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Safe Love Formative Research Desk Review to Inform Campaign Development Studies Reviewed • Zambia Demographic Health Survey, 2007 • National HIV Prevention Convention Report, 2009 • Multiple and Concurrent Sexual Partnerships in Zambia: A Target Audience Research Report, 2008 • HIV/AIDS TRaC Study Examining Consistency in Condom Use Among Population Aged 15-49 in Zambia, 2009 • HIV Prevention Response and Modes of Transmission Analysis, 2009 • Zambia Sexual Behaviour Survey, 2009 2 Zambia Demographic and Health Survey, 2007 HIV prevalence by sex and age 26.0 24.9 24.1 Percentage HIV positive 22.4 19.9 18.3 18.5 17.1 Men 11.8 5.7 12.1 11.5 Women 5.1 3.6 15-19 Source: Zambia DHS, 2007 20-24 25-29 30-34 35-39 40-44 45-49 4 HIV prevalence by sex and urban-rural residence (age 15-49) 15.9 Urban 23.1 Men Women 9.4 Rural 11.0 0 5 10 15 20 25 Percentage HIV positive Source: Zambia DHS, 2007 5 HIV prevalence by sex and marital status (age 15-49) 63.1 Percentage HIV positive 52.5 33.1 Men 28.8 16.1 Women 14.7 9.1 4.5 Never married Source: Zambia DHS, 2007 Married/living together Divorced or separated Widowed 6 HIV prevalence among young people by sex and age Percentage HIV positive 15.2 9.6 10.0 7.9 Men Women 4.4 3.5 3.8 2.4 15-17 Source: Zambia DHS, 2007 18-19 20-22 23-24 7 HIV prevalence among young people by sex and number of sexual partners in past 12 months Percentage HIV positive 30.0 Men 10.3 10.2 Women 8.9 4.1 3.2 0 1 2 Number of sexual partners Source: Zambia DHS, 2007 8 National HIV Prevention Convention Report, 2009 Key drivers of the epidemic Driver 1: Multiple and concurrent sexual partners (MCP) • Bulk of new infections are from casual and multiple concurrent sexual relationships • MCP is most prevalent among long term couples, young people (especially young women), mobile populations, and men who have sex with men (MSM) Driver 2: Low rates of condom use • Condom use remains low, particularly among young people, mobile populations, MSM, and discordant couples Source: National HIV Prevention Convention Report, 2009 10 Key drivers of the epidemic (continued) Driver 3: Low rates of male circumcision (MC) • MC offers at least 60% protection against HIV transmission • MC is not widely practiced in Zambia except among some ethnic religious groups Driver 4: Mobility and migrant labour • Mobility and migration of workers destabilises long-term partnerships and so facilitate MCP including with sex workers Source: National HIV Prevention Convention Report, 2009 11 Key drivers of the epidemic (continued) Driver 5: Vulnerability and marginalized groups • Sub population groups such as sex workers, MSM, prisoners, migrants, and people with disabilities are the most vulnerable Driver 6: Mother-to-Child Transmission (MTCT) • HIV infection in children under 14 years of age constitute about 10% of all HIV infections in Zambia. Most of these are a result of MTCT Driver 7: Alcohol and drug use • Decision-making is impaired under the influence of alcohol and drugs Source: National HIV Prevention Convention Report, 2009 12 Multiple and Concurrent Sexual Partnerships in Zambia: A Target Audience Research Report, 2008 Study Overview • Research objective – Gain insight into the audience’s views, feelings, beliefs, attitudes, behaviours, and experiences around multiple concurrent sexual relationships and male circumcision in the context of HIV prevention • Methodology – 16 focus group discussions and 12 in-depth interviews – Two urban areas: Lusaka and Livingstone – Two rural areas: Chirundu and Solwezi • Primary target audience – Adults between 16 and 55 years of age Source: Multiple and Concurrent Sexual Partnerships in Zambia: A Target Audience Research Report, 2008 14 Socioeconomic factors that contribute to MCP • Poverty – Exchange of sex for money or other types of support – More common among women – Sometimes encouraged by husband and parents, particularly mothers • Wealth – Used to attract sexual partners – Seen as a strong enticement to establish a relationship – More common among men Source: Multiple and Concurrent Sexual Partnerships in Zambia: A Target Audience Research Report, 2008 15 Socioeconomic factors (continued) • Abuse of authority/office – Exchange of sex for “favours” – Business professionals, hospitality industry workers, doctors, teachers, taxi drivers, and musicians reported as likely to be involved in MCP • Desire for material possessions – Women, in particular, have