EVALUATION OF SMC SHORT TERM COMMUNICATION STRATEGY BOTSWANA

Presented by: Lesego Busang (ACHAP) Onkemetse C. Ntsuape (MOH) ACHAP Symposium - International AIDS Conference Washington DC, USA 23 rd July 2012

www.aids2012.org

Washington D.C., USA, 22-27 July 2012

Introduction - Overview

• SMC Adopted as HIV prevention add-on strategy 2009 • STCS Implemented since 2009 • Evaluated in September/October 2011 – Inform LTCS development – Baseline • Collaboration between MOH, ACHAP and PSI

www.aids2012.org

Washington D.C., USA, 22-27 July 2012

Methodology

• Cross-sectional study (September/November 2011) • Quantitative – 2,973 males and 375 females aged 15-49 years • Qualitative approaches – Focus group discussions (35 FGD’s) – Key Informant Interviews (32 KII) • Basis of sampling was 2011 Census Sampling Frame ensuring: – Urban/Rural, geographical and circumcision prevalence representation • Hence 7 health districts were sampled

www.aids2012.org

Washington D.C., USA, 22-27 July 2012

Circumcision Status and Intent

Would ACCEPT Circumcsion 23% PLANNING on Circumcising 36% Circumcised within last 3 years 9% (or 40% of Circumcised) Would NOT Accept Circumcision 14% (or 18.2% of Uncircumcised) Circumcised, No Data on When 1% Don’t know if Circumcised more Would Accept 4% than 3 years ago 12% No Response on Would Accept 1% www.aids2012.org

Washington D.C., USA, 22-27 July 2012

Benefits of SMC – Males

• •

Complete protection Partial protection Reduces man's infection chances Protection against STI Reduces Woman's infection chances Circumcised penis hygienic Improved appearance Size of penis appears Larger Size of penis appears smaller Increased sexual pleasure No need to use condoms Can have more partners Other (Specify Don't Know 2,1% 2,1% 1,6% 0,4% 0,2% 3,6% 0,1% 0,1% 5,4% 1,5% 21,3% 26,8% 50,9% 65,0% 0,0% 10,0% 20,0% 30,0% 40,0% 50,0% 60,0% 70,0% SMC helps reduce the chances of HIV infection (All FGD’s)



* It reduces infection rate but doesn’t mean that you won’t get infected with the virus. (Gaborone females)

SMC promotes hygiene (All FGD’s)

 I take it that circumcision helps one be clean; foreskin accumulates dirt and other diseases (Kweneng females)

www.aids2012.org

Washington D.C., USA, 22-27 July 2012

Anticipated SMC Risks/Complications

Don't Know Other (Specify) No Complication Death Poor Sexual performance Penis damaged Excessive bleeding Infection Swelling of penis Wound does not heal 3,7% 2,6% 8,6% 9,4% 11,3% 14,2% 14,9% 14,3% 23,8% 30,6% 0,0% 5,0% 10,0% 15,0% 20,0% 25,0% 30,0% 35,0% Percent Excessive bleeding –

*

I take it that if you cut someone’s foreskin what comes to mind would be ‘what if I lose a lot of blood and die?’ and the pain, so these things discourages them to go and circumcise.

(Females FGD)

www.aids2012.org

Washington D.C., USA, 22-27 July 2012

Reasons WOULD NOT accept MC if Offered Fear of Pain Don't belive in SMC Cultural/Religious Reasons Have not thought about it Fear of HCT Results Don't have enough information Other No time for healing process Too Old Not Ready HIV Positive

36% 21% 7% 8% 6%

Reason for NOT BEING Circumcised 0.0

5.0

10.0

15.0

20.0

25.0

2% 1% 4% 2% 6% 5%

Fear for pain/complications/death No time for process/healing period Don’t have enough information Don't believe/like SMC Just havent thought of it Facility delays/accessibility/Services Feared for HCT results Cultural/Religious Not ready Health Reasons/HIV Positive Using Other Prevention Beleive already old Financial reasons Other

1.3

1.3

1.3

1.0

3.6

3.1

2.8

1.9

2.0

6.1

4.8

16.5

20.5

www.aids2012.org

30.0

35.0

33.8

40.0

Washington D.C., USA, 22-27 July 2012

60,0% Source of SMC Knowledge and Motivator to Get Circumcised 50,0% Includes Sexual partner 49,5% Source of SMC Knowledge Motivation to Circumcise 40,0% 35,1% 32,6% 30,0% 29,5% 28,6% 19,1% 19,5% 20,0% 10,0% 0,0% 8,9% 9,6% 1,2% 8,1% 0,8% 1,7% 4,0% 10,3% 0,6% 2,0% 0,0% 0,6% 3,5% 0,9% 9,8% Source/Motivator www.aids2012.org

Washington D.C., USA, 22-27 July 2012

The odds of being Circumcised vs not being circumcised during STCS Campaign (excludes circumcised more than 3 years ago) 13,000 12,000 11,000 10,000 9,000 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0,000

