C-Change Picks - Focus on Multiple Concurrent Partnerships (MCP)

C-Change Picks #5 - Focus on Multiple Concurrent Partnerships (MCP)
Information about Social and Behaviour Change Communication, sponsored by C-Change
April 2 2009

From The Communication Initiative (The CI) and the United States Agency for International Development (USAID)'s C-Change programme

 

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C-Change Picks is an e-magazine supported by C-Change and implemented by The Communication Initiative that focuses on recent case studies, reports, analyses, and resources on communication for behaviour and social change to address health, environment, and civil society. If you have received this newsletter from a friend or colleague and would like to subscribe, please contact cchange@comminit.com

 

Issue 5 of C-Change Picks examines multiple concurrent partnerships (MCP) as a social norm in Southern Africa and its impact on HIV prevalence in the region. The issue highlights regional and local perceptions and knowledge related to the practice, existing initiatives that are addressing the attitudes and behaviours related to the practice, and evaluation of the impact of recent initiatives on changing behaviours among both men and women. Also included is a handbook for journalists on culture, HIV and AIDS, and MCP reporting.

 

Reducing multiple concurrent partners is a focus of HIV prevention programmes under the C-Change programme. In Namibia, C-Change is working on a behaviour change communication (BCC) strategy to reduce MCP as part of the country’s national MCP campaign. C-Change is working closely with the Centers for Disease Control and Prevention (CDC) and the members of the National Prevention Working Group’s Take Control Task Force (part of the Ministry of Information and Communications Technology), which includes the United Nations Children’s Fund (UNICEF), Desert Soul, and Nawa Life Trust, to ensure the MCP strategy is integrated into the National Prevention Strategy and is coordinated with other key national campaigns such as male circumcision and alcohol. C Change is providing technical support to these related campaigns, and identifying interpersonal communication (IPC) materials for the training of volunteers, groups, and individuals, along with key implementing partners. Specifically, C-Change is assisting PACT and its implementing civil society and private sector partners in developing BCC strategies for community and workplace programmes on MCP and the related practices of transactional and cross-generational sex.

 

The 2008 UNAIDS Modes of Transmission Study [PDF] estimates that 65% of all new infections in Lesotho over the next 12 months will come through “casual sex.” In response, C-Change is working with the Soul City Institute and local partner Phela to expand and deepen the OneLove campaign to reduce MCP in Lesotho by increasing the mass media component and by working with community organisations to increase dialogue about healthy relationships. C-Change is funding a call-in radio programme where experts discuss relationships, intimacy, and MCP. The March 23 PBS Lehrer Report highlighted the OneLove campaign, developed by Soul City, which features radio and TV dramas and billboards in nine countries in the Southern Africa region. Soul City Institute is both a C-Change and Communication Initiative partner and has been using the edutainment approach to address development issues in Southern Africa since 1994.

 

With CARE Lesotho, C-Change has developed a community discussion guide on relationships, communication, and risks of MCP. C-Change is training facilitators to use the guide to encourage discussions. Activities related to MCP are also beginning in Swaziland.

 

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In this Issue...

 

A Focus on Multiple and Concurrent Partnerships (MCP) in Southern Africa

 

1. Know Your Epidemic, Know Your Response
2. MCP: A Coordinated Regional Response is Key
3. Knowledge, Attitudes, and Practices of MCP in 10 Countries in Southern Africa
4. Reduced Partnerships and Increased Condom Use Led to the Decline of HIV in Uganda
5. Need to Re-Focus on MCP in Uganda
6. Addressing MCP in an Urban, Informal Community in South Africa
7. Findings on MCP in Botswana
8. Evaluation of a Radio and Billboard MCP Campaign in Botswana
9. MCP and Condom Use in Zimbabwe
10. MCP and "Small Houses" in Zimbabwe
11. MCP Handbook for Journalists
12. Two Recent Issues of The Soul Beat on MCP

 

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ADDRESSING MULTIPLE AND CONCURRENT PARTNERSHIPS (MCP) in SOUTHERN AFRICA

 

1. Know Your Epidemic, Know Your Response

 

Published as a "Comment" about HIV prevention in The Lancet and presented at the August 2008 International AIDS Conference, "'Know Your Epidemic, Know Your Response': A Useful Approach, If We Get It Right" expands upon the "rallying cry" that the era of standard global prevention is over. The authors discuss the state of global HIV and AIDS as not a single epidemic, but a multitude of diverse epidemics. They distinguish between "concentrated and generalised epidemics, which are fundamentally different - not because of arbitrary prevalence thresholds, but about who gets infected and how." “Concentration” is described as transmission among defined vulnerable groups, such as sex workers or injecting drug users. Transmission among the general population that would persist, resulting from sustained sexual behaviours, despite effective programmes with vulnerable groups, is considered a “generalised” epidemic.

