘hurt’: Being faithful is protecting the one you love from hurt. You make sure that he only knows the best about you and you give him the best love. The others are just there when he is not around, to keep you company. (FGD, Female, 20-30, Gauteng) As for me, I have my girlfriend, the one that I spend most of my time with. I am faithful to her because even when I have other girlfriends I do not walk around with them for her to see me. I hide the other girlfriends. (FGD, Male, 20-30, Gauteng)

Trust, honesty, faithfulness (3) • Having a married partner was seen as having a relationship with someone who was ‘honest’ and less likely to stray than a person who was single: The [married man] that I told you about – he told me the whole truth about himself and his situation. He never lied to me. A boyfriend, I do not imply that I was the only one having an outside of marriage relationship with the married guy, but boyfriends always have a number of girlfriends and they will never tell you that you are not the only one. But when you call him sometimes you will find that his phone is off, especially boys. Some married men do tell you that they are married, so you decide whether you take him or not. A nice married man will be open with you. (Female, 26, Mpumalanga)

Risk reduction strategies: Limiting partner turnover, concurrency • A number of participants reported changes in their perceptions and sexual relationship practices: Nowadays we live in a dangerous world, there are HIV and AIDS, STIs and such things, so if you share a girl with another man you do not know how many other girls the other guy is sharing with the girl that you are also involved with. It may happen that he and I share this one girl, but he also has four other girls. So that is why I do not like sharing a girl with someone else. I actually do not like it and I do not do it. (Male, 23, Mpumalanga) Sometimes I regret having had overlapping sexual partners, because they are not right. You have sex with two people at the same period of time. It is like even when I was sitting alone sometimes I would ask myself, ‘What am I doing?’ It hurts a lot, even though people do not want to talk about such things. (Female, 21, Eastern Cape)

Risk reduction strategies: Condom use (1) • Many interviewees and participants reported a strong commitment to condom use for HIV prevention. However, it was acknowledged that condom use with a ‘main’ partner usually diminished or ceased over time. There was, however, commitment to condom use with ‘other’ partners: Interviewer: What about with the other partners? Interviewee: With the other partner I used condoms till kingdom comes. There is no way I can trust those ones because sometimes it can happen that she ends up having information that she is your second best and also decides to have someone to keep her busy while you are away. And you do not know the status of the person who will keep her busy in your absence. (Male, 28, Mpumalanga)

Risk reduction strategies: Condom use (2) • In casual partnerships it was noted that a number of factors influenced non-condom use and inconsistent condom use, including ‘breaking the moment’, being under the influence of alcohol, and ‘silent consent’ by one’s partner. She just kept quiet. She never asked me where is the condom or why am I not putting on a condom. She just kept quiet. But when I did it I wanted to see what her reaction would be. So she kept quiet and I just continued. Then afterwards I asked her why she did not stop me and she asked me why I did not use a condom. So it was like we were pointing fingers at each other. So if we were infected we would be dead. (Male, 22, Gauteng). • Incorrect condom use was also noted, including removing condoms during sex and condom slippage and breakages.

Risk reduction strategies: Condom use (3) • A number of women illustrated confidence and assertiveness in condom use. There was not a strong overall sense that condoms would not be used if a women articulated a desire to use them: Facilitator: How do you convince men to use condoms? Female participant: I just tell him to use it. Facilitator: And he agreed? Female participant: He asked me if I do not trust myself and I said that I do trust myself, but let us use condoms. He agreed and we used them. He uses them up to this day. (FGD, Female, 20-30, Mpumalanga) Interviewer: Who initiates condom use in your relationship? Female interviewee: I am the one who initiates it. Interviewer: Do they come with condoms or do they find them at your place? Female interviewee: I have them in my room. (Female, 21, Eastern Cape)

Risk reduction strategies: HIV testing • HIV testing was seen as an important step, individually and for couples. It was also linked to a desire not to have to continue using condoms: We were just chatting and it just came up. We’d both been for a test before we met and as it kept coming up, we decided to go and make sure. I had not been sure at that stage though but I was prepared to brave it out and it turned out that we were both negative and ever since we felt free to not use one. (FGD, Male, 20-30, Western Cape) In the middle of the process he would decide to take out the condom and continue without it. We used to argue a lot about it. He is one person who would use a condom and later feel that it is impeding his pleasure and take it out. I did not like that at all. He then told me that since I do not trust him we should go and have HIV tests. (Female, 20, Northern Cape)

