XVI International AIDS Conference, Toronto, August 2006 ABC Messages for HIV Prevention in Kenya: Clarity and Confusion, Barriers and Facilitators Julie Pulerwitz1; Tiffany Lillie2; Karusa Kiragu1; Lou Apicella3; Ann McCauley4; Tobey Nelson5; Simon Ochieng2;Peter Mwarogo2; Edward Kunyanga6 1Horizons/PATH, 2 FHI, 3Horizons/Population Council, 4Formerly of Horizons, 5Horizons/ICRW, 6Formerly of FHI XVI International AIDS Conference, Toronto, August 2006

Study Overview Diagnostic study (2004) in 2 communities, Nakuru District. Survey with 3 open-ended questions on defining ABCs. N = 538 adults from 7 flower farms and 1,365 in-school youth from 15 schools. 8 FGDs with youth and 6 with adults. Codes for ABC definitions: Correct Partly correct Incorrect “I don’t know” Not a definition (e.g., condoms break) No or unclear answer

Respondent Characteristics Working adults In-school youth Female (%) 49 52 Age range (yrs) 18-49 13-19 Mean age (yrs) 28 15 Highest education level (%) 50% some secondary 81% in primary Married (%) Single (%) 40 ----------

Sexual Activity Adults: Youth: Ever had sex: 85% males; 76% females Currently sexually active: 71% Youth: Ever had sex: 46% males; 14% females Currently sexually active: 39%

Awareness of ABC Terms High levels of awareness of HIV. Great majority heard of each of the ABC terms in context of HIV prevention. Youth less likely to have heard of ABCs than adults (p < .05). Females (both adults and youth) less likely to have heard of condom use than males (p < .05).

Understanding of ABC Terms Respondents had relatively low clarity of ABC terms. “Abstinence” most clear: 39% of adults and 46% of youth supplied clearly correct definition. Only 23% of youth and 35% of adults correctly defined “being faithful.” Often confused with being a good person or loyalty to others, as well as with trusting that sexual partner is faithful. Only 17% of adults and 13% of youth correctly defined “consistent condom use.” Instead of definition, 43% of youth gave opinions, mainly negative, of condom use; 43% of adults did not answer. Adults tended to understand the ABCs better than youth Male & females tended to have similar understanding of ABCs terms Male FFW had a better understanding of being faithful than female FFW Male ISY had a better understanding of consistent condom use than female ISY

Attitudes Toward the ABCs Abstinence and being faithful were largely viewed as positive behaviors. Condoms seen much less positively. “ineffective,” “break easily,” “transmit HIV,” “immoral,” “uncomfortable” Overall, adults held more positive views about condoms than youth, with some adults reporting HIV and pregnancy prevention benefits, but both were most often negative.

Barriers to the ABCs Mixed, conflicting, and inaccurate messages on the ABCs from community as well as institutions. Perceived inability to control sexual behavior, especially for men. Gender-based violence, and women’s lack of power to negotiate sexual behavior. Perceived negative physical effects of abstinence and being faithful (e.g., illness, inability to pass urine). Negative views about condoms. A sense of fatalism (i.e., will get HIV despite behavior). -

Conflicting and Inaccurate Messages Abstinence: “The community thinks that you are abnormal.” “The community regards one as holy and a role model.” (Male youth, FGDs) ******************************************************************** Condom use: “The radio says they have virus.” “We are told it has small holes that can allow the virus to go through.” (Female youth, FGDs)

Gender Dynamics & the ABCs “The way girls dress make it difficult to abstain.” (Male youth, FGDs) ************************************************************ “When children start crying and maybe the husband has neglected her together with the children, she could find herself going for sex outside. She will say, ‘Let me suffer so long as the children eat.’ ” (Flower farm worker, FGDs)

Fatalism about HIV “Even if I stop alone, and in Kenya we are 30 million, that will be a waste of time. This is because others will be doing it and people will continue getting infected.” “Even if people abstained, sex is not the only way one can get HIV/AIDS. For instance, I can abstain. I have not even married, and I have not had sex with anybody and then I get infected through iron sheets or injections in hospitals, I will be having the virus and I will die like anyone else.” (Flower farm workers, FGDs)

Possible Facilitators of the ABCs A and B reported as socially acceptable behaviors. Perception by some that condoms protect from HIV and other unwanted outcomes. Respondents’ suggestions for successful implementation of the ABCs: HIV education, awareness, and communication. Maintaining strong religious convictions. Planning regular encounters with partners to maintain fidelity.

Current Sources of HIV Information Radio reported as the major source of HIV information by adults and youth. However, radio not preferred source. Both groups preferred interactive and interpersonal sources of information (i.e., workshops and seminars). Both groups commonly discussed HIV prevention with friends, but were often skeptical of reliability of information.

Recommendations Ensure messages are clearly defined, consistent, and non-contradictory. Address negative beliefs about condoms for a balanced ABC approach. Leverage positive views toward A and B. Reach audiences with preferred and trusted information sources. Acknowledge barriers and include complementary activities that enable individuals to implement each of the ABC behaviors. Ongoing intervention in Nakuru builds on study findings