 

Since, as stated here, partner reduction is found to reduce transmission in generalised epidemics, the authors find that "we know too little about how to effectively promote partner reduction. But this is no excuse not to immediately increase our commitment to well-evaluated programmes aimed at reducing multiple and concurrent sexual partnerships. Lessons learned from the successes in reducing population-level HIV prevalence in countries such as Uganda may prove useful for prevention programming. It seems that the Ugandan response stimulated personalisation of risk in a way that fostered community mobilisation for behaviour change, without increasing stigma. Second, the intensive use of a coordinated multilevel approach, involving clear and consistent risk-avoidance messaging at all levels, assisted in changing societal norms of behaviour. And third, it seems that focusing such efforts for risk avoidance and partner reduction on adult men was key to reducing the sexual networks that fuel HIV transmission in high prevalence countries."

 

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2. MCP: A Coordinated Regional Response is Key

 

The UNAIDS Regional Support Team for Eastern and Southern Africa and the Soul City Institute held a meeting, attended by HIV prevention communications practitioners from Eastern and Southern Africa, in September 2008 to explore and share experiences and help shape future plans for HIV prevention communication in the region. Against the backdrop of HIV communication initiatives increasingly focussing on addressing the impact of MCP on HIV incidence, the meeting built on the SADC Regional Consultation: Social Change Communication for HIV Prevention that took place in Swaziland in October 2006. Participants discussed and reviewed experiences and evidence on MCP social change communications and campaigns in order to amplify efforts through greater collaboration and consistency of messaging. They also made proposals on how to promote a coordinated response in order to reduce new infections over the next two years, with a particular emphasis on the hyper-endemic countries of Southern Africa.

 

Overall recommendations within this report "Multiple Concurrent Partnerships: Campaigns and Communications: Towards a Coordinated Regional Response" include:

• Commit to the further development of an active community of practice for HIV prevention communication in Southern Africa. UNAIDS emerged with a clear leadership role working in partnership with Soul City, Soul Beat, AIDSPortal and SAFAIDS to further define how a regional 'community of practice' will grow and develop.
• Plan a follow-up meeting for March or April 2009.
• Work on MCP must not be separated from the broader package of combination prevention efforts.
• Messaging should be clear and bold, not seek to prescribe an "answer" to MCP or to "try and do it all" - rather, MCP communication needs to acknowledge that the best solutions will emanate from the individual and community levels.

 

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3. Knowledge, Attitudes, and Practices of MCP in 10 Countries in Southern Africa

 

Designed to inform the development of an HIV prevention campaign by the Soul City Regional Programme (SCRP), "OneLove: Multiple and Concurrent Sexual Partnerships in Southern Africa - A Ten Country Research Report" aimed to gain insight into the audience’s understanding, attitudes, and practices around sexual relationships in the context of HIV prevention. Published in August 2008, the research was conducted in each of the 10 countries which were to form part of the Soul City Regional Programme: Botswana, Lesotho, Malawi, Mozambique, Namibia, South Africa, Swaziland, Tanzania, Zambia and Zimbabwe (Botswana decided against being part of the regional campaign and opted to launch an independent campaign). Overall research findings reveal common reasons for multiple concurrent partnerships (MCP) among people in the 10 countries of this study. Most of these reasons are driven by gender inequality and cultural and social norms that create a context for MCP. Transactional sex and alcohol also play an important role.