Taking stock of the findings • The findings raise the importance of linking qualitative research to quantitative findings to explore contextual factors and rationale for sexual behaviours and practices - in particular, HIV risk and vulnerability • The findings provide insight into nuances related to HIV prevention • Insight is provided into contexts of risk and the organic/indigenous responses to risk reduction • Some important themes not covered in detail include: fatalism and perceptions of the inevitability of HIV infection; low self-esteem in relation to risk behaviour; knowing people who have died of AIDS; gender power relations; economic power relations; and violence (although there was very little in the present data to suggest sexual violence was pervasive).

Emerging goals and implications for HIV prevention communication • Epidemiologically, reducing the extent of concurrent sexual partnerships in South Africa will contribute markedly to incidence reduction (biologically - in relation to viral load) • Two primary risk factors intersect: high partner turnover, which results in high cumulative numbers of sexual partners (strongly influenced by a long period of being single), and a pattern of having concurrent partners amongst both males and females • As a consequence of high partner turnover and concurrency there are likely to be high levels of exposure to diverse interwoven sexual networks - we see high prevalence • Whilst condom use is common, it is less common in high risk contexts (e.g. casual contacts, one-night stands), and there is probably insufficient correct and consistent use

Key focal areas for prevention communication (1) Emphasis needs to be placed on the following behaviours and practices which increase risk of HIV acquisition and need to be promoted as PRIMARY risks: • Having many sexual partners in one’s lifetime • Frequently changing sexual partners and having two or more partners in a year • Starting sexual relationships soon after meeting people and having ‘one-night stands’ • Having more than one partner in the same month • Having overlapping sexual partnerships • Having a main partner as well as having other partners

Key focal areas for prevention communication (2) These can be translated into key messages for PRIMARY prevention of HIV (Note that the concept of ‘faithfulness’ is not well defined) • ‘Manage your risk to HIV by managing your sexual relationships!’ – ‘Quality, not quantity.’ • ‘The more sexual partners you have, the higher your risk of getting HIV.’ • ‘If you have two or more sexual partners a year, you are at higher risk of getting HIV.’ • ‘Avoid “one night stands” and get to know someone before starting a sexual relationship.’ • ‘Having more than one sexual partner in the same month puts you at high risk for getting HIV.’ • ‘Space your relationships. Wait at least six weeks before starting a new relationship.’ • ‘Avoid overlapping sexual partnerships.’

Key focal areas for prevention communication (3) Key COMPLEMENTARY HIV prevention strategies include: • Consistently having condoms available – particularly when exposure to alcohol and high risk contexts is likely • Initiating and articulating the importance of condom use during sex • Correct condom use • Consistent condom use • Knowledge of own HIV status • Knowledge of sexual partner HIV status in established relationships • Consistent condom use if HIV positive. Consistent condom use if HIV status is not known.

Key focal areas for prevention communication (4) These can be translated into messages for COMPLEMENTARY HIV prevention: • ‘Always carry condoms with you.’ • ‘It is your right to insist on condom use during sex.’ • ‘Make sure you know how to use condoms correctly.’ • ‘Use condoms every time. One round, one condom.’ • ‘Know your HIV status. Don’t unknowingly infect others. Always use a condom.’ • ‘Go for HIV testing with your main partner. Share your results and plan your future.’ • ‘If you know you are HIV positive, always use condoms.’

Challenges • The epidemic is severe and a coherent response is urgent • Both quantitative and qualitative data illustrate serious gaps in focus on sexual relationship practices that are key epidemiological drivers of the epidemic • Research often treads a slow pathway into practice, but this exploration and these findings are long overdue – mobilise now! • The quantitative and qualitative surveys are being written up into formal reports in the coming months. • We need to expand indicators for measuring changes described • Further qualitative analysis / research focusing on HIV prevention communication will expand understanding.

Risk and sex in an HIV epidemic: Challenges for HIV prevention communication