Transcript Communication Campaigns in the Context of a Severe HIV and

Risk and sex in an HIV epidemic:
Challenges for HIV prevention
communication
M’zamani Benjamin Makhubele
Gauteng AIDS Conference,
Boksburg, 15 November 2007
Co-researchers: Pumla Ntlabati and Warren Parker
www.cadre.org.za
Background and Study Objectives
 Numerous quantitative studies and epidemiological
analyses have illustrated very high HIV infection risks
associated with partner turnover and concurrent sexual
partnerships
 The dynamics of sexual partnerships are not well
understood
 This qualitative study set out to explore:
- Particular risk factors for HIV acquisition
- Context of HIV risk amongst 20-30 year olds
- Nature of sexual partnerships, particularly concurrent sexual
partnerships
 Identify the implications for HIV and AIDS communication
Key questions
 What are the perceptions and practices of unmarried
sexually active people aged 20-30 in relation to having
high overall numbers of sexual partners and having
concurrent sexual partners?
 How does this interrelate with the context of a severe HIV
epidemic?
 What is the interplay between sexual partnerships and
gender, economic and other contextual factors?
 What is the relationship between sexual practices and
perceptions of risk?
 What prevention strategies are being adopted?
 What are the opportunities for intervention, particularly in
relation to HIV prevention communication?
Methods
 Conducted in two phases: October 06 and March 07
 Participants were recruited in five provinces of the Eastern
Cape, Gauteng, Northern Cape, Western Cape and
Mpumalanga
 6 FGDs and 32 individual interviews (72 respondents – 69
single & 3 cohabitating)
 Conducted in English, Xhosa, Sesotho, Xitsonga,
Setswana and Sepulana
 All interviews and focus groups were tape recorded,
translated into English and transcribed (>860 pages of
data)
 Data read by all researchers, coded in Atlas.ti/
HyperResearch and analysed
Interpreting the data
 Interviews and focus groups provide deep insights into
perspectives and intimacies of peoples’ lives, and we
recognize the contributions of those who shared their
stories with us.
 Diversity of perspectives, practices, sexual strategies,
inconsistencies, contradictions and emotions are
presented openly and honestly. In the overall, what is said
is not unique to sex as it occurs in South Africa, but are
representative of the journey that relates to sex and
relationship development in most parts of the world.
 It is important to avoid approaching the data judgmentally
or to attempt to summarize findings into stereotypes.
Rather, we are attempting to draw on our open
discussions to inform intervention and risk reduction in the
context of a severe epidemic.
‘Main’ and ‘other’ partners (1)
 Both sexes were ‘matter of fact’ about having ‘main’ and
‘other’ partners:
Male: We as men are not faithful. There are about two or three that I
have had sexual relations with during that period [past two years]. The
thing is that as I knew that there was someone more important than
them, someone whom I wanted to protect, so I used condoms with them.
Interviewer: Can you explain what you mean by the important person?
Male: The important person is the one whom you have chosen as the
one you are going to spend your life with.
Interviewer: What do you call the others?
Male: The others are also important, but the thing is that we do not
have them in our lifetime plans. With them it is a matter of lust, like
seeing someone and feeling lust for them and lust is a short term
experience, it is not long lasting - it is easily satisfied (Male, 28,
Mpumalanga).
‘Main’ and ‘other’ partners (2)
And also you find that I have my main boyfriend whom I have sex with
because he is my boyfriend. And you meet someone else and become
close to that person, you are going have sex with him for a different
reason. That is not because he is your boyfriend, but just maybe that
you have grown close to him. (FGD, Female, 20-30, Gauteng)
I guess people have spare boyfriends because I mean most people are
afraid to be, like, alone, like they are afraid. It’s their fear to be alone,
to think hey, if the boyfriend decides that he doesn’t want to have sex
she can go and cry on the other boyfriend’s shoulder. So it’s always
that case.
(Female, 18, Gauteng)
‘Main’ and ‘other’ partners (3)
 There was little sense of love, intimacy or respect in
relation to ‘other’ partners:
I can have others in the same area, but they have to know there is
someone in my life. If they can’t accept that, then we part ways
immediately. I mean, I don’t lack for anything, it was more a favor I
was doing for her anyway.
(FGD, Male, Western Cape)
Interviewer: She has a 30-something year old boyfriend? And the fact
that she has someone else, what does that say to you?
Male: The thing is, I had to follow procedures set in starting the
relationship. I agreed to be understanding to that fact that she has a
boyfriend.