 

Meta-analysis of the country results showed marked consistency between all 10 countries in terms of perceptions, attitudes, and practices around sexual relationships across gender and age. However, in certain countries some issues were more pronounced than others, and there were some differences in how respondents presented the issues. The research identified several different forms of MCP, including: steady partner and other 'side' partners; intergenerational sexual relationships; transactional sexual relationships; and polygamy. Participants also reported a range of reasons for their involvement in MCP, including: dissatisfaction in relationships; culture and social norms; money and material possessions; and use of alcohol.

 

Based on the findings detailed within the report, recommendations include:

• There is a need to communicate messages to reinforce the knowledge of the risks associated with MCP.
• There is a need for sexuality education which includes ways to talk about sex with a partner without fear of negative consequences. Communication needs to promote the idea that a lifelong relationship can be happy and fulfilling.
• Gender inequalities that reinforce female subservience and male dominance need to be addressed.
• Cultural norms that both support the idea that it is 'natural' for men to participate in MCP and advocate that women should not even talk about sex need to be challenged.
• Consistent and correct condom use should be encouraged.

 

For specific audience research for the final 9 “OneLove” countries please see:

Multiple and Concurrent Partnerships in Lesotho

Multiple and Concurrent Partnerships in Malawi

Multiple and Concurrent Partnerships in Mozambique

Multiple and Concurrent Partnerships in Namibia

Multiple and Concurrent Partnerships in South Africa

Multiple and Concurrent Partnerships in Swaziland

Multiple and Concurrent Partnerships in Tanzania

Multiple and Concurrent Partnerships in Zambia

Multiple and Concurrent Partnerships in Zimbabwe

 

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4. Reduced Partnerships and Increased Condom Use Led to the Decline of HIV in Uganda

 

This January 2008 paper works to identify the changes in sexual behaviour that led to an observed dramatic reduction in the prevalence of HIV in Uganda in the early 1990s. Rather than present the evidence from one scientific method, "Changes in Sexual Behaviour Leading to the Decline in the Prevalence of HIV in Uganda: Confirmation from Multiple Sources of Evidence" reviews seven kinds of evidence and examines the consistency among them; they include: models of HIV prevalence and incidence in Kampala and other sentinel sites in Uganda; reports of behaviour change in the primary newspaper in Uganda; surveys with questions about perceptions of personal behaviour change; large demographic and health surveys (DHS) collected in 1988/9 and 1995 and large Global Program on AIDS (GPA) surveys in 1989 and 1995 with questions about reported sexual behaviour; smaller less representative surveys of reported sexual behaviour collected in other years; reports of numbers of condoms shipped to Uganda; and historical documents describing the implementation of HIV prevention programmes in Uganda.

 

All seven types of data produced consistent evidence that people in Uganda first reduced their number of sexual partners prior to or outside of long-term marital or cohabiting relationships, and then increased their use of condoms with non-marital and non-cohabiting partners. "Modelling of the relationship between number of sexual partners and the size of sexual networks demonstrates that, in general, even small decreases in the mean number of sexual partners can sometimes markedly reduce the size of sexual networks. The reductions in numbers of sexual partners in Uganda demonstrated by multiple kinds of data certainly had the potential to break up these sexual networks and thereby reduce the transmission of HIV. The greater use of condoms in the remaining smaller sexual networks further reduced HIV transmission. Then, according to multiple sources, the incidence and prevalence of HIV declined dramatically. These findings are consistent with other analyses of declines in HIV prevalence in other generalised epidemics in sub-Saharan Africa (eg, in Kenya and Zimbabwe), which suggest that giving a strong emphasis to partner reduction while also encouraging condom use (and abstinence) is much more effective than primarily promoting condom use (or abstinence)."

 

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5. Need to Re-Focus on MCP in Uganda

 

"Battling Old Behaviour the New Front in AIDS Fight" looks at the impact of multiple concurrent partners through the history of the HIV pandemic in Uganda, and examines a new campaign initiated by Population Services International (PSI) that aims to discourage the "Sugar Daddy" phenomenon. The article, published in August 2008, argues that a new resurgence in HIV infection in Uganda has been spurred on by an increase in multiple concurrent partnerships (MCP). Although campaigns discouraging the practice in the 1980s led to a decline in HIV prevalence, recent campaigns have shifted the focus to other aspects of prevention, which has led to a new generation that is largely unaware of the risks associated with multiple concurrent partners.

