Assessing a National HIV Behavior Change Campaign Focusing on Multiple Concurrent Partnerships in Swaziland Daniel Halperin, USAID; Neil Andersson, CIET; Marjorie Mavuso, UNFPA; George Bicego, CDC Session on “ Prevention Works: What's the Evidence?” International AIDS Conference, Toronto Aug. 14, 2006

Who has HIV? (Zambia)

Why is HIV so much Higher in Southern Africa? (See SADC Report on Maseru “Prevention Think Tank” Meeting) Multiple concurrent partnerships (“nyatsi,” “lishende,” “small house,” “second office”...) Lack of male circumcision Various other factors, such as relatively developed/highly mobile societies, income inequality, gender dynamics, "dry sex,” etc.

Worldwide, almost all studies show increased HIV risk with increased number of sexual partners Partner reduction has been associated with declines in HIV at the population level in both concentrated and generalized epidemic settings Multiple sexual partnerships

HIV prevalence by number of lifetime sex partners, Sub-Saharan Africa Source: Dr. Vinod Mishra, ORC MACRO 2006 ( DHS & AIS surveys 2003 to 2005)

SEX PARTNERSHIPS IN SWAZILAND Sources: FHI BSS, 2002

Lifetime number of sexual partners, selected countries, mid-1990s However, # of Lifetime Sexual Partners Do Not Explain Everything >20 >60 >40 Pct of men with 10+ partners

“Concurrent” Partnerships * Source M. Carael, 1995; Halperin and Epstein, 2004

“Acute Infection” and Concurrence

Low degree networks create a transmission core In largest component: 2% 41% 64% 10% Mean: 1.74 Mean: 1.80 Mean: 1.86 Largest components Mean: 1.68 Number of Partners Bicomponents in red Source: Martina Morris, University of Washington and James Moody, Duke University, used with permission from a presentation given at a meeting on concurrent sexual partnerships and sexually transmitted infections at Princeton University, 6 May Modeling Sexual Networks:

Just as some drugs don’t cross the blood brain barrier; we have a very difficult time getting condoms to cross the marriage and relationship barriers.

Early successes: Uganda and “Zero Grazing”

How can a person protect themselves against contracting HIV? Source: Lesotho Ministry of Employment & Labour, Report on HIV/STI KAP of Basotho Miners and Farm Workers Percent

Monitoring the Campaign in Swaziland 12 sites (random sample, stratified U/R) 2120 adults (July 2005) and 2112 (July 2006) 21% repeat participants in % female (2005) vs 64% (2006) Average age 28 years (both cycles) CIET

Knowledge

Subjective Norms: “People around here think it’s okay to have”:

Attitudes: “I think it’s ok to have”:

Intentions…

Agency: “It is in my power to decide”:

Practices:

2006: Exposure to Makhwapheni (“secret lover”) campaign (% who answered yes)

“Number of partners is a personal matter of no consequence to anyone else” (% who agree among)

2006: Contrast between Exposed and Unexposed “Have you heard of the Makhwapeni uyabulala campaign?”

“ Map” of the largest component of a sexual network in Likoma, Malawi Source: Kohler H and Helleringer S. The Structure of Sexual Networks and the Spread of HIV in Sub-Saharan Africa: Evidence from Likoma Island (Malawi). PARC Working Paper Series: WPS 06-02

/halperin_speakernotes.pdf

BEHAVIOR CHANGE AMONG MALES IN MANICALAND, ZIMBABWE Source: Gregson et al, 2006

Proportion of year-olds reporting more than one current sexual partner, South Africa 2005 Source: South African National HIV Prevalence, HIV Incidence, Behavior and Communication Survey, 2005

Economic Status and HIV prevalence (Tanzania) Source: AIS

2006: Number of partners is a personal matter of no consequence to anyone else (% who agree among)

Early successes: Thailand and “100% condoms”

Education Status and HIV prevalence in Tanzania Source: AISS

Source: Dr. Vinod Mishra, ORC MACRO 2006 (DHS survey 2004) HIV prevalence* by partner faithfulness (Cameroon)

Sources: Mekonnen et al, AIDS, 2003 *Condom use data available for Akaka site only BEHAVIOR CHANGE AMONG MALE FACTORY WORKERS IN ETHIOPIA

Source: WHO/GPA surveys BEHAVIOURAL AND HIV TRENDS IN UGANDA

CLICK TO ADD TITLE

Premarital sex: % of never married women years old who had sex in the past year ORC Macro

Changes in sexual behavior among men in Uganda, WHO/GPA surveys, 1989 &1995.

BEHAVIOR CHANGE AMONG FEMALES IN MANICALAND, ZIMBABWE Source: Gregson et al, 2006

Behavior changes reported by married Ugandans

The fear of AIDS has reportedly changed social behavior in Arua drastically. Many cinema, disco, video, hotel and restaurant operators complain of loss of business because of poor attendance and poor turnover because loose men and women are no longer entertaining and tolerating each other as before… (New Vision, December 2, 1987, p 3)

The horror of Slim is forcing people to change social habits.…A number of wives openly go so far as to confess that Slim has saved their marriages…In Bugolobi, a young housewife with three children, declared with a gleam in her eye, “there has been a positive change in our marriage. My husband stays at home much more. And I encourage him to do so by enthusiastically keeping him informed of the latest gossip about Slim victims.” (New Vision, October 23, 1987, p10)