sex with many partners to acquire material goods • Mobility – Being away from home provides opportunities for planned and spontaneous relationships – Married women are less mobile so have less opportunity Source: Multiple and Concurrent Sexual Partnerships in Zambia: A Target Audience Research Report, 2008 16 Relationship factors that contribute to MCP • Relationship dissatisfaction – Lack of communication, sexual dissatisfaction, squabbles, mistreatment, and unfaithfulness are reasons for engaging in MCP • Revenge – Some sexual relationships are initiated when one partner wants to take revenge on a regular partner who is having, or is suspected of having, an affair • Withholding of sex – Men denied sex by their steady partners say this is a motivation for additional sexual relationships Source: Multiple and Concurrent Sexual Partnerships in Zambia: A Target Audience Research Report, 2008 17 Relationship factors (continued) • Sexual dissatisfaction – Other partners are desired because they are seen as less sexually inhibited • Low rated spouse – People who perceive their spouses as not of the same “class,” “not attractive,” or “not clean” may engage in MCP • Lack of communication – Significant problem according to participants – Perception that women should be submissive to men means that they do not question their male partners, even when there is a suspicion that he is having an affair or is placing her at risk for being infected with an STI or HIV Source: Multiple and Concurrent Sexual Partnerships in Zambia: A Target Audience Research Report, 2008 18 Relationship factors (continued) • Desire for long-term relationship – Women say they want only one steady and lasting sexual partnership – MCP allows women to identify most suitable marriage partner – When men do not show an interest in marriage or monogamy, women seek additional relationships – Some women become pregnant in the hopes that it will lead to marriage • If the father of the child does not make an offer of marriage, the woman will have relationships with other men • If the father of the child denies the pregnancy, both are likely to go on to new sexual relationships Source: Multiple and Concurrent Sexual Partnerships in Zambia: A Target Audience Research Report, 2008 19 Cultural influences • Alcohol – Mentioned often by participants as a factor leading to MCP, particularly among men – When people drink, they are more like to engage in MCP • Peer pressure – People with only one sexual partner are teased – Adults are influenced by friends to have MCP • Positive perception of MCP – Engaging in MCPs can elevates a person’s status in the community Source: Multiple and Concurrent Sexual Partnerships in Zambia: A Target Audience Research Report, 2008 20 MCP and HIV/AIDS • Perception of risk – Some people engaged in MCP report that they approach their relationships with fear and caution because of HIV/AIDS, especially when it is a means of support rather than sexual satisfaction. – Participants respond that condoms are used in early stages of relationship, but this gives way to unprotected sex in later stages when trust has been established. – Condoms give people the sense that they are protected against disease and unwanted pregnancy. However, suggesting condom use with a spouse may cause suspicion of infidelity. – Fatalistic attitude towards HIV infection. • Some people are no longer afraid of MCP because of the availability of ARVs Source: Multiple and Concurrent Sexual Partnerships in Zambia: A Target Audience Research Report, 2008 21 Gender considerations • Women more affected by poverty than men – Rely on male sexual partners as source of income – Single women more vulnerable because they become entangled in cycles of having several sexual partners to ensure they have an adequate income – Increase risk of HIV infection • Financially independent women are perceived as less submissive – Able to decide when she wants to have sex • Married women are expected to be subservient – Cultural expectations discourage assertiveness and independence and put women at risk for HIV infection Source: Multiple and Concurrent Sexual Partnerships in Zambia: A Target Audience Research Report, 2008 22 Gender considerations (continued) • Women expected to tolerate husbands’ extra-marital sexual affairs, but women who have affairs themselves are condemned • While husbands expect their wives to comply with cultural dictates such as not initiating sex, men consider boring sex lives at