 

A look at President Yoweri Museveni's "love carefully" and "zero-grazing" campaigns from the 1980s reveals that the message was blunt - be faithful because AIDS kills. A World Health Organization study showed more than a 50% reduction in number of people reporting multiple and casual partners between 1989 and 1995. The number of Ugandan men reporting three or more non-marital sexual partners fell from 15% to 3% during the same period. The article points out that today's teenage girls weren't even born during president Museveni's aggressive "zero-grazing" campaign in 1980s that instilled fear into men and women about their personal risks of getting infected by sleeping with multiple partners.

 

A PSI survey found that more than 16% of young women who attend university today have had multiple sexual partners in the past 12 months, many in concurrent relationships with Sugar Daddies and boyfriends. About 36% think such relationships are normal. According to the article, at night, expensive cars stream into university parking lots near the girls' dormitories where Sugar Daddies meet their girlfriends or take them out on dates.

 

PSI’s new campaign involves churches, who use the pulpit to preach against cross-generational sex. Priests and ministers encourage families to talk to their children about the taboo subject of sex and the risks of such relationships. National figures like First Lady Janet Museveni and the Queen of Buganda are also participating. "Go Getter" clubs at universities were created to teach girls life and work skills to foster "self-esteem and empowerment" so they rely on themselves, "not a rich Sugar Daddy."

 

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6. Addressing MCP in an Urban, Informal Community in South Africa

 

This April 2008 study set out to develop a robust surveillance system to measure key risk behaviours and HIV prevalence among adult men who have multiple, concurrent female sexual partners, and who live in an urban, informal community on the outskirts of Cape Town. According to this study, men with more than one, usually younger, female, sexual partners make up a hard-to-reach, high-risk sub-population. This is largely due to them not being captured through conventional HIV surveillance methods. For the study, called Project ooPeto (buddies), men were recruited using the Respondent Driven Sampling (RDS) method, which, as stated in the document, has been extensively and successfully used globally among other hard-to-reach populations (such as injecting drug users, men who have sex with men, and commercial sex workers).

 

Findings within the report, entitled "Sexual Risk Behaviour Among Men with Multiple, Concurrent Female Sexual Partners in an Informal Settlement on the Outskirts of Cape Town," included:

• HIV prevalence was 12.3%.
• 98% reported having concurrent sexual relationships 3 months prior to the survey.
• Most men (83.3%) indicated that their friends would approve if they had sex with women who were not their steady partners or wives and 86.1% indicated that their friends could approve if they changed girlfriends often.
• 46% of participants thought that their main partners had sex with them because they expected or had received some form of material goods; 82% thought this was the case for their casual partners; and 90.6% thought it of their once-off partners.
• Shebeens or taverns were most commonly cited as places where men met with friends for recreation (31.2% and 54.4% respectively). Most men (81.8%) reported drinking more than five beers, ciders, or tots of alcohol during these visits. About 74% indicated that they had met a new sexual partner at shebeens or taverns over the past 30 days.
• 95% of participants indicated that they would attend meetings if they were given the opportunity to talk about relationships and sexual behaviour with a male facilitator once a week (for 10 weeks) with a group of other men.

 

The study recommends that this high-risk group would benefit from specifically-targeted HIV prevention interventions which address partner concurrency, inconsistent condom use, excessive alcohol consumption, and intimate partner violence. It states that individually-targeted and small, peer group interventions aiming to support self-defined behavioural change and shift social norms may be appropriate for this population. Because these men were willing to participate in sexual health programmes, RDS may be employed as a valid entry point into this high-risk sub-population for planning, designing, implementing and evaluating targeted HIV preventive methods.

 

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7. Findings on MCP in Botswana

 

This report, published by PSI Botswana in December 2007, documents the findings of a national tracking survey of youth and adults aged 15-34. The objectives of the study, entitled "Multiple Concurrent Partnerships Among Men and Women aged 15-34 in Botswana," were to compare responses to different ways of asking about MCP; identify characteristics of MCP; and identify behavioural drivers or barriers to MCP at the individual level. Based on interviews with 1,787 youth and adults from districts across the country, the study found that approximately one quarter of the population in Botswana report being engaged in MCP. Men are more likely than women to be involved in MCP, and knowledge about the potential risks of these kinds of relationships is low. Drivers of MCP are different for men and women and include beliefs, attitudes, self efficacy, and alcohol use.