6,245 3,355 3,332 3,136 1,982 1,854 2.900

2.850

2.800

2.750

2.700

2.650

2.600

2.550

2.500

2.450

1,583 2.609

Death not seen as a risk 1,372 ,383 2.837

Pain during procedure not anticipated ,352

www.aids2012.org

Washington D.C., USA, 22-27 July 2012

Odds of "Would NOT Accept SMC" if offered 100,000 90,000 80,000 70,000 60,000 50,000 40,000 30,000 20,000 10,000 0,000

91,305 75,296 17,886 8,656 3.07

6,804 7.000

6.000

5.000

4.000

3.000

2.000

1.000

.000

2.302

No knowledge on HCT need prior SMC ,434 2.769

Unemployed ,361 2.815

No knowledge on hygiene benefit ,355 • Tested for HIV and booked clients still not showing up in large numbers • Ever tested for HIV already too high to have an impact; fewer people don’t know their HIV status.

www.aids2012.org

Washington D.C., USA, 22-27 July 2012

Recommendations

• Strive to achieve high levels of correct knowledge.

• Develop targeted messaging for identified gaps; ie for concerns on “pain/complications” and “believes” • • • Use circumcised men to respond to perceptions on pain. Educate communities on use of local anesthesia to address pain.

Explore use of non-surgical devices; ie PrePex.

• Increase use of interpersonal communications.

• Promote other SMC benefits such as cleanliness.

• Develop/customize messages to local context.

• Strategically assign mobilizers to communities. • Empower leaders on SMC facts ( buy-in and cultural concerns ). • Pilot materials extensively before roll out.

www.aids2012.org

Washington D.C., USA, 22-27 July 2012

THANK YOU

Credits and Acknowledgements: •Health Education Officers •Districts Health Management Teams •Community leaders •Study Participants

www.aids2012.org

Washington D.C., USA, 22-27 July 2012

Evaluation Objectives

• Establish the extent to which the objectives of the STCS were met; ie establish if – the general public is informed about the Government of Botswana/Ministry of Health/ position on SMC as an HIV prevention strategy.

– men currently seeking SMC services at health facilities have adequate information on SMC – service providers at health facilities and the media personnel have capacity to disseminate and report correct and accurate messages on SMC and HIV prevention to the general public.

– political and social leaders at all levels advocate for SMC.

– SMC stakeholders effectively communicate facts on SMC in line with the SMC short term communication strategy.

• Provide a baseline levels for the role out of SMC in Botswana • Provide Knowledge, Attitudes and Practice (KAP) levels.

www.aids2012.org

Washington D.C., USA, 22-27 July 2012

Period before starting sex One week after 2% Two/Three weeks after 5% Four/five weeks after 13% Six wks or more 80% www.aids2012.org

Washington D.C., USA, 22-27 July 2012

Condom use change after SMC

Other; 4% Reduced/ Stopped, 7% Increased; 3% Started; 1% Continued not using; 1% Continued using; 83% www.aids2012.org

Washington D.C., USA, 22-27 July 2012

70,0% 60,0% 50,0% 40,0% 30,0% 20,0% 10,0% 0,0%

Change in number of sexual partners after Circumcision by period of circumcision

60,6% 31,1% 8,3% 50,0% 26,2% 23,8% Stayed the same Decreased Increased

Circumcised during Campaign Circumcised before Period circumcised Campaign www.aids2012.org

Washington D.C., USA, 22-27 July 2012

35,0 Reason for increasing number of sexual partners 33,3 29,6 30,0 25,0 20,0 14,8 15,0 10,0 5,0 0,0 7,4 7,4 7,4 Reason www.aids2012.org

Washington D.C., USA, 22-27 July 2012

Conclusions Cont.

• Generally the higher the knowledge levels the better the results;, regardless of whether the knowledge is on a negative factor or not; ie NO KNOWLEDGE of HCT as a requirement for SMC did not have negative impact on SMC uptake. – It is important to increase knowledge across all SMC facts. – Hence strive to achieve high levels of correct knowledge (deemed positive or negative knowledge), to take advantage of positive outcomes brought about by higher knowledge.

• Fear for pain/complications/death is a key challenge that needs to be addressed.

• Interpersonal communications are important vehicles for SMC message delivery and motivators to SMC.

– However radio provides the best coverage.

• Community leaders are willing to mobilize for the program but are not empowered.

www.aids2012.org

Washington D.C., USA, 22-27 July 2012

SAMPLE SLIDE 2

• Speaking at AIDS 2012 • What to think about?

– Keep it simple – Larger text is easier to read – Single words rather than sentences • Bullet points are there to remind you, not to tell the whole story

www.aids2012.org

Washington D.C., USA, 22-27 July 2012

SAMPLE SLIDE 3

www.aids2012.org

Washington D.C., USA, 22-27 July 2012

SAMPLE SLIDE 4

• Credits and Acknowledgements • List credits and acknowledgements – Insert organization credits acknowledgements as opposed to individuals – Insert Organization logo’s where required and with the permission of the organizations being acknowledged.

www.aids2012.org

Washington D.C., USA, 22-27 July 2012