Risk, sex and HIV: risk understanding and management for youth in sub Saharan Africa Nicola Desmond Wellcome Trust Fellow Liverpool School of Tropical Medicine Malawi-Liverpool-Wellcome Trust Major Overseas Programme IAC, Melbourne, Australia July 21 st -26 th 2014

Risk realities amongst youth in SSA today Combination prevention approaches may fail to acknowledge risk realities of youth today Framing HIV as ‘disease’ is inadequate Biomedical approaches alone continue to ‘exceptionalize’ HIV response Importance of emphasizing the diversity of HIV risk & local epidemics requiring ‘contextualized’ response Need for holistic NOT deficit approaches

Risk framing Importance of community –Appropriate responses require acknowledgement of individual agency embedded within social structures influenced by collective culture 1 Landscapes of risk –How people respond to HIV risk informed by how they perceive and respond to other risks in daily lives 2 Risk moments –Individual risk perception framed by multiple, often contradictory, discourses which shape series of ‘risk moments’ 3 References 1.S. Kippax, N. Stephenson, R.G. Parker, & P. Aggleton, (2013) Between Individual Agency and Structure in HIV Prevention: Understanding the Middle Ground of Social Practice Ph, Am. J. PH Vol 103 (8) 2.Desmond N, Prost, A, Wight, D (2012) Managing risk through treatment seeking in rural north-western Tanzania: Categorising health problems as malaria and nzoka, Health Risk & Society 14:2, Desmond N, (2009) ‘Ni kubahatisha tu! ‘It’s just a game of chance!’: Adaptation & resignation to perceived risks in rural Tanzania

Risk landscapes: case studies from Tanzania

Need to embed behavior change for youth within understanding of social landscapes of risk Risk associated with social position Social capital as strategy to exercise agency to control future & minimise risk exposure Social reputation enhanced through social contributions

Social capital for risk management Youth learn the value of cooperative social relations to manage risk in rural Tanzania –‘but it becomes so easy if people are in a particular group, you would get help so easily contrary to when you are not in that particular group as people will say that you are uncooperative and should be neglected during times of need’

Understanding youth cultures as situated between tradition & modernity Traditional influences –Limited ability to interpret misfortune to direct future –Chance & fatalism dominant public & private discourses Modern influences –Greater awareness of role of agency in managing risk –Greater risk-taking necessary to exploit greater choices available to youth

Youth situated between modernity & tradition Youth daladala drivers using traditional medicine to control risk of modern lifestyles in peri-urban Tanzania –‘This medicine can be used to prevent car accidents when it is usually applied to the forehead. Many people who drive for a living have these kinds of scars. But these treatments can also be used for purposes other than to protect the individual. For example a driver can have medicine inserted to ensure he gets many clients and makes money’

Need to embed behavior change for youth within social norms specific to context –Early forced marriage promoted by parents to prevent ‘shameful’ behaviour such as unmarried pregnancy in coastal Tanzania 1 –Early sexual debut inadvertently encouraged by parents to fulfill expectations for household contributions with few alternative options in coastal Tanzania 1 –Early sexual debut for boys promoted as sign of masculinity in Uganda 2 –Youth as perpetrators of ‘social justice’ to punish inappropriate behaviour through ‘kula mande’ (‘gang rape’) in coastal Tanzania 1 References 1.Desmond, N (2008) ‘Figa moja halibandiki chungu’ One cooking stone cannot hold a pot: Contradictions between awareness & change – sociocultural factors inhibiting behavior change for HIV in Pangani District, Tanzania 2.A. Nobelius, B. Kalina, R.Pool, J. Whitworth, J. Chesters & R. Power (2010) Delaying sexual debut amongst out-of-school youth in rural southwest Ugand, Culture, Health & Sexuality 12(6)

Conclusions: A new agenda for prevention amongst youth How should HIV be addressed within understanding of broader risk landscape? –Re-scripting sexual behaviour of youth at micro-level to address local context of risk Importance of social interventions targeting communities & changing norms for youth –Transformative processes for changing norms Leadership Parenting & socialization –Focus on community / relationship not individual to define less risky ways to express selfhood

Acknowledgements Martina Brostrom - UNAIDS Dr Vera Pieroth & team - UZIKWASA Dr Daniel Wight – MRC SPHSU Communities of Magu District, Mwanza Region & Pangani District, Tanga Region, Tanzania