 

The study also offers key recommendations for MCP interventions. According to the research, there is a clear need for MCP interventions to first prioritise addressing the gap in knowledge and risk perception that exists in relation to concurrent partnerships. For example, increasing the proportion of sexually active people aged 15-34 who identify concurrent or overlapping relationships as more risky than monogamous, spaced relationships is essential. Thereafter, the study recommends adopting different messages for men and women, and focusing on social mobilisation around alcohol use and abuse.

 

According to the study, addressing deeper-seated determinants of MCP, such as peer expectations of monogamy, attitudes to sex, love, and commitment or women's lack of ability to decide on sex within relationships will be much more challenging and require more time and resources than addressing knowledge, risk, perception and the associated cost/benefit analyses of MCP. In addition, MCP interventions will not happen in isolation but in the context of other prevention activities, including condom promotion. It is essential that condom promotion is mindful of overall HIV prevention objectives and does not promote condoms as an alternative to partner reduction.

 

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8. Evaluation of a Radio and Billboard MCP Campaign in Botswana

 

This is a September 2008 evaluation of a mass media campaign implemented by PSI Botswana earlier in 2008. According to organisers, the campaign was integrated into community-based inter-personal communication projects in addition to mass media channels. The main messages focused on challenging norms about MCP and HIV risk by using common sayings and pointing out the risks inherent in the behaviours the sayings help to normalise or legitimise. Although the evaluation found that the campaign did not generally teach people anything new, it did cause many people to think differently about how their own behaviour and that of their partner can increase their HIV risk.

 

The reaction to the HIV risk messages contained in the campaign was unanimously positive, indicating that the campaign tapped into points of conflict in the minds of the audience. The campaign succeeded in getting people to reflect on their own behaviour and HIV risk, as well as spark discussion around the issues, though most of the discussion occurred privately between friends and partners, as respondents generally felt uncomfortable discussing the topics in public. Although some men and women reported positive dialogue about the MCP and HIV with their partners, some women reported being afraid to discuss the issues and one woman reported having been beaten by her partner for questioning his comings and goings.

 

"Multiple Concurrent Partnerships Mass Media Campaign: Assessment of Reach, Recall and Effectiveness" concludes with several recommendations. These include expanding the campaign, using television, increasing coverage of billboards and radio airplay, and translating the messages into local languages. The evaluation notes that many respondents also spoke of the importance of combining media messages with facilitated discussions, and also suggested using roadshows and training unemployed youth as mobilisers.

 

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9. MCP and Condom Use in Zimbabwe

 

"Concurrent Heterosexual Partnerships, HIV Risk, and Related Determinants among the General Population in Zimbabwe," published by PSI Zimbabwe in February 2008, documents types of concurrent relationships and explores factors and contexts influencing the practice of engaging in such relationships among the general population. This two-phase study is a follow-up to a 2006 qualitative survey that sought to understand moderating demographic characteristics of concurrent sexual practices. The report suggests that while in the past, HIV prevention initiatives have focused on reducing the number of sexual partners, emerging findings point to the importance of acknowledging overlapping sexual networks or concurrent relationships. Most couples in these relationships eventually stop using condoms, thus increasing vulnerability to the entire sexual network.

 

Results from this study can be used to develop communication campaigns to promote the reduction of concurrent relationships as well as safer sexual practices within these relationships. The report provides key areas to address regarding condom use and the risks associated with unprotected sex. These include:

• the practice of not using condoms within a short time after a relationship begins;
• perceptions that young women and men (especially adolescents) are inexperienced sexually and thus low-risk;
• the lack of condom use among men who keep "small-houses";
• perceptions that divorced or separated women are low-risk, and the subsequent lack of condom use;
• the need for money, other goods, and/or services that overrides people's, particularly women's, fears, and perceived vulnerability for contracting HIV; and
• the fact that young men and women do not usually make the decisions regarding condom use, but acquiesce to the "authority" of the more dominant, older sexual partner.