(Male, 27, Eastern Cape)
Casual sexual partnerships (1)
 For some, casual partnerships did not include having
‘main’ partners, but rather a series of overlapping casual
sexual relationships:
Interviewer: Can you tell me how this happened, that you got involved
with up to three women?
Male: I thought it was the right thing for me at the time...
Interviewer: Did you have one regular partner or was it just the three,
no distinction?
Male: No, I was involved equally with all of them.
Interviewer: And were you serious about these relationship or was it
all just for fun?
Male: I think it was just something to suit the moment, I wasn’t really
serious at the time. I didn’t have a serious partner and I could tell that
they were also not serious about me.(Male, 27, Eastern Cape)
Casual sexual partnerships (2)
 Casual partnerships had to be actively managed:
Amongst the three that I had told you about, one was a one-night stand.
The other one that I saw for a month or two came into the picture while
I was having my current girlfriend. So I would have sex with one this
week and have sex with the other the following week. I avoided a
situation where I had sex with one today and have sex with the other
the following day because it is not nice to do that. What I would do was
go and see one and not do anything sexual with her and then pass by
the other one and pick her up for the night.
(Male, 23, Mpumalanga)
Let us say there is Sipho and Themba and whoever else. Sipho will
arrive at seven, Lucky will arrive at ten. [These women] manage, but I
do not know how. Sometimes you find that maybe Themba lives in
Finetown, Sipho lives here and others live in other different places, so
that they do not meet.
(Female, 22, Gauteng)
Rationale for casual sexual partnerships
 Casual partnerships had a wide range of rationales,
including:
- being someone who ‘loves sex’, ‘lust’, ‘greed’, ‘when
you want to have sex it is like you are mad’ (males)
- having sexual opportunities constantly available
- fear of loneliness
- being related to self-esteem and being unable to say ‘no’
Interviewer: What led to those situations where you were seeing more
than one boyfriend?
Female: What can I say? I was losing control over myself. I was unable
to control my feelings and ended up agreeing to different men’s
propositions at the same time… How can I say this? Maybe I love that
person while I am involved with another one. It is difficult for me to say
no to the person I love, so I end up saying yes.
(Female, 21, Eastern Cape)
Initiation of sexual relationships
 Sexual relationships were initiated with very little delay –
often occurring in a matter of days or one or two weeks
after meeting. One-night stands were also common.
Interviewer: And how long does it take to sleep together?
Male: I don’t take more than three days then I ask her to visit. We can
sit and chat and I know that we will end up having sex.
(Male, 25, Eastern Cape)
Interviewer: So on average, how long before you have sex?
Female: It’s just days, like if you meet over the weekend, sometime
during the week you will sleep with him.
(Female, 28, Eastern Cape)
Perceptions of peer influence
 Peer influence was seen as supporting promiscuity
amongst both sexes:
Most of my friends have many boyfriends, like three or four boyfriends.
So when they see me sticking to one guy they take me as someone who
thinks she is better than them, who is not in style. It is not like I do not
want to do it, but I think about my life. If I can have more than one
boyfriend I will not manage to satisfy them because I am one. It is
better if it is one person. I cannot manage to do things for more than
one boyfriend. I will not manage. (Female, 22, Gauteng)
Like when you don’t have many girlfriends it is like you are a
moshemane (boy). Things like that. They will say you are gay or
something. They can mock you. Interviewer: And if they see you with a
whole lot of different girls? Interviewee: They will say ‘haai, uyinja
wena’ (you are a top dog)! You are the man. (Male, 18, Gauteng)
Influence of mobility (1)
 Concurrent and overlapping sexual partnerships were
readily sustained in contexts where people were mobile:
It is just because of traveling around, going to different places. So
when you get to those places you see other things as well. Sometimes
you give your numbers to someone and she calls you, or she gives you
her numbers and she calls you as well and then you feel you should
give it a try. And at the end you end up having a sexual relationship
even though you have a girlfriend.
(Male, 26, Gauteng)
The thing is I don’t break up with these people. It’s more like putting
things on hold because of distance and lack of opportunity. I can see
any of them, even after months of no contact and even if they have main
partners I know they will see me when the need arises. We will get
together and have sex and she will then leave.