home as a factor for engaging in MCP Source: Multiple and Concurrent Sexual Partnerships in Zambia: A Target Audience Research Report, 2008 23 Recommendations • Strategic communication – Conduct more research to better segment audiences and target messages • Strategic alliances – Public-private partnerships to foster a holistic approach to MCP • Sustained interventions – Behaviour change is a long term, iterative process – Sustained communication interventions help changing attitudes and modifying behaviours while challenging long-established attitudes and practices Source: Multiple and Concurrent Sexual Partnerships in Zambia: A Target Audience Research Report, 2008 24 HIV/AIDS TRaC Study Examining Consistency in Condom Use Among Population Aged 15-49 in Zambia, 2009 Prevalence of MCPs among sexually active men and women age 15-49 Source: HIV/AIDS TRaC Study Examining Consistency in Condom Use Among Population Aged 15-49 in Zambia, 2009 26 Concurrency The probability of population aged 15-45 to have only one sexual partner at a time increases with: • Perceived susceptibility for contracting HIV – Men and women who perceive that engaging in concurrency increases the risk of contracting HIV are less likely to report engaging in concurrency. (p<.001, OR=2.5). • Perceived sexual benefits – Men and women who attach a negative value to the sexual benefits of engaging in concurrency are less likely to engage in concurrency. (p<.001, OR=1.8). Source: HIV/AIDS TRaC Study Examining Consistency in Condom Use Among Population Aged 15-49 in Zambia, 2009 27 Concurrency (continued) • Perceived negative outcome – Men and women who have high perceptions about the negative consequences that result from engaging in concurrency are less likely to engage in concurrency. (p<.001, OR=1.5). • Quality of relationship – Men and women who have high perceptions about the quality of their primary relationships are less likely to engage in concurrency. (p<.01, OR=1.37). • Marital status and sexual experimentation – Men and women who are married are less likely to engage in concurrency (p<.05, OR=1.35). – Sexual experimentation and frustration in primary relationships increases the likelihood of engaging in concurrency (p<05, OR=1.2). Source: HIV/AIDS TRaC Study Examining Consistency in Condom Use Among Population Aged 15-49 in Zambia, 2009 28 Recommendations Communication programs should: • Convey messages that promote consistent condom use with all non-marital and non cohabiting partners (NMNCs). • Focus on improving women and men’s ability to negotiate condom use consistently (self-efficacy) with all NMNCs. • Increase awareness on the increased susceptibility to HIV/AIDS that results from engaging in MCPs. • Challenge positive benefits and promote negative beliefs of having MCPs. Source: HIV/AIDS TRaC Study Examining Consistency in Condom Use Among Population Aged 15-49 in Zambia, 2009 29 HIV Prevention Response and Modes of Transmission Analysis, 2009 Extent of MCP • MCP common among Zambians irrespective of age, marital status, or geographical location of residence (Kwatu, 2008) • MCP more common among economically empowered men and economically disempowered women, and among unmarried than married people (Health Communication Partnership [HCP], 2008) • People experiencing sexual problems are more likely to be engaged in MCP (HCP, 2008) • Men consistently report much higher frequency of MCP than women but MCP behaviours and extramarital affairs are underreported in surveys, especially by women Source: HIV Prevention Response and Modes of Transmission Analysis, 2009 31 Percentage who had 2+ partners in the past 12 months 25 22.4 21.8 20.4 20 16.2 Percentage 15.2 15 Men Women 10 5 5.0 1.1 1.2 1.4 0.8 0 15-19 Source: Zambia DHS, 2007 20-24 25-29 30-39 40-49 32 Number of partners in the last 12 months and HIV prevalence 32 29 HIV prevalence (%) 27 20 20 0 partner 16 2 partners 13 3+ partners 11 Men Source: Zambia DHS, 2007 1 partner Women 33 Postpartum abstinence contributes to MCP • Women‘s sexual abstinence for months after childbirth may be an important factor leading to men having sexual partners outside their main relationship • Six and twelve months after birth, 43% and 20% of Zambian women still practice postpartum abstinence (DHS, 2007) Source: HIV Prevention Response and Modes of Transmission Analysis, 2009 34 Predictors of MCP • • • • Early sexual debut Being married Early marriage Absence from home (Sandoy et al., 2007) Source: HIV Prevention