 

The document also provides key recommendations for interventions that tackle the actual issue of concurrency, rather than just condom use for those practising concurrency:

• Stimulate more open communications between partners regarding sexual preferences and the need for and possibility of enjoying a stimulating sex life together.
• Men (and some women) perceive that they need to have sex on a frequent basis and thus seek other sexual opportunities when away from their regular partner. Suggesting alternative forms of recreation or safe ways to vent sexual frustration may represent one element of a communication campaign.
• A variety of economic and employment factors influence the practice of concurrency. The media and peers add to pressure that result in young women and men exchanging sex to older partners in return for non-essential items such as cell phones or fashion accessories to enhance their status.
• Corrupt practices and abuse of power practised by some people in authority, including teachers, policemen, magistrates and pastors, whereby sex is requested in exchange for favours such as good exam grades are exposing girls and women to risks for contracting HIV/AIDS.

 

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10. MCP and "Small Houses" in Zimbabwe

 

"Multiple Concurrent Partnerships: The Story of Zimbabwe - Are Small Houses a Key Driver?" looks at the phenomenon of "small houses" in Zimbabwe, and how they appear to be a key driver of the HIV epidemic. According to the author, a "small house" is essentially a longer-term sexual relationship between a married man and another, usually younger, woman. "Small houses" are viewed by Zimbabwean men as a safer alternative to casual sex, which they understand to be high risk, because they see women in "small houses" as being faithful to them. Because of this perception, they are unlikely to use condoms. However, the report states that mutual fidelity is very rare, and that there are many factors that lead women in "small houses", their married male partners, and the men's wives to be unfaithful.

 

Recommendations within this paper identify a few areas where behaviour change communication (BCC) activities can specifically be aimed, such as raising awareness of the risks associated with “small houses”, openly condemning the practice, increasing the use of condoms where concurrent relationships exist, and addressing cultural practices that put women at risk by engaging communities to identify and implement solutions.

 

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11. MCP Handbook for Journalists

 

A product of the Soul City Institute for Health and Development Communication’s OneLove Southern Africa Regional campaign, " Multiple and Concurrent Sexual Partners: What's Culture Got to do With It? A Handbook for Journalists" is designed for journalists as a tool to promote informed discussion around HIV and MCP. The handbook contains findings from research conducted in Southern Africa by Soul City that confirmed that certain cultural practices, social norms, and beliefs promote and even institutionalise MCP as socially acceptable and widely practised. This, in turn, was found to largely contribute to higher risks of HIV infection and prevalence.

 

The handbook goes on to discuss AIDS, MCP and culture, and reporting on HIV/AIDS and culture. It provides case studies of three different types of MCP - steady partner and other 'side' partners; intergenerational and transactional sexual relationships; and polygamy - and provides a number of resources for journalists, including suggestions for sources, websites, and additional reading.

 

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12. Two Recent Issues of The Soul Beat on MCP

 

The Soul Beat 125 – HIV Prevention: OneLove

 

The Soul Beat 119 – HIV Prevention: Multiple Concurrent Partnerships (MCP)

 

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Communication for Change (C-Change) implemented by AED, is USAID's flagship programme to improve the effectiveness and sustainability of communication for behaviour and social change as an integral part of development efforts in health, the environment, and civil society. C-Change works with global, regional, and local partners to use communication to change behaviours and social norms, supported by evidence-based strategies, state-of-the-art training and capacity building, and cutting-edge research. The ultimate goal is the improved health and well-being of people in the developing world. Please see the C-Change website. To contact C-Change, please email cchange@aed.org

 

The Communication Initiative (The CI) network is an online space for sharing the experiences of, and building bridges between, the people and organisations engaged in or supporting communication as a fundamental strategy for economic and social development and change. It does this through a process of initiating dialogue and debate and giving the network a stronger, more representative and informed voice with which to advance the use and improve the impact of communication for development. This process is supported by web-based resources of summarised information and several electronic publications, as well as online research, review, and discussion platforms providing insight into communication for development experiences. Please see The CI website.

 

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This publication is made possible by the support of the American people through the United States Agency for International Development (USAID) under the terms of Agreement No. GPO-A-00-07-00004-00. The contents are the responsibility of the Communicative Initiative and the C-Change project, managed by AED, and do not necessarily reflect the views of USAID or the United States Government.