Evaluating Botswana’s Campaign on Concurrent Partnerships using Coarsened Exact Matching Iris Halldorsdottir, Noah Taruberekera, Rebecca Firestone, Lung Vu, Virgile Capo-Chichi, Richard Harrison 25 October 2012

 Campaign background  Campaign structure  Impact evaluation  Methods  Results  Lessons learned Outline PAGE 2

 Goal: zero by 2016  2006 SADC Think Tank –Key drivers: high CP, low levels of consistent condom use and male circumcision  National Operational Plan ( ) – HIV Prevention scale-up focus on drivers  2007 CP Point Prevalence –15-35 years, at least 1 partner –Men 17.5%, Women 17.4%  2007 CP Formative (Soul City)  2008 Development of CP Campaign Plan Background page 3

Botswana’s Concurrent Partnerships Campaign Campaign team National AIDS Coordinating Agency Natl Prevention Technical Advisory Cmte PSI Campaign strategy Teaser campaign – get people talking Phase 1 – address risk perceptions, knowledge, awareness of CP Phase 2 – assess consequences, personalize risk Mechanisms Social mobilisation – reach key influencers and leaders Mass media – TV, radio, print, billboards, combis Interpersonal communication – CBOs, FBOs, door- to-door, bars/shebeens

Theory of change page 5 Behaviour - harm reduction within MCP IPC Direct exposure Exposure from all sources Drivers of individual behaviour  Opportunity Ability Motivation Drivers of individual behaviour  Opportunity Ability Motivation Intention to avoid MCP Behaviour - reduce MCP Reduced HIV incidence Reduced HIV incidence Community sensitisation Mass media Integration Key influencers Key influencers Media Social diffusion Institution diffusion Intention to reduce harm within MCP Adapted from Hornik and Yanovitzky, 2003

Did exposure to campaign messages among adults aged  (1) reduce concurrent partnerships and factors associated with having concurrent partnerships? Point prevalence of CP Cumulative prevalence of CP  (2) increase HIV risk reduction behaviors and associated factors? Consistent condom use HIV testing Campaign evaluation questions PAGE 6

 National two-stage cluster sampling survey (n=1237) –Stage 1 PPS sampling of enumeration areas (EAs) from census sampling frame EAs in high exposure areas prospectively matched to EAs in low exposure areas, based on geography and availability/coverage of radios and televisions –Stage 2 Households within selected EAs selected using simple random sampling One eligible individual in each household randomly interviewed.  Coarsened exact matching to compare exposed/non-exposed –Retrospective matching on radio and/or television access and or ownership, and place of residence L1 (Global Imbalance measure) =  Multiple logistic regression on sub-sample (n=1138) –Two exposure variables Exposure to at least one national campaign Exposure to specific campaigns –Stratification by gender Evaluation Methodology page 7

Descriptive statistics page 8

Did campaign exposure reduce concurrent partnerships or increase HIV risk reduction behaviors? Program exposure effects (vs. no exposure) on behaviors and behavioral factors Adjusted OR (95% CI) Effects for concurrency Concurrency point prevalence1.3 (0.8, 2.1) Concurrency cumulative prevalence1.1 (0.8, 1.6) Peer pressure not to engage in CP1.7 (1.1, 2.7) Negative attitude to having variety of partners1.6 (1.1, 2.3 ) Effects for HIV risk reduction Consistent condom use1.3 (1.01, 1.7) Tested for HIV1.6 (1.1, 2.4) Condom use self-efficacy1.4 (1.02, 1.8) Perceived HIV risk1.5 (1.1, 2.0) No evidence the campaign influenced concurrent partnerships Campaign was associated with HIV risk reduction behaviors

Campaign effects concentrated in men PAGE 10 Program exposure effects (vs. no exposure) by gender Men AOR (95% CI) a Women AOR (95% CI) a Effects for concurrency Negative attitude to having variety of partners2.0 (1.3, 3.1)0.9 (0.4, 1.7) Effects for HIV risk reduction Consistent condom use1.7 (1.1, 2.6)1.1 (0.7, 2.8) Condom use self-efficacy1.6 (1.02, 2.4)1.2 (0.8, 1.9) Perceived HIV risk3.0 (1.9, 4.6)0.8 (0.5, 1.2)

 Cross-sectional survey  Recall bias  Not fully nationally representative, but equally covered low and high implementation areas Limitations PAGE 11

Conclusions page 12  Campaign exposure was associated with risk reduction strategies - more consistent condom use; greater HIV testing; greater confidence in condoms as an HIV risk avoidance strategy  Risk reduction effects primarily concentrated among men, along with some evidence of changes in attitudes to view sexual networking more negatively  Stand-alone campaigns on concurrency likely not sufficient in duration or intensity to change a culturally entrenched, socially tolerated behaviour  Adults in this context need a range of HIV risk reduction strategies  Combination prevention

 Clear identification of the counterfactual  Only one round of data required  Superior to other common matching methods in the quality of the match it can provide  Easy to implement with the right software Lessons learned in using CEM page 13

 National AIDS Coordinating Agency, Bostwana  Centers for Disease Control and Prevention  US Agency for International Development/Pepfar  Contact: Acknowledgements page 14