(Male, 25, Eastern Cape)
Influence of mobility (2)
 For young women, the influence of mobility included
relationships with married men that are interlinked with
childbearing and economic support:
I will start with the father of my child. He used to love me but after I
had a child he left me. I have also learned that to be involved with a
married man has its good and bad sides… He is married and on top of
that got transferred, leaving me lonely. He has told me not to get
involved with someone else because I am involved with him. The
second thing is that he is not even promising to pay lobola for me. I
have also told him that I am not prepared to be a second wife. So I
have told him that I need to go on with my life, but he does not agree. I
have raised concerns about the distance as well, and when he is off or
over weekends he goes to his wife in [another town]. It is difficult for
him to come and see me here because the little free time he has he goes
to his wife. (Female, 26, Mpumalanga)
Trust, honesty, faithfulness (1)
 Having frequent partner turnover and concurrent partners
was seen as normative:
I actually don’t know where lack of trust and faithfulness culturally
came from. Everywhere – people are just cheating. I don’t know where
it came from – when cheating and unfaithfulness became the norm –
but I think people think they are invincible. I mean like one of my
distant relatives, she fell pregnant and she was like ‘I don’t know who
the father is!’. (Female, 25, Eastern Cape)
I also have one partner that I’m very close to and I may spend up to six,
eight months without having sex with any other person. We don’t use
condoms and sometimes it occurs to me that she could maybe place my
life in jeopardy by having affairs on the side. I always end up mulling
this possibility over, but what can I do?
(FGD, Male, 20-30, Western Cape)
Trust, honesty, faithfulness (2)
 The concept of faithfulness was not understood as having an
exclusive relationship. Rather it had to do with protecting one’s
partner from ‘hurt’:
Being faithful is protecting the one you love from hurt. You make sure
that he only knows the best about you and you give him the best love.
The others are just there when he is not around, to keep you company.
(FGD, Female, 20-30, Gauteng)
As for me, I have my girlfriend, the one that I spend most of my time
with. I am faithful to her because even when I have other girlfriends I
do not walk around with them for her to see me. I hide the other
girlfriends. (FGD, Male, 20-30, Gauteng)
Trust, honesty, faithfulness (3)
 Having a married partner was seen as having a
relationship with someone who was ‘honest’ and less
likely to stray than a person who was single:
The [married man] that I told you about – he told me the whole truth
about himself and his situation. He never lied to me. A boyfriend,…
always have a number of girlfriends and they will never tell you that
you are not the only one. But when you call him sometimes you will
find that his phone is off, especially boys. Some married men do tell
you that they are married, so you decide whether you take him or not.
A nice married man will be open with you.
(Female, 26, Mpumalanga)
Risk reduction strategies: Limiting
partner turnover, concurrency
 A number of participants reported changes in their
perceptions and sexual relationship practices:
Nowadays we live in a dangerous world, there are HIV and AIDS, STIs
and such things, so if you share a girl with another man you do not
know how many other girls the other guy is sharing with the girl that
you are also involved with. It may happen that he and I share this one
girl, but he also has four other girls. So that is why I do not like
sharing a girl with someone else. I actually do not like it and I do not
do it. (Male, 23, Mpumalanga)
Sometimes I regret having had overlapping sexual partners, because
they are not right. You have sex with two people at the same period of
time. It is like even when I was sitting alone sometimes I would ask
myself, ‘What am I doing?’ It hurts a lot, even though people do not
want to talk about such things. (Female, 21, Eastern Cape)
Risk reduction strategies:
Condom use (1)
 Many interviewees and participants reported a strong
commitment to condom use for HIV prevention. However,
it was acknowledged that condom use with a ‘main’
partner usually diminished or ceased over time. There
was, however, commitment to condom use with ‘other’
partners:
Interviewer: What about with the other partners?
Male: With the other partner I used condoms till kingdom comes. There
is no way I can trust those ones because sometimes it can happen that
she ends up having information that she is your second best and also
decides to have someone to keep her busy while you are away. And you
do not know the status of the person who will keep her busy in your
absence.
(Male, 28, Mpumalanga)
Risk reduction strategies:
Condom use (2)
 In casual partnerships it was noted that a number of
factors influenced non-condom use and inconsistent
condom use, including ‘breaking the moment’, being
under the influence of alcohol, and ‘silent consent’ by
one’s partner.
She just kept quiet. She never asked me where is the condom or why am
I not putting on a condom. She just kept quiet. But when I did it I
wanted to see what her reaction would be. So she kept quiet and I just
continued. Then afterwards I asked her why she did not stop me and
she asked me why I did not use a condom. So it was like we were
pointing fingers at each other. So if we were infected we would be
dead. (Male, 22, Gauteng).