Response and Modes of Transmission Analysis, 2009 35 Partner preference • Preference for having married women or men as girlfriends or boyfriends because they were thought to have fewer sexual partners and to be less likely to have an STD • Men also said that for married men it is safer to have a married woman as a lover, since she is less likely to tell her friends (Chiawa, Bond, and Dover, 1997) Source: HIV Prevention Response and Modes of Transmission Analysis, 2009 36 Recommendation The practice of MCP in Zambian society is an example of how individual choices are shaped by social and cultural influences. Thus a campaign to reduce MCP will need to focus not only on individuals, but also on families, communities and policy. This may mean challenging entrenched social and cultural norms. These norms include seeing involvement in MCP as acceptable for men and regarding women who are sexually proactive as likely to be having relationships with other men. Source: HIV Prevention Response and Modes of Transmission Analysis, 2009 37 Zambia Sexual Behaviour Survey, 2009 Median age at first sex and first marriage among people age 15-24 Source: Zambia Sexual Behaviour Survey, 2009 39 Percent of respondents who had more than one ongoing sexual partnership in the past 12 months Men 15-49 (%) Women 15-49 (%) Total (%) Urban 7.7 0.4 3.8 Rural 13.3 0.8 6.5 Single, never married 11.2 2.0 7.8 Married/cohabitating 5.2 0.2 2.4 Polygamous marriage 91.9 0.7 31.4 Formerly married 9.8 3.8 5.5 11.3 0.6 5.5 Residence Marital status Total Source: Zambia Sexual Behaviour Survey, 2009 40 Respondents age 15-49 who had more than one ongoing sexual partnership in the past 12 months 20 18.5 18 16 15.0 14.5 Percentage 14 11.3 12 Men 10 Women 8 6 4 2 2.2 1.8 2.2 0.6 0 2000 2003 Source: Zambia Sexual Behaviour Survey, 2009 2005 2009 41 Percent of respondents age 15-49 who report condom use with most recent sexual partner Source: Zambia Sexual Behaviour Survey, 2009 42 Percent of respondents age 15-49 who had multiple partners in last year, and used a condom at last sexual intercourse Source: Zambia Sexual Behaviour Survey, 2009 43 ONE LOVE. KWASILA! Campaign design • Target audience – Men ages 25-35 living in urban areas • Behavioral objective – Reduce sexual partners and/or increase consistent condom use, HIV testing, and disclosure • Communication objective – Increase self-risk perception and provoke thought, dialogue, and action around MCP and mutual rights and responsibilities of partners 45 Campaign products • TV/Film – Animated spots, talk shows, music video, and DVDs • Club Risky Business – TV mini-series – Audience interacted through text messages (SMS) and radio station call-in programmes 46 Campaign products (continued) • Radio drama series “Bittersweet” – 26 episodes aired on ZNBC Radio 2 and Radio Phoenix – Translated into Bemba and aired on Radio 1, Mkushi community radio, Radio Mano • Print – Newspaper features, supplements, advertisements, posters, discussion guides, bumper stickers, and tax discs for cars 47 Campaign website http://www.onelovekwasila.org.zm • Establish an online presence • Build “One Love. Kwasila!” brand • Create an online portal for men’s health issues 48 Results (October 2009) • Created a buzz with target audience – Within four weeks of airing the TV mini-series, 49% of regular nonLusaka urban television viewers recalled the slogan and 32% had seen or heard of Club Risky Business • Sparked audience engagement – 17,137 SMS competition entries received – More than 6,000 Facebook fans discuss characters’ actions and relevance to their lives as well as sex, relationship, and health topics – Radio series generated 37 calls and 384 SMS – 3,466 website visits and 8,960 page views – 632 YouTube channel views and 10,348 upload views 49 Results (continued) • 600 branded inter and intra city buses – Also carried Club Risky Business as onboard entertainment • 5,000 tax discs • 5,000 bumper stickers 50 Lessons learned • Integrated campaigns keep audience engaged in a number of ways • Drama works – People relate to emotions • Indigenous and high quality products improve message delivery and also contribute to campaign sustainability • Engaging audience through radio, competitions, and social media is recommended • Momentum needs to be sustained • Research should involve campaign implementers from the outset • Partnerships are important to manage multiple aspects • Linkages to trusted and credible resources/support services are key 51