 Incorrect condom use was also noted, including removing
condoms during sex and condom slippage and
breakages.
Risk reduction strategies:
Condom use (3)
 A number of women illustrated confidence and
assertiveness in condom use. There was not a strong
overall sense that condoms would not be used if a women
articulated a desire to use them:
Facilitator: How do you convince men to use condoms?
Female: I just tell him to use it.
Facilitator: And he agreed?
Female: He asked me if I do not trust myself and I said that I do trust
myself, but let us use condoms. He agreed and we used them. He uses
them up to this day. (FGD, Female, 20-30, Mpumalanga)
Interviewer: Who initiates condom use in your relationship?
Female: I am the one who initiates it.
Interviewer: Do they come with condoms or do they find them at your
place?
Female: I have them in my room. (Female, 21, Eastern Cape)
Risk reduction strategies:
HIV testing
 HIV testing was seen as an important step, individually
and for couples. It was also linked to a desire not to have
to continue using condoms:
We were just chatting and it just came up. We’d both been for a test
before we met and as it kept coming up, we decided to go and make
sure. I had not been sure at that stage though but I was prepared to
brave it out and it turned out that we were both negative and ever since
we felt free to not use one.
(FGD, Male, 20-30, Western Cape)
In the middle of the process he would decide to take out the condom
and continue without it. We used to argue a lot about it. He is one
person who would use a condom and later feel that it is impeding his
pleasure and take it out. I did not like that at all. He then told me that
since I do not trust him we should go and have HIV tests.
(Female, 20, Northern Cape)
Taking stock of the findings
 The findings raise the importance exploring contextual
factors and rationale for sexual behaviours and practices in particular, HIV risk and vulnerability
 The findings provide insight into nuances related to HIV
prevention
 Insight is provided into contexts of risk and the
organic/indigenous responses to risk reduction
 Some important themes not covered in detail include:
fatalism and perceptions of the inevitability of HIV
infection; low self-esteem in relation to risk behaviour;
knowing people who have died of AIDS; gender power
relations; economic power relations; and violence
(although there was very little in the present data to
suggest sexual violence was pervasive).
Emerging goals and implications for
HIV prevention communication
 Epidemiologically, reducing the extent of concurrent
sexual partnerships in South Africa will contribute
markedly to incidence reduction (biologically - in relation
to viral load)
 Two primary risk factors intersect: high partner turnover,
which results in high cumulative numbers of sexual
partners (strongly influenced by a long period of being
single), and a pattern of having concurrent partners
amongst both males and females
 As a consequence of high partner turnover and
concurrency there are likely to be high levels of exposure
to diverse interwoven sexual networks - we see high
prevalence
 Whilst condom use is common, it is less common in high
risk contexts (e.g. casual contacts, one-night stands), and
there is probably insufficient correct and consistent use
Key focal areas for prevention
communication (1)
Emphasis needs to be placed on the following behaviours
and practices which increase risk of HIV acquisition and
need to be promoted as PRIMARY risks:
 Having many sexual partners in one’s lifetime
 Frequently changing sexual partners and having two or more
partners in a year
 Starting sexual relationships soon after meeting people and
having ‘one-night stands’
 Having more than one partner in the same month
 Having overlapping sexual partnerships
 Having a main partner as well as having other partners
Key focal areas for prevention
communication (2)
These can be translated into key messages for PRIMARY
prevention of HIV (Note that the concept of ‘faithfulness’ is
not well defined)
 ‘Manage your risk to HIV by managing your sexual relationships!’
– ‘Quality, not quantity.’
 ‘The more sexual partners you have, the higher your risk of
getting HIV.’
 ‘If you have two or more sexual partners a year, you are at
higher risk of getting HIV.’
 ‘Avoid “one night stands” and get to know someone before
starting a sexual relationship.’
 ‘Having more than one sexual partner in the same month puts
you at high risk for getting HIV.’
 ‘Space your relationships. Wait at least six weeks before starting
a new relationship.’
 ‘Avoid overlapping sexual partnerships.’
Key focal areas for prevention
communication (3)
Key COMPLEMENTARY HIV prevention strategies include:
 Consistently having condoms available – particularly when
exposure to alcohol and high risk contexts is likely
 Initiating and articulating the importance of condom use during
sex
 Correct condom use and consistent condom use
 Knowledge of own HIV status
 Knowledge of sexual partner HIV status in established
relationships
 Consistent condom use if HIV positive and if HIV status is
unknown.